Integrated care for homeless people

Homeless people experience a higher rate of serious health problems, and have greater problems accessing healthcare than the general population. With this in mind, a project offering integrated care for homeless people was piloted with the aim of reducing mortality and morbidity, and reducing acute secondary healthcare usage among its clients.

The pilot took place during 2009 at the 120-bed St Mungo's Cedars Road hostel in Clapham, London, supported by a £20,000 grant. Due to its success, the project was mainstreamed by community services in 2011. From early 2012 the scheme will be relocated to Thames Reach's Graham House in Vauxhall.

This project reflects the Charity's commitment to supporting new ways of delivering healthcare that meets the needs of local populations. It also demonstrates commitment to robust evaluation in order to evidence the efficacy of these new models of care, so that they can be adopted in other parts of the country.

Within the project, a full-time Band 7 nurse and health support worker are based on site, with a weekly in-house session provided by the project GP. The service aims to improve residents' healthcare, and access to treatment. The project team currently manages a caseload of 10-12 clients: those assessed to be most at risk of death or disability at any one time.

A main target has been to ensure clients are engaged with all the specialist services they should be accessing, through help such as transport provision and reminders of appointments. Common new referrals for clients have included HIV services, chest clinics, neurology, psychology, counselling, and dentistry.

As a result, deaths among those involved have fallen significantly. Residents are also now admitted into A&E less with 52 per cent lower admissions than pre-project, and hospital admissions have fallen by 77 per cent. The scheme has also proved cost effective, due to the reduction in secondary care usage.

"The project has shown that it is possible to offer intermediate care to homeless hostel residents and improve health outcomes and secondary care usage as a result," says Samantha Dorney-Smith, joint service lead, Homeless, Blood Born Virus Health Care and Refugee Health Teams. "It has provided equal access to intermediate care services for this disenfranchised group based on clinical need and demonstrated that tackling the health inequality experienced by the homeless can be done cost effectively." 

  • Key facts

    Organisation lead:
    Guy’s and St Thomas’ NHS Foundation Trust 

    Financial support:
    £20,000 grant

    Start date:
    January 2009 

  • Report

    Mid point review (Word document, 445kb)