Improving care transfers for homeless patients after hospital discharge: a realist evaluation

Cornes, Michelle; W Aldridge, Robert; Biswell, Elizabeth; Byng, Richard; Clark, Michael; Foster, Graham; Fuller, James; Hayward, Andrew; Hewett, Nigel; Kilminster, Alan; Manthorpe, Jill; Neale, Joanne; Tinelli, Michela; Whiteford, Martin

Abstract

Background: In 2013, 70% of people who were homeless on admission to hospital were discharged back
to the street without having their care and support needs addressed. In response, the UK government
provided funding for 52 new specialist homeless hospital discharge schemes. This study employed
RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) guidelines between
September 2015 and 2019 to undertake a realist evaluation to establish what worked, for whom, under
what circumstances and why. It was hypothesised that delivering outcomes linked to consistently safe,
timely care transfers for homeless patients would depend on hospital discharge schemes implementing
a series of high-impact changes (resource mechanisms). These changes encompassed multidisciplinary
discharge co-ordination (delivered through clinically led homeless teams) and ‘step-down’ intermediate
care. These facilitated time-limited care and support and alternative pathways out of hospital for people
who could not go straight home.
Methods: The realist hypothesis was tested empirically and refined through three work packages.
Work package 1 generated seven qualitative case studies, comparing sites with different types of
specialist homeless hospital discharge schemes (n = 5) and those with no specialist discharge scheme
(standard care) (n = 2). Methods of data collection included interviews with 77 practitioners and
stakeholders and 70 people who were homeless on admission to hospital. A ‘data linkage’ process
(work package 2) and an economic evaluation (work package 3) were also undertaken. The data linkage
process resulted in data being collected on > 3882 patients from 17 discharge schemes across England.
The study involved people with lived experience of homelessness in all stages.
Results: There was strong evidence to support our realist hypothesis. Specialist homeless hospital
discharge schemes employing multidisciplinary discharge co-ordination and ‘step-down’ intermediate
care were more effective and cost-effective than standard care. Specialist care was shown to reduce
delayed transfers of care. Accident and emergency visits were also 18% lower among homeless
patients discharged at a site with a step-down service than at those without. However, there was an
impact on the effectiveness of the schemes when they were underfunded or when there was a shortage
of permanent supportive housing and longer-term care and support. In these contexts, it remained
(tacitly) accepted practice (across both standard and specialist care sites) to discharge homeless patients to the streets, rather than delay their transfer. We found little evidence that discharge schemes fired a
change in reasoning with regard to the cultural distance that positions ‘homeless patients’ as somehow
less vulnerable than other groups of patients. We refined our hypothesis to reflect that high-impact
changes need to be underpinned by robust adult safeguarding.
Strengths and limitations: To our knowledge, this is the largest study of the outcomes of homeless
patients discharged from hospital in the UK. Owing to issues with the comparator group, the
effectiveness analysis undertaken for the data linkage was limited to comparisons of different types
of specialist discharge scheme (rather than specialist vs. standard care).
Future work: There is a need to consider approaches that align with those for value or alliance-based
commissioning where the evaluative gaze is shifted from discrete interventions to understanding how
the system is working as a whole to deliver outcomes for a defined patient population.
Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services
and Delivery Research programme and will be published in full in Health Services and Delivery Research;
Vol. 9, No. 17. See the NIHR Journals Library website for further project information.

Citation

Cornes, M., W Aldridge, R., Biswell, E., Byng, R., Clark, M., Foster, G., …Whiteford, M. (2021). Improving care transfers for homeless patients after hospital discharge: a realist evaluation. Health Services and Delivery Research, 9(17), https://doi.org/10.3310/hsdr09170

• Journal Article Type: Article
• Acceptance Date: May 31, 2021
• Online Publication Date: Sep 30, 2021
• Publication Date: Sep 30, 2021
• Deposit Date: Feb 21, 2024
• Publicly Available Date: Feb 23, 2024
• Journal: Health Services and Delivery Research
• Print ISSN: 2050-4349
• Electronic ISSN: 2050-4349
• Publisher: NIHR Journals Library
• Peer Reviewed: Peer Reviewed
• Volume: 9
• Issue: 17
• DOI: https://doi.org/10.3310/hsdr09170