No abstract

The annual cost of unscheduled care for homeless patients is eight times that of the housed population (Department of Health, 2010) and homeless patients are overrepresented among frequent attenders in accident and emergency departments (A&E). Despite this expenditure, the average age of death for homeless patients is just 47 years (Thomas, 2012) and patients have a reduced quality of life caused by multi-morbidity. Hospital stays should present an ideal opportunity to engage homeless people and link them into community services, but historically this has not been true. Trimorbidity (the combination of physical health, mental health and addiction problems) is often central to the challenge of managing homeless patients in a hospital setting (Hewett et al, 2012). The Pathway charity has developed a model of enhanced care coordination for homeless people in hospital that is now being adopted

BackgroundUK “Pathway” teams offer specialist hospital care coordination for people experiencing homelessness. Emergency healthcare use is high among homeless people, yet “homelessness” is not routinely coded in National Health Service (NHS) data. Pathway team records provide an opportunity to assess patterns in admissions and outcomes for inpatients identified as homeless.MethodsRetrospective analysis of patients referred to “Pathway” homelessness teams in seven UK hospitals to explore the patterns of hospital admission, morbidity, secondary healthcare utilisation and housing status. Each patient was individually identified as experiencing homelessness. Within a six-month period, demographic data, reason for admission, morbidity, mortality and secondary care hospital usage 120-days before and 120-days after the index admission was collected.ResultsA total of 1009 patients were referred, resulting in 1135 admissions. Most admissions had an acute physical health need (94.9%). Co-morbid mental illness and/or substance misuse was common (55.7%). Reasons for admission included mental and behavioral disorders (overdose, alcohol withdrawal or depression, 28.3%), external causes of morbidity and mortality (assault or trauma, 18.7%), and injury, poisoning and external causes (head injury, falls and fractures, 12.4%). Unplanned Emergency Department attendances reduced after index admission and unplanned hospital admissions increased slightly. Planned admissions doubled and total bed days increased. Housing status was maintained or improved for over 60% of inpatients upon discharge. Within 12 months of index admission, 50 patients (5%) died, 15 deaths (30%) occurred during the index admission.ConclusionsDisengagement with health services is common among homeless people. Many deaths are due to treatable medical conditions (heart disease, pneumonia, cancer). Observed increases in planned admissions suggests intervention from Pathway teams facilitates necessary investigations and treatment for homeless people. Equity, parity of care, and value should be inbuilt interventions for inclusion health groups and evaluations need to move beyond simply seeking cost reductions.

Innovative testing approaches and care pathways are required to meet global hepatitis B virus (HBV) and hepatitis C virus (HCV) elimination goals. Routine blood‐borne virus (BBV) testing in emergency departments (EDs) in high‐prevalence areas is suggested by the European Centre for Disease Prevention and Control (ECDC) but there is limited evidence for this. Universal HIV testing in our ED according to UK guidance has been operational since 2015. We conducted a real‐world service evaluation of a modified electronic patient record (EPR) system to include opportunistic opt‐out HBV/reflex‐HCV tests for any routine blood test orders for ED attendees aged ≥16 years. Reactive laboratory results were communicated directly to specialist clinical teams. Our model for contacting patients requiring linkage to care (new diagnoses/known but disengaged) evolved from initially primarily hospital‐led to collaborating with regional health and community service networks. Over 11 months, 81,088 patients attended the ED; 36,865 (45.5%) had a blood test. Overall uptake for both HBV and HCV testing was 75%. Seroprevalence was 0.9% for hepatitis B surface antigen (HBsAg) and 0.9% for HCV antigen (HCV‐Ag). 79% of 140 successfully contacted HBsAg+patients required linkage to care, of which 87% engaged. 76% of 130 contactable HCV‐Ag+patients required linkage, 52% engaged. Our results demonstrate effectiveness and sustainability of universal ED EPR opt‐out HBV/HCV testing combined with comprehensive linkage to care pathways, allowing care provision particularly for marginalized at‐risk groups with limited healthcare access. The findings support the ECDC BBV testing guidance and may inform future UK hepatitis testing guidance.