Pathway teams for multiple exclusion GP & Nurse Led Multidisciplinary Care Coordination Teams for Homeless Patients with Complex Needs Dr Nigel Hewett OBE FRCGP London
3rd International Street Medicine Conference Houston Texas 2007
University College London Hospital
Needs Assessment
Homelessness is a health problem Homeless patients in England attend A&E 5 times as often as the housed population, are admitted 3 times as often, and stay 3 times as long. This results in unscheduled secondary care costs 8 times that of housed patients. Homeless patients (including hostel dwellers) admitted to hospital in Glasgow with a drug related problem are 7 times more likely to die over the next 5 years than housed patients with the same drug related reason for admission. A 25 year old man living in a Canadian shelter or rooming house has only a 1 in 3 chance of surviving to 75 years old, compared to 2 in 3 for all 25 year old men in Canada. A study of homeless women in 7 cities across England, Canada, Denmark and the US found that the risk of death amongst younger homeless women was 5-30 times higher than amongst their housed counterparts, with no observable effect on mortality of health insurance and therefore access to free health care in the different countries.
We are spending a fortune and outcomes are appalling The average age of death for homeless people is just 47 years Crisis. Homelessness: a silent killer. London, Dec 2011 Tri-morbidity characterises homeless acute admissions physical ill health with mental ill health and drug and/or alcohol abuse
Simple, replicable, care coordination model Think homeless! 80% of patients referred with 48 hours of admission Homeless nurse practitioner with care navigator supports patient and begins care plan Regular GP led ward rounds coordinate care, advocate for patient and liaise with community agencies Weekly multi-agency care planning meetings Care, connect, understand, advocate
Quality You were the only ones that felt my life was worth saving- I am now back with the family I have not seen for 10 years I ve never stayed in hospital as long as this (2wks), I trust you, that s why I am staying The change is tangible,...full confidence that contacting the team will produce results Joint working with housing options has greatly improved customer care..enormous support with complex substance misuse clients at UCH
What is different about this approach? Vertical integration specialist primary care reaching in to the hospital to coordinate care Horizontal integration care coordinated across physical ill health, mental ill health and substance misuse teams within the hospital and out into the community
Hewett et al. A general practitioner and nurse led approach to improving hospital care for homeless people BMJ 2012;345:e5999
Steps to the latest service 2010 early evaluation used by Michael Porter of Harvard Business School as a local example of Value based health care delivery 2011-12 funding obtained for needs assessment across Kings Health Partners, new provision proposed 2013 - steering group uses data to promote the service as a flagship for KHP Oct 13 funding approved, training December 13 and launch January 2014
KHP Needs assessment summary Grand total KHP annual secondary care costs for homeless patients 9,241,452 Guy s and St Thomas is the lead provider of unplanned secondary care to homeless patients in London around 5,000 A&E attendances and 1,400 admissions annually Considerable history and expertise particularly 3 Boroughs Health Inclusion Team & START homeless mental health team at SLAM Good relationship with local CCG s and South London CSU
A service involving 13 staff Multi-agency Page 23
RCP Guidance for Secondary Care All shapes and sizes of hospitals can do their bit: Level 1: all hospitals to have a system for identifying potentially vulnerable adults including homeless people (rough sleepers and hostel dwellers). Level 2: a locally-negotiated in-reach housing adviser to work in collaboration with an identified person/ team in the hospital (such as the discharge team). Level 3: for hospitals with significant numbers of homeless patients, a Pathway-type model, with a team to support multiagency care coordination.
Next steps for the RCP Leadership role in promoting high standards of patient-centred care for all groups of patients, including the most vulnerable Homeless patients highlighted as an illustrative patient group in Future Hospital report and ongoing programme This work is part of our ongoing commitment to tackling health inequalities and supporting physicians to do the same