The cost-effectiveness of specialist hospital discharge and intermediate care services for patients who are homeless

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

Abstract

Background: Recognising the diverse healthcare needs of the population, there is a growing emphasis on tailoring hospital discharge processes to address the unique challenges faced by individuals who are homeless, aiming to enhance the efficiency and effectiveness of post-hospitalisation care for this vulnerable demographic. This study aimed to evaluate the costs and consequences of specialist hospital discharge and intermediate care (support after discharge) services for people who are homeless in England.

Methods: We estimated the comparative costs and consequences of different types of specialist care provided by 17 homeless hospital discharge and intermediate care services. We compared ‘clinically-led’ (multidisciplinary) services with those that were ‘housing-led’ (uniprofessional). A retrospective observational study was conducted to estimate effectiveness and costs for two'intervention groups'(clinically-led and housing-led) and a previously published RCT for'standard care'. Use of resources data for specialist care was sourced through linkage with Hospital Episode Statistics. The measure of effectiveness was the number of bed days avoided (in terms of hospital stays for all readmissions in the follow-up period) per homeless user. Additional secondary analysis of three services looked at quality-adjusted life years (QALYs) and service delivery costs. The perspective adopted was NHS in England.

Results: Data from the comparative analysis showed that specialist homeless hospital discharge (HHD) care is likely to be cost-effective compared with standard care. Patients accessing specialist care use fewer bed days per year (including both planned and unplanned readmissions). Patients using specialist care have more planned readmissions to hospital and, overall, use more NHS resources than those who use standard care. We interpret this as a positive outcome indicating that specialist care is likely to work more effectively than standard care to improve access to healthcare for this marginalised group. Specialist care remained cost-effective over a range of sensitivity analyses. Secondary analyses of three specific schemes found better QALY outcomes, but results are not generalisable to all 17 schemes.

Conclusion: Specialist HHD services are likely to be cost-effective for the NHS compared with standard care, although further research is needed to access patient level data for both costs and outcomes to conduct a rigorous statistical analysis between groups and address possible underlying biases due to data coming from non-randomised study design.

• Journal Article Type: Article
• Acceptance Date: Apr 4, 2025
• Online Publication Date: Jun 3, 2025
• Publication Date: Jun 3, 2025
• Deposit Date: Jun 12, 2025
• Publicly Available Date: Jun 12, 2025
• Journal: BMC Health Services Research
• Electronic ISSN: 1472-6963
• Publisher: Springer Verlag
• Peer Reviewed: Peer Reviewed
• Volume: 25
• Issue: 1
• Article Number: 794
• DOI: https://doi.org/10.1186/s12913-025-12704-x
• Keywords: Economic evaluation, Cost-effectiveness, Intermediate care, Homelessness, Hospital discharge