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dc.contributor.authorCornes, Men
dc.contributor.authorAldridge, RWen
dc.contributor.authorBiswell, Een
dc.contributor.authorByng, Ren
dc.contributor.authorClark, Men
dc.contributor.authorFoster, Gen
dc.contributor.authorFuller, Jen
dc.contributor.authorHayward, Aen
dc.contributor.authorHewett, Nen
dc.contributor.authorKilmister, Aen
dc.contributor.authorManthorpe, Jen
dc.contributor.authorNeale, Jen
dc.contributor.authorTinelli, Men
dc.contributor.authorWhiteford, Men

<jats:sec id="abs1-1"> <jats:title>Background</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec id="abs1-2"> <jats:title>Methods</jats:title> <jats:p>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 (<jats:italic>n</jats:italic> = 5) and those with no specialist discharge scheme (standard care) (<jats:italic>n</jats:italic> = 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 &gt; 3882 patients from 17 discharge schemes across England. The study involved people with lived experience of homelessness in all stages.</jats:p> </jats:sec> <jats:sec id="abs1-3"> <jats:title>Results</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec id="abs1-4"> <jats:title>Strengths and limitations</jats:title> <jats:p>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).</jats:p> </jats:sec> <jats:sec id="abs1-5"> <jats:title>Future work</jats:title> <jats:p>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.</jats:p> </jats:sec> <jats:sec id="abs1-6"> <jats:title>Funding</jats:title> <jats:p>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 <jats:italic>Health Services and Delivery Research</jats:italic>; Vol. 9, No. 17. See the NIHR Journals Library website for further project information.</jats:p> </jats:sec>

dc.format.extent1 - 186en
dc.publisherNational Institute for Health Researchen
dc.titleImproving care transfers for homeless patients after hospital discharge: a realist evaluationen
dc.typeJournal Article
plymouth.journalHealth Services and Delivery Researchen
plymouth.organisational-group/Plymouth/Faculty of Health
plymouth.organisational-group/Plymouth/Faculty of Health/Peninsula Medical School
plymouth.organisational-group/Plymouth/REF 2021 Researchers by UoA
plymouth.organisational-group/Plymouth/REF 2021 Researchers by UoA/UoA03 Allied Health Professions, Dentistry, Nursing and Pharmacy
plymouth.organisational-group/Plymouth/Research Groups
plymouth.organisational-group/Plymouth/Research Groups/FoH - Community and Primary Care
plymouth.organisational-group/Plymouth/Research Groups/Institute of Health and Community
plymouth.organisational-group/Plymouth/Research Groups/Institute of Translational and Stratified Medicine (ITSMED)
plymouth.organisational-group/Plymouth/Research Groups/Institute of Translational and Stratified Medicine (ITSMED)/CCT&PS
plymouth.organisational-group/Plymouth/Users by role
plymouth.organisational-group/Plymouth/Users by role/Academics
dc.rights.embargoperiodNot knownen
rioxxterms.typeJournal Article/Reviewen

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