Call for evidence - inclusion health

Case Studies

• Islington Homeless Health Inclusion

  by Clare Driscoll, almost 3 years ago

  Across the country, people experiencing homelessness (PEH) suffer from some of the most severe health inequalities and face significant barriers in accessing health and care services when compared with the general population. Indeed, PEH die 30 years earlier than the average UK adult, and nearly one-third of deaths are from preventable and treatable conditions.

  PEH face specific challenges in accessing mainstream primary care services due to inflexible service times, unstable or transient accommodation, lack of continuity of care, fragmented services and a lack of awareness by healthcare practitioners as to the complexity of PEH needs. This results in PEH disproportionately... Continue reading

  Across the country, people experiencing homelessness (PEH) suffer from some of the most severe health inequalities and face significant barriers in accessing health and care services when compared with the general population. Indeed, PEH die 30 years earlier than the average UK adult, and nearly one-third of deaths are from preventable and treatable conditions.

  PEH face specific challenges in accessing mainstream primary care services due to inflexible service times, unstable or transient accommodation, lack of continuity of care, fragmented services and a lack of awareness by healthcare practitioners as to the complexity of PEH needs. This results in PEH disproportionately relying on acute health services, impacting the NHS by an estimated £85m annually.

  To respond to this in Islington, NCL ICB Inequalities Funding is being used to deliver an inclusive Homeless Health Inclusion programme known as the Islington Hostel Outreach GP service. The service has three primary aims:

  • To identify and treat the physical needs of people experiencing homelessness (PEH)
  • To understand the physical health needs of PEH in Islington
  • To support a culture change with regards to mainstream primary care interactions with PEH

  The Islington Hostel Outreach GP Service is staffed by 4 GPs and 1 Outreach Nurse who provide a mix of Hub based clinics and 'roaming' cluster clinics (Hostels visits). Each of the GPs work closely with a specific cluster of hostels in geographical proximity. The Outreach Nurse works closely with each cluster of hostels and has strong links at the service Hubs on Seven Sisters Road (Solidarity Hub), Stacey Street Hostel Hub and runs a weekly women only drop-in clinic. The service clinical lead provides a monthly GP and nurse drop-in clinic at Solidarity Hub with a range of pre-bookable and drop-in access slots.

  In this way, the service provides high quality medical care for residents in local Islington Hostels and persons currently homeless or at imminent risk of homelessness who are based in Islington. The service team seek to enable improved access to primary and secondary care services for service users and strengthen ties with service users and their registered GP practices. Service users who do not currently have a registered GP are supported to register with a local practice.

  This model allows the clinical team to offer a wide range of health offers including long-term chronic condition reviews, wound care, cervical screenings, and onward referrals to community/ secondary care services.

  After an initial service scoping engagement exercise with PEH group who regularly attend a local day centre, the Islington Hostel Outreach Service was piloted in 2022/2023 and has now received renewed Inequalities Funding from NCL ICB to continue in 2023/2024. Over the course of the pilot, the team conducted 114 consultations and supported 20 patients to register with an Islington GP surgery. During these consultations, 65 onward referrals were made to secondary care (including two ‘2 week wait’ suspected cancer referrals), community services and other local services. Estimates suggest that 3 emergency department attendances and 4 GP call outs have been prevented by the services. Furthermore, 68% of all contacts in the pilot were the result of opportunistic engagement, underlining the importance of taking the care to the patient with people experiencing homelessness.

• Providing healthcare and screening for asylum seekers residing in short term accommodation in Hounslow

  by Ellie Tobin, almost 3 years ago

  The ICB Borough Team in Hounslow, alongside Little Park Surgery in Feltham have worked in collaboration to co-design, deliver at pace, and continually evaluate a new model of delivering outreach healthcare for asylum seekers residing in short term hotel accommodation in the borough. These sites are different than the IACs commissioned by the Home Office, and are an “overnight” initial accommodation prior to dispersal into IAC hotels around the country. When established, there was no specialist healthcare provision commissioned for these settings, which despite being intended for overnight stays could see people residing for up to a period of weeks... Continue reading

  The ICB Borough Team in Hounslow, alongside Little Park Surgery in Feltham have worked in collaboration to co-design, deliver at pace, and continually evaluate a new model of delivering outreach healthcare for asylum seekers residing in short term hotel accommodation in the borough. These sites are different than the IACs commissioned by the Home Office, and are an “overnight” initial accommodation prior to dispersal into IAC hotels around the country. When established, there was no specialist healthcare provision commissioned for these settings, which despite being intended for overnight stays could see people residing for up to a period of weeks with no healthcare access. As such, the system started to see significant demand on 111, 999, UTC and ED, including for routine and minor primary care issues as no one yet had NHS numbers so could not register with GPs. The ICB and the local practices worked together to design a model of on-site care delivery in the hotels, to build trust and rapport with the residents, to support them with immediate and necessary healthcare needs.

  The service has been successful not only in improving individuals' welfare, improving immediate access to healthcare upon arrival into the UK, but A&E attendances from hotel are now down by more than 60%, with improved 111 call handling rates too. The team have worked together with Public Health to improve access to NHS numbers, catch ups to the UK immunisation schedule, and providing immediate and necessary care for individuals in these settings, including communicable disease response in collaboration with UKHSA. This has also allowed identification of need prior to dispersal into hotels around the country. Patient feedback has been very positive also.

  The learning from this service has helped to shape service design across NW London for this cohort

• Homeless Step Down Pathway Case Study 9

  by Teri Milewska, almost 3 years ago

  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... Continue reading

  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.

  Housing support continuation

  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 phot 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

  Discharge planning

  • 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)

• Homeless Step Down Pathway Case Study 8

  by Teri Milewska, almost 3 years ago

  Social History

  The patient, T has no partner nor dependents, was homeless and then went to prison. He was released on 22/12/2020 and has been sleeping rough. Smokes- 20-40 cigarettes a day, Alcohol, 8-16 cans of lager daily plus Intravenous Drug User (IVDU) Heroin.

  Past and Present Medical History

  Chronic Obstructive Pulmonary Disease (COPD),

  Schizophrenia, Personality Disorder, Hepatitis C,

  Bilateral Femoral Deep Vein Thrombosis and

  Infected Right Venous Ulcer for 4 years

  Drug History

  T is on Thiamine 100mg three times daily, Vitamin B Compound Strong 2 three times daily, Paracetamol 1g 4 times daily when required, Apixaban 5mg twice... Continue reading

  Social History

  The patient, T has no partner nor dependents, was homeless and then went to prison. He was released on 22/12/2020 and has been sleeping rough. Smokes- 20-40 cigarettes a day, Alcohol, 8-16 cans of lager daily plus Intravenous Drug User (IVDU) Heroin.

  Past and Present Medical History

  Chronic Obstructive Pulmonary Disease (COPD),

  Schizophrenia, Personality Disorder, Hepatitis C,

  Bilateral Femoral Deep Vein Thrombosis and

  Infected Right Venous Ulcer for 4 years

  Drug History

  T is on Thiamine 100mg three times daily, Vitamin B Compound Strong 2 three times daily, Paracetamol 1g 4 times daily when required, Apixaban 5mg twice daily plus Methadone 40mg/40mls daily, and nicotine replacement therapy.

  Reason for Admission/Referral:

  Step down as a Homeless patient as he was Covid-19 Positive. Nursing management of right infected venous leg ulcer.

  Presentation on Admission at Mildmay Mission Hospital

  T arrived mobilising independently. He was oriented to time, place and person. Vital signs were stable.

  Since admission, T has received services in Mildmay Mission Hospital from the various multi-disciplinary (MDT) members. These including:

  Physiotherapy sessions which in most cases declined to participate.

  The Housing officer has engaged with him in numerous occasions for housing application.

  Dietician input. Weight as at 06/02/2021 was 65.9kg. (TS) weight on the 13/02/2021 was 68.8kg.

  T also had the chance to be given Nicotine Vape on request by staff.

  Daily wound dressing commenced on the day of admission with the following: -

  Wound being irrigated by Prontosan

  Urgotul Ag Silver use as primary dressing

  Padded with Xupal

  Wound then secured with K-Soft and Crepe Bandage.

  On admission, the wound was measured as follows;

  Right Lateral aspect of the leg =10cmx5cm

  Right Medial aspect of the leg =11cmx6cm

  Wound as at 09/02/2021 measured as follows;

  Right Lateral aspect of the leg=9cmx4cm

  Right Medial aspect of the leg=5cmx4cm.

  T has been very happy and grateful to the staff at Mildmay as this is the first time in four years that, he has seen a significant improvement of his leg ulcer, he also reported that since his admission at Mildmay he feels that he is treated as a human being.

  Written by Kobe Kwateng Staff Nurse

• Homeless Step Down Pathway Case Study 7

  by Teri Milewska, almost 3 years ago

  This is a brief outline of how a patient with a working diagnosis of Schizophrenia and Emotionally Unstable Personality Disorder (EUPD) was managed at the Mildmay. Patient Q, called this for confidentiality, was a 36-year-old man with a diagnosis of Schizophrenia for about 15 years. The Schizophrenia was being managed on high doses of Clozapine. He was referred to the Mildmay Hospital by the Homeless Team through Homeless Care Pathway.

  He had delusional beliefs, and periods of great excitability, anger and frustrations, and periods of deep depression. He had suspected personality disorder and history of behavioural issues. He also had... Continue reading

  This is a brief outline of how a patient with a working diagnosis of Schizophrenia and Emotionally Unstable Personality Disorder (EUPD) was managed at the Mildmay. Patient Q, called this for confidentiality, was a 36-year-old man with a diagnosis of Schizophrenia for about 15 years. The Schizophrenia was being managed on high doses of Clozapine. He was referred to the Mildmay Hospital by the Homeless Team through Homeless Care Pathway.

  He had delusional beliefs, and periods of great excitability, anger and frustrations, and periods of deep depression. He had suspected personality disorder and history of behavioural issues. He also had an alcohol habit in excess of 6-8cans /day. He was referred whilst living in an accommodation-based service (mental health residential setting) where he did not wish to stay. Prior to that he had been in hospital for 2 months where he had had several procedures done on his knee culminating with him having a high knee brace in situ and mobilising on elbow crutches. While his mental health was not always stable and a risk of suicide was identified, he agreed with his care team that the risk was not necessarily increased by his living in the community. His ability to cope was at risk if he was unwell. His plans were to move on to live independently in the future but expected low level regular support for the time being, and a responsive and increased level of support from time to time when needed.

  On the ward, his behaviour was erratic, impulsive, intense and unpredictable. His mood had intense episodes of anxiety, irritability and dysphoria. Several times, especially late at night or early mornings, he would call emergency services to inform them he wanted to harm or kill himself. On several occasions, Ward staff had to deal with concerns expressed by emergency services personnel with regards to his safety. When staff attempted to reassure him, he would become verbally aggressive and would use some explicit racial terms to describe staff. Considering his threats to harm himself and suicidal ideation, his bedroom had had to be stripped and potential risk items removed. He once attempted to hit a member of staff with one of his crutches. Sometimes he would refuse to take his medication, especially in the mornings. He did not want to be woken up for his medication, and it was unsafe to leave it for him to take it later. His girlfriend once called the ward, and her input was quite helpful to staff in managing his moods and behaviours.

  Medical staff eventually adjusted the times he took his medication to accommodate his wishes for uninterrupted sleep. Being on Clozapine meant he had to have strictly regular blood tests. He was on very high dosage of it. Medical staff ensured he was registered with the Clozapine Patient Monitoring Service (CPMS). In his case, it was every 4 weeks. The patient used to decline to have his bloods taken by a nurse as he preferred Doctors. Sometimes Doctors’ schedules meant they will not be able to do bloods on due days. Contingent measures had to be put in place in such situations to ensure bloods were done on time.

  There were some guidelines to be followed with regards to Clozapine administration:

  • Clozapine should NOT BE ADMINSTERED if the blood tests issued a RED blood result.
  • If there is a break in treatment of 48 hours or longer the dose must be titrated up again from 12.5mg.
  • If a break of more than 72 hours, blood tests will need to be done weekly again for a few weeks.
  • Repeat glucose levels, LFT and blood lipids every 3 months.

  After various inputs from the MDT during his period of admission, he appeared more manageable and was eventually discharged to a place of safety.

• Homeless Step Down Pathway Case Study 6

  by Teri Milewska, almost 3 years ago

  Julie – name change.

  Julie is a 47year old woman who has had a history of problematic drinking for many years, which required a medical detox. She had been admitted to Guys & St Thomas hospital to complete a planned detox, which went very well and was complete within the expected time.

  Julie was due to go straight to rehab from detox which was all set up. However, as she had been able to complete the detox 7 days ahead of schedule, a referral was made for her to come to Mildmay for the 7 days to stabilise and rest... Continue reading

  Julie – name change.

  Julie is a 47year old woman who has had a history of problematic drinking for many years, which required a medical detox. She had been admitted to Guys & St Thomas hospital to complete a planned detox, which went very well and was complete within the expected time.

  Julie was due to go straight to rehab from detox which was all set up. However, as she had been able to complete the detox 7 days ahead of schedule, a referral was made for her to come to Mildmay for the 7 days to stabilise and rest. This was agreed and Julie arrived here at Mildmay feeling good about the detox but anxious about coming to a new place.

  We talked about what she can expect being at here and what is expected of her. This relieved some of the anxiety and she was able to settle quickly. She agreed to not leaving the hospital without an escort as she understood this could put her at risk of relapse.

  We went to the shops a few times and it was the run up to Christmas and she wanted to send out cards before going to rehab. These trips went well and Julie was able to talk through any difficulties she was having while being out of the more secure surroundings of Mildmay.

  After the 7 days Julie went off to rehab with the accompaniment of her external key worker.

  Her worker let me know that Julie got there safely.

• Homeless Step Down Pathway Case Study 5

  by Teri Milewska, almost 3 years ago

  Lucy – name changed.

  Lucy is a 41yr old woman with a history of crack and heroin use. She was severely underweight and had not been adhering to her HIV treatment. She also had some gynae issues and needed a total tooth extraction due to severe decay.

  She had been prescribed methadone by the external drug and alcohol service to help her to stop using heroin. As she stopped needing to buy heroin to avoid opiate withdrawal symptoms, this enabled her to stop buying crack as well. She then maintained a drug free status which enabled her to work towards... Continue reading

  Lucy – name changed.

  Lucy is a 41yr old woman with a history of crack and heroin use. She was severely underweight and had not been adhering to her HIV treatment. She also had some gynae issues and needed a total tooth extraction due to severe decay.

  She had been prescribed methadone by the external drug and alcohol service to help her to stop using heroin. As she stopped needing to buy heroin to avoid opiate withdrawal symptoms, this enabled her to stop buying crack as well. She then maintained a drug free status which enabled her to work towards going to rehab.

  In order to be accepted into rehab she needed to detox from methadone. The external service organised the funding for her to complete a methadone detox in Guys and St Thomas. It was also agreed that due to Lucy’s other health issues she would benefit from a period of time here at Mildmay, where she would have the opportunity to stabilise and address some of the other health issues before going to rehab.

  I was able to visit Lucy during her detox at GSST to introduce myself and to give her some information regarding her admission to Mildmay. She felt this relieved some of her anxiety about coming to a new place and having someone to meet her that she had met helped with the transition

  On admission to the Mildmay hospital she was still struggling with some effects of the detox such as not being able to sleep and she had some vomiting. She was able to get her circadian rhythm back in the first few weeks and the vomiting past in the first days.

  Lucy attended the relapse prevention group and 1-1 sessions that supported her in maintaining abstinence from drug use. Initially she was quiet and didn’t feel able to contribute much in the groups. She was concerned about how other people viewed her, but over the weeks her confidence grew and she became an active member. She was able to offer insight into some of her own issues, as well as supporting other group members, with topics that they had struggled with.

  Lucy started taking her medication more regularly and attended her appointments at the dentist and gynaecology departments at other hospitals. At first I attended with her as she didn’t feel confident about going on her own but I stopped going when she felt strong enough and didn’t need me to be with her. Her trips out on her own went well with no issues.

  Her stay here also provided her with the opportunity to see her daughters regularly, to improve the relationship with them. This was important to her as she felt that she would then be able to focus on herself in rehab.

  She informed me that had she gone straight to rehab from the detox she may not have been able engage from the start, but now she is stronger and feels that she will be able to participate and get the most out of it.

  She was discharged from Mildmay with no issues and went in a taxi with her external key worker to rehab as planned.

  Theresa Hibbert

  (Drug and Alcohol worker)

• Homeless Step Down Pathway Case Study 4

  by Teri Milewska, almost 3 years ago

  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... Continue reading

  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)

• Homeless Step Down Pathway Case Study 3

  by Teri Milewska, almost 3 years ago

  John (name changed) is a 56yr old, single, street homeless male who has a significant history of addiction to inhaling lighter gas and alcohol. He had been admitted to hospital after accidentally setting himself on fire while using gas, which resulted in significant burns to his legs and pelvis area. He remained in an acute inpatient hospital for 3 months receiving treatment. The treatment included skins grafts and a stoma was fitted as his bowels where also damaged by the fire.

  Once John was at a stage where he was able to continue healing but not well enough to return... Continue reading

  John (name changed) is a 56yr old, single, street homeless male who has a significant history of addiction to inhaling lighter gas and alcohol. He had been admitted to hospital after accidentally setting himself on fire while using gas, which resulted in significant burns to his legs and pelvis area. He remained in an acute inpatient hospital for 3 months receiving treatment. The treatment included skins grafts and a stoma was fitted as his bowels where also damaged by the fire.

  Once John was at a stage where he was able to continue healing but not well enough to return to the community he was referred to Mildmay on the detox pathway for 12 weeks. The aim for this was to start addressing his drug addiction issues and to provide on going burns care.

  John initially struggled to settle here and was often aggressive with outbursts of angry and abusive language. He often talked about having violent thoughts and voices that tell him to harm people. The people that he had violent thoughts towards could be anybody in his immediate surroundings to a person from his past. The MDT regularly discussed concerns and reviewed the risk assessment regarding the violent thoughts and potential danger to himself and staff. It was agreed that as he was able to explain when he was having these thoughts, staff were able to maintain a safe distance when he was in a heightened mood but able to continue to work with him.

  He was keen to talk about his history and went into great detail about his experiences. While John talked about something that had happened in the past his mood often became elevated and he expressed himself in a way that showed a high level of emotion that had not seemed to have reduced over time. It was like the event had happened yesterday. This appeared to be very stressful for him but he explained that talking about his story was helping him to understand the things he has been through.

  John engaged well in the Relapse Prevention Group and has attended every session. It was evident that John wants to address his issues and has made an effort to understand the topics. He explored his drug using history and worked on developing other coping strategies that could help him make more positive choices in the future. He also engaged very well with mindfulness practices and he explained that having a direction for his thoughts reduces the negative thoughts he has.

  In addition to drug and alcohol support he also engaged with the Mildmay psychologist who explored more skills that could help him manage his anger.

  Over the time that John has been here at Mildmay his aggressive behaviour has reduced significantly. He has begun to learn how to communicate in a more assertive way so that he gets a better outcome than aggressive. He also feels that going to rehab is a real option, now that he is more able to manage his thoughts. Also, being around other patients here has benefitted him in that he has had an opportunity to develop the ability to interact with others in a positive way. His family has also started to re-establish their connections with him, which he feels very happy about. Having his family around him has given him extra motivation to address his addiction issues.

  As a result of John’s progress here at Mildmay, his external service key worker has recognised this and has felt able to refer him to traditional residential drug and alcohol rehabilitation which has been something that John is keen to go to. This had previously not been an option due to John’s aggressive behaviour.

  The plan is that John will be having his stoma reversed in the next few weeks, in an acute hospital then return to Mildmay for a recovery period of 2 weeks. He will continue with the addiction work while he is here until he has an admission date for rehab. Coming back to Mildmay after the operation will allow John to be in familiar surroundings with staff that he has developed working relationships with, which will increase the likelihood of a smooth transition to rehab.

  Theresa Hibbert

  Drug and Alcohol worker

  Mildmay Mission Hospital

• Homeless Step Down Pathway Case Study 2

  by Teri Milewska, almost 3 years ago

  CASE STUDY 2

  SOCIAL BACKGROUND:

  Patient was a Nigerian National who came to the UK on a student visa in 2012. CN applied for settlement 20 Mar 2013, but his application was rejected. Unknown to the patient, he did not know the reason/s why. He was previously homeless, sleeping on buses in London and the Brent area. He also lived in Croydon working cash in hand as a gardener. He has three siblings living in Nigeria but no contact.

  MEDICAL SUMMARY:

  CN was admitted to the Mildmay with the following medical issues.

  Newly dx retroviral

  Right cerebellar subacute infract

  Low... Continue reading

  CASE STUDY 2

  SOCIAL BACKGROUND:

  Patient was a Nigerian National who came to the UK on a student visa in 2012. CN applied for settlement 20 Mar 2013, but his application was rejected. Unknown to the patient, he did not know the reason/s why. He was previously homeless, sleeping on buses in London and the Brent area. He also lived in Croydon working cash in hand as a gardener. He has three siblings living in Nigeria but no contact.

  MEDICAL SUMMARY:

  CN was admitted to the Mildmay with the following medical issues.

  Newly dx retroviral

  Right cerebellar subacute infract

  Low mood and

  Leg pain

  IMMIGRATION SUMMARY AND SUPPORT:

  He previously made an application to the Home Office, but this was rejected, but unknown to the patient, he did not know the reason/s. He was admitted to the Mildmay on the 29/3/2022 on the homeless pathway. However, during his housing assessment, it was later established he had limited options due to non-status and referred to Hackney Migrant Centre for immigration advice. He was given a few appointments to discuss his immigration issues and health to establish what support could be offered to him. A subject of access request was also made to the Home Office to request, but as advised, could take some time. Hackney Migrant had to wait about 2 months, before his file was received.

  Hackney Migrant was also looking at legal reps to support in making an Article 3 application to the Home Office, after receiving information from Islington Law, based on his mental and physical health, that he does have grounds to make an application.

  SOCIAL WORK INVOLVEMENT:

  CN was initially assessed by Mildmay to establish whether he had a case to be referred to Brent for a Care Act assessment to be done. He was very guarded with his information and extremely isolated. He was referred to Brent social services to request for a Care Act Assessment to be completed, based on his mental and physical health. However, Brent had advised that CN did not have any care and support needs, but no feedback to the patient on the outcome. A complaint was put to Brent social services to request for a letter to be sent to the patient, but no response. Brent social services also established that his main last address was not in Brent, therefore, not an ordinary resident and had no local connection.

  The patient was also offered VRS (voluntary return service) back to Nigeria, but the patient declined the offer.

  Research was also done to see whether if he returned back to Nigeria, he could be provided with HIV care, which was found to be free, but this would depend on other factors, such as his resettlement after so long, stigmatization, employment and self-management.

  HOUSING SUPPORT:

  During his time at the Mildmay, the patient was referred to a number of external agencies who work with people with no recourse, refugees and migrants. However, due to the fact that his initially application to the Home Office was rejected, some were unable to offer any support and advised to get immigration advice. Other services only provided support, but no accommodation. There were also others, who were unable to accept, as he was not eligible for the service.

  The patient was spoken to on a few occasions, about VRS and his very limited options in finding accommodation. He was also advised to think about friends he may be able to stay with.

  Night shelters were also contacted, but they were not yet available due to time of year. The passage in Victoria was also contacted to discuss about his situation and whether they were able to assist, but unfortunately, they could not.

  DISCHARGE PLANNING:

  • Due to length of time at Mildmay, discharge planning meetings was held with Hackney Migrant centre, SW and Housing, to establish what other practical solutions we could come up with to support the patient, being that he had been referred to a number of services.
  • It was established that due to very limited options, that Hackney Migrant would look at sourcing hosting schemes and referral to Hackney Night shelter.
  • MDT report was also provided to Hackney Migrant, to provide clarity on the patients’ physical and mental health.
  • Housing worker will continue to look at other services, not already researched.
  • Continual discussions with patient about his discharge and for him to revisit the options that was given to him
  • To encourage to get out and about due to long spells of isolation

  CHALLENGES:

  ACCOMMODATION OPTIONS AVAILABLE

  RESOURCES

  CRITERIA’S FOR POSSIBLE SERVICES

  FEEDBACK FROM SERVICES (BRENT SOCIAL SERVICES)

  LIMITED INFORMATION FROM PATIENT

  CLARITY OF CIRCUMSTANCES

  FUNDING

  DELAYS IN RESPONDING

  Case studies written by Sheila James

  Housing Officer