“Quite often people are in hospital and they’ve got nothing: no food, no clothes, no toiletries,” says Kate Gillespie, Derventio Housing Trust’s strategic lead for its Healthy Futures initiative. “We get all that sorted out, so people at least have a bit of dignity when they are discharged.”
That’s just the start of the scheme’s work with homeless people due to leave hospital. Many have multiple, complex needs, such as mental health problems and addictions, and are trapped in a vicious cycle of ongoing health issues and repeat admissions.
Over a 12-week period, staff work intensively to find housing for patients, settle them into their new homes and help them live independently – while making better use of primary care, rather than relying disproportionately on acute services.
“Sometimes it’s because they don’t manage their health, so they actually get ill enough to need to go in [to hospital] all of those times,” Gillespie says. “We’ve also got people who are going in because it’s their social contact. They’re so isolated that the only kind of love and nurture they get is a trip to A&E, where they get a sandwich and a cup of tea and a ‘there, there’ from the nurses. When someone has nothing else they’re going to keep coming back for it.
“It’s like they’ve got a dependency on acute care. We transfer that dependency to us, and then take the time to wean them off it. If we get someone who’s in A&E three times a week, the next step down from that is a walk-in centre. Then their GP, then the pharmacy.”
Healthy Futures, which also offers brief interventions to help with the timely discharge of inpatients with less complex housing and support needs, has worked with more than 330 patients since it began in October 2013. Some 170 patients have received ongoing community-based support.
In the six months before becoming Healthy Futures clients, those patients had been admitted to acute beds on 487 occasions, had gone to A&E 616 times, and had called 999 and been taken there by an ambulance 364 times.
The project has led to an 88% fall in avoidable admissions of clients, a 90% drop in clients’ visits to A&E, and 84% fewer 999 ambulance transfers. Hospital stays have also been cut by an average of 16 days. Two thirds of patients felt their physical health had improved, and the same proportion reported better mental health.
Healthy Futures’ achievements come despite working in a climate of cuts to adult social care, at a time when finding housing is harder than ever. Key to getting funding has been its use of robust data proving its impact and efficiency. Patients give consent for their health records to be accessed, so their use of acute care before working with the project can be tracked – and commissioners can clearly see the positive effect.
Great staff are also vital, Gillespie says. “They’re just amazingly capable and patient and resourceful. I’m immensely proud of them.”
Guardian Public Service Awards 2016 health and wellbeing winner: Deventio Housing Trust
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