Salford Partnership Out of Hospital Care Model

Inclusion Health Case Study

• Permission- Sadly, this case study submitted is for a deceased person, but permission has been obtained from their next of kin. When asked Lucy’s sister said: “Anything to get that support back in place and help others as you all worked wonders for Lucy and I can't fault any of you”.
• Permission- Greater Manchester Mental Health (GMMH) Foundation Trust has provided permission for this case study. Partner agencies, Salford City Council and Inclusion Health GP have also provided their consent for this to be shared.
• Permission- We give NHSE permission to share and publish this case study in the framework.
• Logo- We give permission for the GMMH logo to be used with the case study in the framework.
• Organisations- GMMH, Salford City Council, ForHousing and Salford Primary Together (SPCT) inclusion Health GP were involved (via the Out of Hospital Care Model pilot)
• The challenge:

Lucy was a 50-year-old woman who was identified as homeless during her general hospital admission in 2021. Lucy had a housing assessment with a Salford City Council housing officer whilst she was on the hospital ward. Lucy was allocated to a 1-bedroom bungalow in Salford on discharge through the Out of Hospital Care Model, which was a pilot partnership between Salford City Council, GMMH and SPCT.

Lucy had complex physical health problems; she had a diagnosis of advanced liver disease and hepatic encephalopathy. She had been referred for consideration of a liver transplant. She was successfully treated for hepatitis C in 2015, the liver disease, was thought to be secondary to the Hep C infection. She had an extended admission to hospital from August to November 2021 and she moved into the new accommodation after this admission.

The GMMH dual diagnosis practitioner discussed with Lucy her mental health and substance misuse history. Lucy had been using heroin and crack cocaine for over 20 years. Lucy reported that using substances was behind her; she had been injecting heroin and crack cocaine for many years and was supported by services who had recently discharged her. She told us that she had no desire to use since her physical health was so poor and she physically couldn’t go and source any drugs.

One of Lucy’s brothers and her mother had died in recent years. She was still grieving the premature loss of them both and would often talk about her past, traumatic experiences. Lucy would express a lot of fear around her hospital admissions. Lucy would sometimes communicate her distress and fear through agitation and anger, particularly when she was treated in hospital against her wishes. Around six years previously Lucy had been diagnosed with psychosis and was prescribed an anti-psychotic, although this had not been reviewed for some time.

Unfortunately, Lucy had several re-admissions to hospital with features of decompensated liver disease, including bleeding from her gut due to liver cirrhosis, hepatic encephalopathy (confusion due to liver cirrhosis) and severe liver and subsequent kidney failure. During some of these admissions, Lucy presented as aggressive due to her confusion, however due to previous mental health diagnoses this was not always recognised.

Her admissions to hospital were distressing experiences for Lucy. It was difficult to gain intravenous access for Lucy so she would need a central line put in place which caused her distress, and this became infected. She would often vomit blood and experienced incontinence.

Lucy was admitted in March 2021, again following an episode of confusion. During this admission she showed signs of further deterioration, her kidneys as well as an admission to critical care. She was in considerable pain, but prescribing was limited to non-opiate based analgesia due to the risk of further exacerbation of her hepatic encephalopathy.

Towards the end of April 2021, while still an inpatient, Lucy expressed to the consultant who was looking after her that she no longer wished to have care in hospital and wanted to return home (which was the out of hospital model provided accommodation).

The challenges were around Lucy’s needs to be fully understood by universal services in the context of mental health, substance misuse, physical health, and homelessness. Lucy’s family were very important to her, but she was unable to sofa surf any longer due to her deterioration in physical health. The challenges for the services were balancing her wishes with her needs. Lucy’s distress and capacity required to be reviewed regularly and services required good joint working to reduce readmissions to hospital and to provide a dignified end of life support. Being homeless was a huge potential barrier for onward referrals between hospital and community teams. Having a historical mental health diagnosis, chronic substance misuse and declining physical health was challenging in terms of the level of knowledge, skills and understanding required for the universal services involved.

• The approach/solution

The Out of Hospital Care Model pilot partners worked together to ensure:

• The GMMH dual diagnosis practitioner, the Salford City Council hospital-embedded Housing Options worker, housing support worker and relevant staff from SPCT discussed Lucy, her needs, joint care planning and actions at least weekly. A weekly MDT was created virtually.
• Lucy’s family, specifically her twin sister who acted as her carer, were supported throughout. The GMMH dual diagnosis practitioner acted as advocate, offering referral for a carer’s assessment and liaising with adult social care to promote Lucy and her family’s experience and wishes.
• A collaborative care plan was shared with the ward, which included a trauma informed way of working with Lucy to reduce her distress and increase her confidence in wanting to stay on the ward. This included a psychological formulation and details of other agencies involved to promote joint working.
• The GMMH dual diagnosis practitioner regularly visited Lucy in hospital and liaised with the ward to share key information, promote Lucy and her family’s wishes, and increase communication to reduce the risk of preventable discharge and readmission.
• SPCT provided an enhanced primary care response through a home visit on discharge from hospital and weekly telephone calls.
• The GMMH dual diagnosis practitioner liaised with community teams to ensure the package of care provided was sustainable and was able to promote end of life services when required. The weekly MDT allowed this information to be shared with SPCT.
• The partners attended “Complex Needs Training” facilitated by St Anne’s hospice which provided opportunities to build links and connect communities to support for people experiencing homelessness with advanced ill and terminal health.
• Lucy’s temporary accommodation was furnished ground floor, accessible accommodation provided by ForHousing housing association, as part of a small portfolio of properties for this pilot. Salford City Council provided floating housing related support with the worker having a small caseload. This was not closed during her repeated admissions to hospital. This allowed her to be discharged to an appropriate property and all onward referrals would remain in place, such as district nurses and adult social care packages of care.
• Lucy’s wishes were upheld. When Lucy asked to be discharged to the flat for end-of-life care this happened with the wrap around support of the partners. When this was no longer sustainable Lucy was involved in the decision to be admitted to a hospice and have her family around her in her last weeks.
• The Out of Hospital Care Model was supported by Pathways Partnership Program, which allowed the partnership to receive monthly supportive calls and attend relevant training offered by Pathways. This consultation supported the interventions offered to be evidence based and allowed the model to be best practice in line with similar national models.
• Insights and Impacts
• Sadly, Lucy is not unique in being a homeless person with various needs struggling to access all required universal services due to their situation.
• Evidence has shown that homeless people have trimorbidity (physical health, mental health, substance misuse), are 50 times more likely to have Hepatitis C than the general population (Beijer, U, et al, 2012) and are more at risk of early onset frailty (Pathways, 2020). The DOH (2010) found homeless people are 3 times more likely to be admitted to hospital and stay in 3 times as long as those who are not homeless.

Homeless Link Homeless Health Needs Audit (2022) found that homeless people are almost 3 times more likely to report having a longstanding illness, disability, or infirmity than the general population and most of those with a diagnosed physical health condition are managing multiple comorbidities. Groundswell (2020) survey showed that 59% of women reported their health had contributed to them becoming homeless.

In 2013 it was reported that 70% of patients who were homeless were discharged from hospital to the streets without having their care and support needs addressed (Cornes, M. et al, 2021) and in 2022 it was found that for those who had been admitted to hospital nearly a quarter (24%) had been discharged to the streets (Homeless Link, 2022).

Having the partnership working together via the Out of Hospital Care Model meant that Lucy did not have to navigate the complicated homelessness and health and social care system alone. She had mental health, physical health, housing, and substance misuse professionals to assess, support, advocate and promote her needs through her end-of-life pathway.

Lucy did not have to risk being ill on the streets, nor having to be brought back into hospital without a suitable discharge option or having a delayed discharge due to lack of accommodation. Lucy did want to self-discharge due to a trauma response to being in hospital, but this was explored and reduced at times by multi-agency working and shared formulation and communication.

Unfortunately, due to the chronic nature of Lucy’s health the intervention did not improve her physical health, but it did allow Lucy (and her family) to have a dignified end of life, without the risk of street homelessness, with her wishes upheld and all services working in a joined-up response.

The partnership accessed specific training to support their practice and was able to provide specialist advice to the other services involved to support knowledge and decrease any discrimination born out of a lack of knowledge and understanding of co- occurring conditions.

• Revolving Doors (2019) published a capability framework for working with people who have co-occurring mental health and alcohol and/or drug use conditions (COMHAD). The out of Hospital Care Model demonstrated it met all aspects of the framework:
• Values - showing compassion and empathy.
• Effective management - flexible, person centred, assertive outreach.
• Right care, right time - no wrong door.
• Working effectively and collaboratively with multiple agencies - effective local pathways, information sharing processes and partnership working.
• Working with families, carers, and significant others - recognising their own challenges and support needs.
• Physical health and health promotion - preventing further poor physical health and treating current issues.

Cornes, M et al (2017) looked at how to improve outcomes for people, including homeless people in intermediate care. The study concluded the following principles, which have been evident in the out of hospital care model in Lucy’s case:

• Engagement work - working in consultation with Lucy around care planning, including decisions about the place of care and transitions to it.
• Lucy’s physical reablement and broader health and well-being objectives were promoted by health, housing, and social care professionals as best they could.
• Health, housing, and social care professionals worked together making sure local advocacy support was available.
• During the critical transitional periods of Lucy’s care there remained a continuity of care.
• What people said

Lucy had told SPCT that she just wanted to get out of hospital and was happy with the accommodation offered via ForHousing and Salford City Council, commenting that she “loved it”.

Lucy’s sister asked GMMH dual diagnosis practitioner and Salford City Council housing support worker to come to Lucy’s funeral and thanked them for all the support, saying how much it meant to Lucy and the family.

SPCT said that this case study is a powerful example of the importance of teamwork, not only between the enhanced Pathway team that the Out of Hospital Care Model allowed for but also with the larger MDT community that helped to develop training.

The GMMH dual diagnosis practitioner said that they felt proud and privileged to be able to develop such a strong and trusting relationship with Lucy, who lacked such relationships particularly towards the end of her life. They were proud to be able to advocate for her at the end of her life and ensure that her care was as dignified and as aligned with her wishes as it could possibly be.

Salford City Council said that this way of working provided accommodation with a level of security, certainty, safety, and stability to a vulnerable person in an upsetting situation that wouldn’t have been immediately offered by other temporary accommodation routes.

• Tips for success
• Working in a homeless partnership model supported by 2021 NICE Guidance: NG214.
• Weekly MDT.
• Carer/family involvement.
• Seeking consultation and advice from specialist organisations.
• Making advocacy essential.
• Seeking to build relationships, challenging working cultures and any discriminatory practices.
• Making training mandatory and promote training to outside agencies.
• Looking after staff through a trauma informed way of working - offering reflective practice and debriefs due to the emotional aspect of working with someone at the end of life. The partners facilitated a session on grief and loss with the homeless community after Lucy’s death.

Lessons learned were around how to seek buy-in to multiagency working from larger organisations, understanding the stressors on the wider system and how this can be a barrier to achieving the desired outcomes.

• What next?
• Funding for this pilot has now ended but the partners continue to provide specialist support for homeless people in Salford, including those who are discharged from hospital.
• The partners attend a weekly wider MDT facilitated by SPCT.
• Salford City Council can refer any homeless person experiencing barriers in accessing universal services for support with their mental health and drug and alcohol needs to GMMH for assessment, support, and treatment. This has funding until March 2025 from the Rough Sleeper Initiative.

We believe this case study meets all the following principles:

1) Commit to action on inclusion health

2) Understand the characteristics and needs of inclusion health groups locally

3) Develop the workforce for inclusion health

4) Developing integrated and accessible services for inclusion health

5) Demonstrate impact and improvement for inclusion health

References:

Beijer, U et al (2012) Prevalence of tuberculosis, hepatitis C virus, and HIV in homeless people: a systematic review and meta-analysis. The Lancet Infectious Diseases; 12:11, 859–870

Cornes M, Aldridge RW, Biswell E, Byng R, Clark M, Foster G, Fuller J, Hayward A, Hewett N, Kilmister A, Manthorpe J, Neale J, Tinelli M & Whiteford M (2021) Improving care transfers for homeless patients after hospital discharge: a realist evaluation. Health Services and Delivery Research Volume: 9, Issue: 17.

Cornes, M, Whiteford, M, Manthorpe, J, Neale , J, Byng, R, Hewett, N, Clark, M, Kilmister, Fuller, J, A, Aldridge, A, Tinelli, M. (2017) Improving hospital discharge arrangements for people who are homeless: A realist synthesis of the intermediate care. Health and Social Care in the Community, vol. 26, Issue 3.

Department of Health [Office of the Chief Analyst] (2010). Healthcare for single homeless people. London: Department of Health.

Groundswell, (2020), Women, Homelessness and Health: A Peer Research Project. Available at: https://groundswell.org.uk/wp-content/ uploads/2020/02/Womens-Health-Research-Report.pdf

Homeless Link (2022) Unhealthy State of Homelessness 2022: Findings from the Homeless Needs Audit. Available at: Homeless_Health_Needs_Audit_Report.pdf (kxcdn.com)

NICE (2021) Guideline: Integrated health and care for people experiencing homelessness. Available at: https://www.nice.org.uk/guidance/ng214/documents/draft-guideline

Pathways, (2020), Premature frailty, geriatric conditions and multimorbidity among people experiencing homelessness: a cross-sectional observational study in a London hostel. Available at: https://www.pathway.org.uk/wp-content/uploads/Fraility-research-paper.pdf

Revolving Doors (2019) Capability Framework: Working effectively with people with co-occurring mental health and alcohol/drugs conditions. Clinks. Available at: Capability-Framework-FINAL-3.pdf (revolving-doors.org.uk)