Safe Discharge Requirements for Homeless Patients in Healthcare Settings

Discharge Masterclass Pathways Homeless Team Katie Carter (Advocacy and Discharge coordinator ARCH Healthcare Gregg Lock (Hospital In-reach Nurse - SCFT)

Pathways Homeless Team Who are we? Why we exist Who we work with (pts and professionals)

What does a d/c look like? *Example of a typical d/c Housing don t allocate accommodation until day of d/c (when pt presents) Pt will need to get to accommodation (deposit required) Pt won t have bedding or have benefits and will require access food banks, day centres. Just life referral (to ensure support to follow up with appointments engage in health/benefits activity) Wound care GP/community homeless team

Who may be involved (alongside ward specialities) Housing Pavilions Adult social care Pharmacy MH team Safeguarding team RISE

Safe d/c requirements TTO s ready first thing on day of d/c however pt deemed medically fit later in the day it can cause difficulties/delay we would request next day d/c (based on the above) Wound care and follow-up plans Is pt registered with GP locally? If not may pose issues if placed out of area Assessments, investigations (bloods/scans) that can be done as inpatient (as a lot of complex pts unlikely for them to return) Care needs? Pt maybe functioning on the ward but can they function beyond hospital? What brought them in to hospital in the first place? Self-neglect? Is pt already known to community ASC team (are they liaising with the hospital team?)

Safe d/c requirements (cont) Pavilions are they involved? Regarding ongoing (substitute) prescribing are pts already in structured treatment? Or they may need appointment the following day of d/c Information from physiotherapy, OT s will have been collated and forwarded to housing Pain relief is pt adequately covered for pain relief? If having opiate based medication do they need to be weaned off (liaising with pain team and Pavilions) also thinking of alternatives

Hold ups TTO s (advance planning day before would be ideal) Housing make take a while to (if pt requires level access) Out of area pts (other things to consider transport getting the pt there, lack of communication from other local authority) Mobility if pt already resides in accommodation and mobility is affected may not be suitable for pt to return

Hold ups (cont) Care act assessments (adult social care can only assess once pt is medically fit) ASC not assessing as ward/sw feels pt has no care and support needs Safeguarding s/DV (if not safe for pt to return/need for alternative accommodation) Rehab/Step down if pt is identified as having rehab goals or requires step down bed services declining based on no address to return to (despite a concrete plan from our team/housing) Placements will ultimately take longer while care matching/funding applied for

Be mindful We ve got one of yours in here MFFD Get them out You re ready to go home Why are they still here?

Contacts TEAM WORKING HOURS: Monday- Friday 8am - 4pm TEAM CONTACT DETAILS t: 07884195417 katie.carter1@nhs.net gregg.lock@nhs.net