Attributes of CSSs:
Long-standing philosophy to deliver health care to single people who are homeless. Operating for many years, with service evolving over time in response to needs. Most staff have considerable experience of this work.
Funded by NHS to provide service exclusively to single people who are homeless, asylum seekers and people with no recourse to public funds. MT1 also worked with people who are housed, but vulnerable, and use day centres. Service unavailable for homeless families and general population.
No fixed medical site. CSSs ran clinics in hostels and day centres for single people who are homeless – some have fully equipped rooms for healthcare delivery, some lack adequate facilities.
CSS staff and sessional workers – nurse practitioners, administrator/co-ordinator, mental health workers/counsellors. No GPs.
Local homelessness context:
Located in cities with large populations of single people who are homeless, including many sleeping rough. According to CSS staff, increase in numbers sleeping rough, in people from Eastern Europe and in people who have no recourse to public funds. Rough sleepers now more dispersed in MT1 locality.
According to staff, increase in complexity of health and substance misuse problems among people who are homeless, and in their use of the drug ‘spice’a
Several hostels/temporary accommodation projects/day centres for single people who are homeless in the vicinity of CSSs.
Citywide/local networks of statutory and voluntary sector agencies involved in the provision of temporary accommodation, day centre services and street outreach to people who are homeless.
Other specialist primary health care services in area for single people who are homeless.
Policy/funding/resource influences:
Cuts to housing, health and social support budgets, lack of affordable housing, and changes to welfare benefits and sanctions have contributed to people becoming and remaining homeless.
According to CSS staff, funding cuts to their service/restrictions have resulted in reduction in posts/redesign of service elements.
Conditions/funding requirements placed on homelessness sector services by local authority commissioners have meant that some services accept only people sleeping rough, and opening hours at some day centres reduced. These changes affect the work of CSSs as their clinics were dependent on patients and themselves having entry to these services.
Restructuring of homelessness services and closure of some hostels in locality of CSSs have contributed to increase in rough sleeping in the area.
Some strategic work with CCGs and local authorities. Provide information/advise/attend meetings. | Operational mechanisms:
Number of patients relatively small, compared with many mainstream general practices.
CSS staff knowledgeable about the problems and needs of people who are homeless and of local services. Regular staff meetings/training around patient care.
Operate Monday to Friday. Run drop-in clinics at set times at various hostels and/or day centres. CSS staff ‘seek out’ service users with health concerns who do not present for health care at these settings.
Frequent street outreach by staff from both CSSs to engage with people sleeping rough and encourage them to access health care.
Environment – some hostels and day centres are very busy. CSS staff described by participants as welcoming, non-judgemental, friendly and helpful, and greet patients by name.
CSS nurses undertake health assessments, health promotion and screening. Provide treatment/stabilisation for some acute health problems (some nurses are prescribers), but mainly case management for people with long-term conditions. Encourage/assist patients to register with local GPs and attend appointments.
Comprehensive health assessments for new patients, including social/housing histories. Information is sometimes gathered over several consultations as patients engage with nurses.
Person-centred approach to health care – nearly all participants described nurses as caring, listening, giving patients enough time and involving patients in decisions about their care.
Initial help given by nurses for non-medical needs, for example advise, assist with completing forms, signpost to housing and welfare benefit services, and advocate on behalf of patients.
Patients discharged from caseload once they have not used the service for some time.Integration mechanisms:
Close working with some GPs in locality. Regular joint clinics with GPs in some hostels (MT1), and occasional clinics held by CSS at general practice surgery (MT2). Meetings with GPs to discuss patient care. Have access to GPs’ medical records and vice versa.
Fairly close working with local mental health and substance misuse services (MT1 have more contact than MT2 with the latter). Refer/signpost patients to these services.
Communication by both CSSs with hospitals around A&E attendance and hospital discharge. Have access to hospital admission databases (MT1).
Fairly close working with local dental service for people who are homeless (MT2).
Close working with street outreach teams – regular joint street outreach sessions.
Close working with several hostels and day centres. Besides running clinics, CSS staff deliver influenza vaccination programmes and health promotion at these sites, intervene if there are health emergencies and provide support/training to staff.
Attendance by CSS staff at multidisciplinary case management meetings with local agencies, including those concerning people sleeping rough, high-risk or complex cases and frequent A&E attenders.
Communication with external agencies, including housing services and voluntary sector organisations | Participants’ characteristics:
Large percentages were sleeping rough, were born outside the UK and had no recourse to public funds (particularly MT2); mental health and substance misuse problems relatively common, including misuse of Class A drugs (particularly MT1).
Health screening (primary outcome):
Lowest Primary Outcome Score of all models for health screening of HSIs. Most noticeable differences were in screening of mental health and alcohol use, with Mobile Teams scoring considerably lower.
Management of SHCs:
Most cases of alcohol and drug problems mentioned by case study participants were documented in medical records.
Several cases of chronic respiratory problems and, particularly, depression were mentioned by case study participants but not documented in medical records.
Treatment plan initiated for most SHCs identified in medical records.
Low rates of continuity of care for all SHCs. When GP services are added, rates are comparable to those of Usual Care GPs for all SHCs except drug problems, where the rate is higher. For most SHCs, rates of continuity of care considerably lower than those of Dedicated Centres and Specialist GPs.
High scores for explanation of SHCs, suggesting that the nurses had good rapport with participants.
Self-rated health status and well-being:
Low levels of physical and psychological functioning at baseline (all models). No improvement in scores after 8 months.
Smoking and nutrition:
Large percentage were smokers, and many described poor nutrition. Slight improvements by 8 months in smoking and eating habits. Less likely than Dedicated Centre and Specialist GP participants to have received help from CSS staff with nutrition.
Oral health and dental treatment:
Baseline – poor oral health, dental pain and dental phobia common (all models). Many in need of dental treatment; rates of registration with dentist and dental attendance low.
Slight increase in dental registration rates by 8 months, and substantial increase in percentage who had seen a dentist in previous 4 months. Only slight reduction in percentage needing dental treatment. Two-fifths believed dental health worsened during study.
Use of services and costs:
More contacts with primary health care nurses than other models; fewer GP contacts than Dedicated Centre and Specialist GP participants, but slightly more than Usual Care GP participants. Similar rates to those of Specialist GP participants for use of out-of-hours services and nights spent in hospital. Overall service use costs similar to those of Specialist GP participants, lower than those of Dedicated Centre participants and considerably higher than those of Usual Care GP participants.
Satisfaction with CSS:
Participants described finding it easy to see a CSS nurse. High satisfaction ratings for overall experience of CSS, and very high satisfaction rates for Quality of Care provided by Mobile Team nurses. Nearly all reported confidence/trust in nurse. a higher satisfaction ratings than the general population with regard to primary care nurses at GP sites. |
