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Rough sleepers_ health and healthcare - Westminster

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					 A review of the health needs and healthcare costs of rough sleepers in 
         the London boroughs of Hammersmith and Fulham,

              Kensington and Chelsea, and Westminster
Rough sleepers needs assessment
 The review includes three work streams:

     Literature review - to set the scene, understand the 
      health needs, and identify interventions to support 
      rough sleepers

     Qualitative research - interviews to understand the 
      barriers to healthcare (undertaken by Broadway)

     Analysis of hospital data to understand the healthcare 
      utilisation
   Setting the scene (literature review)
• Health needs – most common are alcohol or drug dependence, mental 
illness,   and dual diagnosis.  Homelessness is associated with tri-morbidity

• Service use – greater use of A&E and hospital services than general  
population. Rough sleepers face a range of barriers to accessing services

• Costs - homeless people consume about 4 times more acute hospital 
services than the general population, costing £85m. Very little cost effectiveness 
research – although some economic evidence for intermediate care 

• Effectiveness of interventions  - overall lack of good quality research, 
although some evidence for case management for mental health and substance 
misuse, and that housing should be provided as part of integrated model.

• Models of service delivery - models of care range from mainstream practices 
providing homeless services to fully coordinated primary and secondary care. 
Discharge planning should be a component of an integrated model to prevent 
inappropriate discharge back on to the streets and reduce emergency 
readmissions 
Reducing barriers to accessing healthcare
(qualitative research)
 As identified in the qualitative study, there are 
 examples of practice which could enhance access to 
 health services and improve health outcomes:

     health services removing barriers to access and 
      enhancing patient experiences

     using homelessness support services to enhance access 
      to health services

     taking services to where homeless people are

     services coming together to improve joint working
Examples to support access to health services
(qualitative research)
 Enabling access
       Specialist homeless GPs
       GPs registering people without the need for proof of identity
       Local accommodation projects which have a health focus
       Accompaniment to appointments, eg Groundswell peer health advocates
       Open referral system to secondary healthcare, eg UCL Pathway team

 Bringing services to the patient
     Day centres where health services are brought in
     Outreach e.g. outreach team that are accompanied by a mental health 
      social worker and in nurses from GP practices going out with the homeless 
      outreach teams
     Hostel in-reach 
     One stop shops, eg  a supported accommodation projects offering regular 
      ‘health MOT’ sessions
 
 Working across service and organisational boundaries
       Find and treat tuberculosis services
       Dual diagnosis outreach worker
Discharge from hospital
(qualitative research)
Concerns include:
 Early discharge before patient feels health needs have been fully met.
 Discharge to the street either because homelessness is not identified 
  or hospital staff do not make the necessary referrals following the 
  disclosure of homelessness.
 Poor communication between service providers upon discharge.
 Discharge without clothing or transport. 
 
Suggested improvements:
 The provision of respite accommodation with adequate healthcare.
 A system of care coordination for every homeless person to ensure 
    that all their health and social care needs have been fully addressed 
  Analysis of hospital data
 3450 individuals confirmed to be rough sleepers was identified from the 
  CHAIN (Combined Homelessness and Information Network) system 
  and matched with NHS general practice registered data.

 Those rough sleepers from CHAIN were identified between January 2010
  and December 2011.

 933 patients had NHS numbers within Health services data.

 For those rough sleepers:
    High proportion of 30-59 age population compared with INWL general 
     population

    Common countries of birth:  UK (49%), Poland (12%), Ireland (4%), 
     Lithuania (4%), Romania (3%), Portugal (2%), Rest from 76 other
     countries
More than half of rough sleepers had contacts 
with a hospital
                                  Out of 933 patients that 
                                   registered with a GP 
                                   practice in INWL GP 
                                 practice 555 patients had 
                                 contacts with acute NHS 
                                          hospital.



                                  Nearly 40% of rough 
                                  sleepers attended all 
                                 three types of hospital 
                                      services (A&E, 
                                     outpatients and 
                                        inpatients)
Hospital Activity ratios for rough sleepers,
compared with INWL general population



                                   Rough sleepers have 
                                    significantly high 
                                    hospital activities 
                                     compared  with 
                                   general population
Total cost of services for rough sleeping
population, split by hospital service per year




Excess hospital cost of rough sleeping per year  = (real cost of rough sleeping per year –
  Estimated cost for 933 patients from Inner North West London  with same age and 
                                        gender  
  Rough sleepers have high rates of did not
  attends (DNA) to hospitals




One Westminster based GP said:

‘We  need to be as concerned with the people who do not attend
the service as the people who do, cause often the ones who are
not attending us have the greater need.’
10% of rough sleepers contribute to 50% of
health care cost
Other findings (data analysis)
 Increase in trends in hospital activity: 2 fold increase in rate of 
  hospital activity from 2010 Jan- 2011 Dec to 2012 Jan- 2012 June period.

 Outpatient activity: Rough sleepers have high number of attendance 
  due to mental illnesses, trauma & orthopaedics and alcohol related 
  attendance

 Inpatient activity: Rough sleepers have significantly high emergency 
  rates while low rates elective admissions compared with general 
  population.

 Inpatient activity: Main diagnosis for admissions for rough sleepers 
  are mental illnesses, injuries, poisoning, alcohol related problems and 
  musculoskeletal problems. 
Number of rough sleepers in Westminster
by ward location of GP practice
 Ward location of GP practice   Number of rough sleepers
 St James's                               312
 West End                                  59
 Warwick                                   40
 Westbourne                                36
 Harrow Road                               26
 Vincent Square                            25
 Church Street                             18
 Little Venice                             13
 Maida Vale                                11
 Queen's Park                               9
 Marylebone High Street                     8
 Churchill                                  7
 Hyde Park                                  6
 Knightsbridge and Belgravia                5
 Tachbrook                                  5
 Abbey Road                                <5
 Bayswater                                 <5
 Lancaster Gate                            <5
 Bryanston and Dorset Square               <5
 Regent's Park                             <5
    Final Summary
 Hospital utilisation and hospital cost for rough sleepers are significantly higher 
    than the tri-borough general population

 Rough sleepers have a high proportion of co-morbidities and a high frequency of 
    attendances/ admissions. A small sub group of rough sleepers have a particularly 
    high level of need - 10% of the rough sleepers accessing hospital services consume
    approximately 50% of the total cost of hospital services
 
 Commonest diseases for these rough sleepers are Mental illnesses, Alcohol related 
    diseases, Trauma & Orthopaedics.
 
 Rough sleepers have high rates of DNA (did not attends)


 Access to healthcare is problematic  and rough sleepers face many barriers e.g. GP 
    registration

 Integrated model of service delivery needs to ensure access to a package of care 
    which links health, social care, housing, and voluntary sector provided ser vices. 
    Discharge planning following a hospital admission requires  joint working and an 
    agreed process.
Next Steps
 Central London CCG programme of work:

 - Targeted health promotion with ‘Groundswell’: peer 
 advocacy to support the highest users of secondary 
 care
 - Nurse outreach service
 - Community hepatitis C treatment service
Commissioning cycle

				
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posted:6/24/2014
language:English
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