Out-of-hospital integrated care models (including hospital discharge schemes and intermediate care) for people experiencing homelessness

LTP Priority: Inclusion Health Groups – people who are homeless and rough sleepers and transformed ‘out of hour’ and fully integrated community based care

Population Intervention Triangle: Segments (link to Section 1 PHE PBA): Service

Type of Interventions: ‘Out-of-hospital’ integrated care models (including hospital discharge schemes and intermediate care) designed to secure safe timely transfers of care for people who are experiencing homelessness.

Major driver of health inequalities in your area of work

Mortality rates of people experiencing homelessness (chronic, rough sleeping) are eight to twelve-fold higher than general population

Mean age of death is 44 males & 42 females compared to 76 and 81 respectively in general population;

Co-morbidity not uncommon amongst people who have experienced homelessness and rough sleeping for some time;

People report much poorer health than general population and barriers to access health care, care and support in the community;

ONS estimated 597 deaths of people experiencing rough sleeping in England and Wales in 2017 – increased by 24% over last five years; recent UCL report one third deaths from treatable conditions.

Target groups

  • Rough sleepers and Homelessness
  • Gypsy Roma Traveller people and communities
  • Vulnerable migrants
  • Sex workers


Out-of-hospital integrated care models (including hospital discharge schemes and intermediate care) for people experiencing homelessness.


The intervention seeks to enable timely and safe transfers of care from hospital for people who may be experiencing homelessness on admission, or those who lose their home during their inpatient stay. Expected outcomes are:

  • Improvements in patient experience
  • Improvements in care quality and outcomes (including mental health, cancer, cardiovascular and respiratory conditions)
  • Reduction in use of A&E and hospital re-admissions
  • Reduction in DTOC owing to housing
  • Reduction in preventable deaths on the street.

This work can be implemented at scale and pace by encompassing interventions into local approaches to integration for other populations with multiple and complex needs/conditions e.g. as part of Better Care Fund programme implementation.


Homeless hospital discharge schemes are more effective and cost effective than standard care. However, those schemes with direct access to specialist intermediate care (step-down) are more effective and cost effective than schemes without: managing the transfer of care not just the exit from the acute sector is what makes the difference.

There are five component parts to the model:

  • Pre-admission: primary and community-based services accessible & working together to prevent the need for A & E and admission
  • Patient in-reach: knowledge and expertise in supporting patients with multiple and complex needs, including, for example, how to prevent self-discharge
  • Discharge co-ordination: ward staff access to experts in housing/homelessness, care and support
  • Intermediate care and discharge to assess: suitable accommodation available in the community
  • Exit: there is someone managing the transfer from end-to-end, withdrawing only when longer term health, care and support services are in place and working well

NIHR Effectiveness and Cost Effectiveness Study. Practice Guidance and Tool Kit due to be published in Autumn 2019 Chief Investigator: Michelle Corns.

Guidance for Commissioners

See above; also, existing guidance/case studies could be applied e.g. NICE NG74.