Integrated Health and Social Care for People Experiencing Homelessness

Overview

This Guidelines summary covers providing integrated health and social care services for people experiencing homelessness. For a complete set of recommendations, refer to the full guideline.

General Principles

• Recognise that more effort and targeted approaches are often needed to ensure that health and social care for people experiencing homelessness is available, accessible, and provided to the same standards and quality as for the general population.

Co-design and Co-delivery of Services

• Recognise the value of co-designing and co-delivering services with people with lived experience of homelessness, to improve the quality of health and social care (see the section on the role of peers in the full guideline). See also the section on involving people in service design and improvement in NICE’s guideline on people’s experience in adult social care services and NICE’s guideline on community engagement.

Supporting Engagement with Services

• Promote engagement by providing services that:
  • are person-centred, empathetic, non-judgemental
  • aim to address health inequalities
  • are inclusive and pay attention to the diverse experiences of people using the service.
• Consider using psychologically informed environments and trauma-informed care. Recognise that people’s behaviour and engagement with services is influenced by their traumatic experiences, socioeconomic circumstances and previous experiences of services.

Sustaining Engagement with Services

• Recognise the importance of longer contact times in developing and sustaining trusting relationships between frontline health and social care staff and people experiencing homelessness (see also the fourth recommendation in the section on developing services).
• Promote shared decision making, building self-reliance and using strengths-based approaches to care (also known as assets-based approaches). See also NICE’s guideline on shared decision making.
• Recognise that people experiencing homelessness, especially those with experience of rough sleeping, need services that provide a long-term commitment to care to promote recovery, stability and lasting positive outcomes (see the section on long-term support in the full guideline).

Supporting Re-engagement With Services

• Be aware that some people experiencing homelessness may find it difficult to look after themselves because of their circumstances and may find services difficult to engage with. For people who disengage from or refuse health and social care services:
  • actively support re-engagement
  • enable people to re-engage with services at the same point as they left, if appropriate.

Communication and Information

• Follow the recommendations on communication and information in NICE’s guidelines on:
  • patient experience in adult NHS services
  • people’s experience in adult social care services
  • service user experience in adult mental health
  • babies, children and young people’s experience of healthcare.
• Health and social care staff working with people experiencing homelessness should:
  • be empathetic, non-judgemental and use recovery-oriented language that avoids jargon and acronyms
  • use communication methods based on the person’s preferences, for example, phone call, text message, email, letter, face to face
  • send clear information about contacts or appointments and reminders that reach people in time, and follow up people who do not attend.
• Take into account each person’s communication and information needs and preferences, and their circumstances. For example:
  • provide translation and interpretation services if needed
  • ensure that written information is available in different formats and languages, including Easy Read
  • provide extra support for people with low literacy levels or with speech, language and communication difficulties
  • consider the person’s access to phone or internet.
• Consider involving an advocate to support communication, even when this is not a statutory requirement. This may be someone nominated by the person or an independent advocate who can, for example:
  • support people to overcome stigma and previous negative and traumatic experiences
  • help people with low literacy levels to access information and services
  • reinforce information about available services and appointments.
• Give people experiencing homelessness information about:
  • their rights to health and social care services, including for those with no or limited recourse to public funds
  • how to access health and social care services, including:
    • primary care services and how to register with a GP without a permanent address
    • specialist health services that can be accessed directly, such as maternity, blood-borne virus, drug and alcohol recovery, mental health, sexual health, and family planning services
    • outreach services
    • local authority services, including housing services and social care
  • voluntary and charity sector services.

Planning and Commissioning

Developing Services

• When developing services for people experiencing homelessness, commissioners should:
  • work together to strategically plan and deliver health and social care across larger areas, recognising that people move between areas
  • work with other relevant services, such as prison and probation services and domestic abuse services
  • enable long-term support for those who need it (see the section on long-term support)
  • ensure that health and social care services are designed to meet the level and type of local need (see the section on models of multidisciplinary service provision)
  • define and measure outcomes, including health and social outcomes and service use
  • consider the likely benefits of using long-term contracts for providers
  • support statutory bodies to fulfil their legal responsibilities and use their powers
  • encourage and enable the contribution of peers (experts by experience) in supporting people experiencing homelessness and delivering and designing more effective services (see the section on the role of peers in the full guideline).
• Consider providing services and support aimed at the needs of particular groups of people experiencing homelessness, as appropriate, such as:
  • women (also see the NICE guideline on pregnancy and complex social factors)
  • young people
  • older people
  • disabled people
  • people with no or limited recourse to public funds because of their immigration status
  • LGBT+ people
  • people from different minority ethnic or religious backgrounds.
• Develop strategies across services to improve access to health and social care for people experiencing homelessness. See the section on improving access to and engagement with health and social care.
• Ensure that there are processes to:
  • support people experiencing homelessness to register with a GP and
  • document and address any problems with GP registrations for people experiencing homelessness.
• Consider reducing caseloads and lengthening contact time for health and social care practitioners working with people experiencing homelessness to enable them to use approaches that sustain engagement with services.

Improving Access To and Engagement With Health and Social Care

• Design and deliver services in a way that reduces barriers to access and engagement with health and social care, for example, by providing:
  • outreach services (see the section on outreach services in the full guideline)
  • low-threshold services
  • flexible opening and appointment times
  • self-referral
  • drop-in services
  • ‘one-stop shops’ for multiple services
  • incentives and help to access care, such as transport support, vouchers or digital connectivity
  • advocates (see the fourth recommendation in the section on communication and information)
  • peer support (see the section on the role of peers in the full guideline)
  • care navigation
  • psychologically informed environments and trauma-informed care.
• Do not penalise people experiencing homelessness for missing appointments, for example, by discharging people from the service. Consider seeking specialist help, such as peer supporters or independent advocates, to support the person to attend appointments and re-engage with care after missing appointments (see the section on the role of peers in the full guideline).
• Ensure that people can access help when needed, including through emergency care, and avoid policies that withdraw support and close cases after a standard duration, unless a safe transfer of care to another service has been agreed with the person or the person agrees that they no longer need the service.
• Commissioners and service providers should follow the recommendations on improving access to services in NICE’s guideline on common mental health problems.
• Ensure that people experiencing homelessness with multiple health or social care needs are not excluded from services because of restrictive eligibility criteria. For example, people with mental health problems are not denied access to mental health services because they have drug and alcohol treatment needs (see also NICE’s guideline on coexisting severe mental illness and substance misuse).
• Ensure that people experiencing homelessness who are assessed as frail and in need of social care and support get long-term care packages, including residential care or supported housing, irrespective of their age.
• Ensure that paper or digital forms needed to access health or social care or to get help with NHS costs are readily available and that people are supported to fill them in, including providing translation when needed.
• Ensure that people experiencing homelessness can access online health and social care information and are supported to use online services, for example by providing internet access at places where people experiencing homelessness spend time, such as day centres or hostels.
• Primary care service providers should ensure that people without an address can register with a GP practice, in line with the NHS Primary medical care policy and guidance manual.
• Ensure that frontline health and social care staff who come into contact with people experiencing or at risk of homelessness are able to fulfil their duties under the Homelessness Reduction Act 2017.
• Ensure that frontline health and social care staff are able to identify when a person needs to be referred for specialist homeless health and social care, and that processes are in place to support timely referral.
• Consider moving people up waiting lists for health and social care appointments if they are experiencing homelessness because their circumstances may mean they are at higher risk of deterioration and premature death.

Assessing Individual Needs

• Be aware that health and social care practitioners have a statutory and professional duty to identify immediate risk of harm to self or others. See also the section on assessment and treatment under the Mental Health Act in NICE’s guideline on service user experience in adult mental health.
• Assess the health and social care needs of the person experiencing homelessness. When carrying out the assessment:
  • take into account their capacity, rights to autonomy and self-determination, and any safeguarding issues and
  • avoid unnecessary and potentially distressing repetition of their history if it is already on record
  • involve peers or advocates as appropriate (see also the section on the role of peers in the full guideline).
• Include in the assessment:
  • A comprehensive assessment of the person’s physical and mental health needs (including acute and long-term conditions) and social care needs. This should take into consideration their housing and benefits situation, bearing in mind the need to address health inequalities, and be responsive to diversity, and inclusion needs.
  • Asking if the person has children or dependents and assessing how this affects their needs.
  • Understanding the historical context of their situation, including past psychological trauma and experience of services.
• In assessments to inform a health and social care plan for people who might benefit from high levels of support, use a multidisciplinary approach to enable a comprehensive and holistic assessment of their needs, involving:
  • the person, and their advocate if one is nominated or appointed
  • input from professionals with specialist expertise and practitioners who have detailed knowledge of the person’s health and social care needs, including staff working in homelessness and housing services.
• Use hospital admissions as an opportunity to offer a comprehensive, holistic needs assessment, including referral, if indicated.
• Use the multidisciplinary assessment to inform the local authority-led care and support needs assessment, under the Care Act 2014 (see the section on care and support needs assessment and care planning in NICE’s guideline on people’s experience in adult social care services).
• Review the person’s needs, strengths and aspirations whenever their circumstances change or whenever they request a review, rather than using standard review periods.

Intermediate Care

• Provide intermediate care services with intensive, multidisciplinary team support for people experiencing homelessness who have healthcare needs that cannot be safely managed in the community but who do not need inpatient hospital care. These may be for people who are:
  • discharged from hospital (step-down care)
  • referred from the community who are at acute risk of deterioration and hospitalisation (step-up care).See also NICE’s guideline on intermediate care including reablement.

Transitions Between Different Settings

• Homelessness multidisciplinary teams or leads should support people experiencing homelessness through transitions between settings (such as the street, hostels, Housing First and other supported housing, hospital, mental health services, social care, residential or community drug and alcohol treatment, and custody) and consider providing time-limited intensive support, which includes:
  • having a key practitioner coordinating care
  • building a relationship of trust
  • providing links to services in the community
  • gradually lowering the intensity of support, as appropriate.
• Practitioners in any setting supporting people experiencing homelessness should:
  • ensure that all handovers of care responsibilities are planned and coordinated, and relevant information is shared if agreed
  • offer pre-emptive, structured support before, during and after transitions
  • recognise that people may be vulnerable during periods of transition, but also that there may be opportunities for intervention.
• Clinical teams, working with hospital discharge teams and specialist homelessness multidisciplinary teams, where available, should have procedures to:
  • minimise self-discharge and
  • prevent discharge to the street.If self-discharge or discharge to the street happens, review the circumstances and implement learning.
• For people moving between different care settings, follow the recommendations in NICE’s guidelines on:
  • transition between inpatient mental health settings and community or care home settings
  • transition between inpatient hospital settings and community or care home settings for adults with social care needs
  • transition from children’s to adults’ services for young people using health or social care services.

For recommendations on housing with health and social care support, safeguarding, long-term support, and staff support and development, refer to the full guideline.