Homeless Step Down Pathway Case Study 4

Social background:

The patient was born in India, but also lived in Portugal, but has since lived in the UK over 7.5 years. He has two daughters who are both married living in the Wembley area, but does not know where exactly both are residing.

His wife passed away around 4-5 years ago, but has been communicating with his brother-in-law who resides in Southall. Previously, he was living in Southall and visiting his daughters.

Medical summary:

The patient was admitted to Northwick Park hospital back in February 2023 with the following issues.

• Hypertension
• Alcohol intoxication
• Pneumonia
• Acute kidney injury
• Anaemia and
• Vascular dementia

Following his discharge from Northwick Park on the 22/3/23, he was transferred to the Mildmay Mission hospital on the homeless pathway for up to 6 weeks as a step down from acute to continue his treatment and support to relieve his homelessness.

Housing support

Before the patient was admitted to Mildmay, his social worker had referred him for 24-hr supported living services due to his sensory and health issues. The manager from Churchill Healthcare came and assessed the patient on the 6/4/23 to establish his suitability for the 24-hr service in Ealing.

Whilst at the Mildmay, the housing worker supported the patient by way of communicating with Churchill Healthcare in requesting feedback following the assessment and to accompany the patient to view the placement on the 17/4/23.

Once the viewing was completed, it was requested for the referral application to be completed, which was done with the patient, a copy given to the patient and sent back to Churchill HEALTHCARE.

As the patient had lost all of his ID and papers, including his passport, St. Mungo’s and Look Ahead was contacted to see if they had a copy of his ID and/or passport, but advised that as it has been some time, that any copies of his ID would be in archive. A UK citizen card was applied for as photo ID for him, as urgent and his social worker has previously requested for a copy of his NINO number from HMRC.

The manager at Churchill Healthcare and his social worker was communicated to advise on the ID applied for and the NINO number chased with HMRC, which the landlord required. Once the photO ID had arrived, this was communicated to both the manager and social worker and the NINO letter from HMRC came a day before he was due to be discharged.

Whilst at the Mildmay, a call had been received by the ward staff to advise that the patient’s pension credit had stopped, as they did not know where he was. The patient was supported by calling the named person and explaining that the patient was currently at the Mildmay and when he had been admitted and his discharge date. DWP was provided with the Mildmay address and also checked that he was using the correct card which was all resolved and advised that they would pay the patient 4 weeks’ money owed to him and continue to pay him as usual.

Discharge planning

• Accompanied patient to his discharge placement and sign-up
• Social worker ordered bedding and cutlery items for patient to provide on day of discharge
• Suggested to apply for Attendance Allowance (maximise benefits)- which was completed on the 1/6/23 and sent to Churchill Healthcare to support to sign form and provide bank details before sending
• New GP registration online form completed and details provided to Churchill Healthcare
• Details of pharmacy given, which Churchill Healthcare sue and deliver medications to clients in the supported living service
• Called DWP to provide them with the new placement address, contact details of the placement and emailed manager to advise.

Challenges

• Getting hold of and communicating with social worker
• Delays in Churchill Healthcare feeding back information following email requests
• Contacting external agencies (ID)

-Sheila James

(Housing Worker)