The Multi-disciplinary Team: START Homeless Outreach Services

The START Homeless Outreach Services work across South London and are an integrated health and social care multi-disciplinary team for rough sleepers and people living in hostels, in 3 boroughs. They are funded by the 2 local ICBs as well as NHSE and OHID and provide both mental health and dual diagnosis care for people with co-occurring conditions. This is delivered by using a relationally focused outreach approach that works across transitions, to achieve recovery, stable housing and an eventual transfer back into mainstream care.

The teams are made up of social workers, psychiatric nurses, OTs, psychology and psychiatry, peer support, nurse prescribing and GP trainees and can offer medication, Care Act assessment, formal safeguarding, admission to hospital, application to Court of Protection, physical health care, referral to specialist residential care or rehabilitation as well as therapy and practical support. This is all available after a period of pre-treatment aimed at engagement and developing trust so that successful outcomes are more likely and is carried out by staff outreaching new clients in an intensive and engagement focused manner. The teams also act as a bridge between the third sector and statutory services, supporting and educating the former and advocating to and acting as inclusion health leads to the latter.

The team is featured in the NICE Guidance for practitioners as an example of integrated health and social care made accessible for homeless people.

Data is captured for the pilot teams funded by NHSE and OHID and demonstrates encouraging outcomes in improving accessibility of mental health and substance use care, reducing homelessness and increasing positive move on and a reduction in use of emergency health care and criminal justice contact. These findings and the approach of the team are being shared across partners in health and homelessness forums in London and the service model has been influential in several newly commissioned teams both in and outside the capital.

The following case studies provide a flavour of the approach and work:

Shelly is a 35 year old Somali woman with a history of early trauma. She lost her flat and son after an episode of post-natal illness, was not seen by mainstream services and ended up street homeless. She was evicted repeatedly from hostels and TA for assaulting staff in what appeared to be highly dysregulated states, but was seen as having substance misuse issues. She was unable to engage with any mental health care or assessment. The team care coordinator started working with Shelly when she moved into an Assessment Centre and built a positive, confiding relationship based on understanding her early experiences, tolerating resistance to contact and consistent care. This led to a more robust assessment and eventually an inpatient admission. She was diagnosed with Bipolar Affective illness, treated and moved into specialist hostel. She sees her START worker regularly, continues medication, is seeing her sister again and is soon to step down to low support housing.

Key words: engagement, holistic assessment, relational care, assertive treatment

Nicky is a 45 year old Spanish man who is a long term alcohol user and has EUPD. He has been street homeless for many years due to lack of benefits. He has repeated crisis presentations. He was referred by his hostel in a state of profound self-neglect: he was incontinent and his room full of hoarded rubbish. For weeks he just shouted at his social worker: eventually persistence paid off, he was supported to see the hostel GP and clean his room and see the addictions psychiatrist. His SW built a trusting relationship, worked around harm minimisation and after 6 months Nicky went to detox and rehab and was resettled out of London.

Key words: hopefulness, persistence, motivational interviewing, outreach

The teams are hoping to secure long term commissioning through demonstrating the outcomes achieved by this approach and to eventually merge the dual diagnosis and mental health sub teams into one overarching, statutory complex needs MDT for homeless clients in South London.