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Improving care transfers for homeless patients after hospital discharge: a realist evaluation
- Authors:
- CORNES Michelle, et al
- Journal article citation:
- Health and Social Care Delivery Research, 9(17), 2021, Online only
- Publisher:
- National Institute for Health Research
- Place of publication:
- London
Background: 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. Methods: 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 (n = 5) and those with no specialist discharge scheme (standard care) (n = 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 > 3882 patients from 17 discharge schemes across England. The study involved people with lived experience of homelessness in all stages. Results: 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. Strengths and limitations: 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). Future work: 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. (Edited publisher abstract)
Increasing access to Care Act 2014 assessments and personal budgets among people with experiences of homelessness and multiple exclusion: a theoretically informed case study
- Authors:
- CORNES Michelle, et al
- Journal article citation:
- Housing Care and Support, 21(1), 2018, pp.1-12.
- Publisher:
- Emerald
Purpose: The purpose of this paper is to present a case study describing the progress that is being made in one city in England to increase access to Care Act 2014 assessments and personal budgets among people with experiences of homelessness and multiple exclusion. Design/methodology/approach: A case study employing a “study group” to describe and reflect on local development work. Findings: The authors focus on the “systems change” activity that was undertaken by one voluntary sector partnership project to address issues of referral and access to adult social care. This included the development of a “Multiple Needs Toolkit” designed to support voluntary sector workers to communicate more effectively with adult social care around the application of the new Care Act 2014 eligibility thresholds. The authors discuss the role of “persistent advocacy” in increasing access to assessments and also the limitations of this as regard the potential for poorer joint working. Originality/value: Throughout, the authors draw on the “ambiguity-conflict” model of policy implementation to assess if the learning from this single case study might be applied elsewhere. (Edited publisher abstract)
Improving hospital discharge arrangements for people who are homeless: a realist synthesis of the intermediate care literature
- Authors:
- CORNES Michelle, et al
- Journal article citation:
- Health and Social Care in the Community, 26(3), 2018, pp.e345-e359.
- Publisher:
- Wiley
This review presents a realist synthesis of “what works and why” in intermediate care for people who are homeless. The overall aim was to update an earlier synthesis of intermediate care by capturing new evidence from a recent UK government funding initiative (the “Homeless Hospital Discharge Fund”). The initiative made resources available to the charitable sector to enable partnership working with the National Health Service (NHS) in order to improve hospital discharge arrangements for people who are homeless. The synthesis adopted the RAMESES guidelines and reporting standards. Electronic searches were carried out for peer‐reviewed articles published in English from 2000 to 2016. Local evaluations and the grey literature were also included. The inclusion criteria was that articles and reports should describe “interventions” that encompassed most of the key characteristics of intermediate care as previously defined in the academic literature. Searches yielded 47 articles and reports. Most of these originated in the UK or the USA and fell within the realist quality rating of “thick description”. The synthesis involved using this new evidence to interrogate the utility of earlier programme theories. Overall, the results confirmed the importance of (i) collaborative care planning, (ii) reablement and (iii) integrated working as key to effective intermediate care delivery. However, the additional evidence drawn from the field of homelessness highlighted the potential for some theory refinements. First, that “psychologically informed” approaches to relationship building may be necessary to ensure that service users are meaningfully engaged in collaborative care planning and second, that integrated working could be managed differently so that people are not “handed over” at the point at which the intermediate care episode ends. This was theorised as key to ensuring that ongoing care arrangements do not break down and that gains are not lost to the person or the system vis‐a‐vis the prevention of readmission to hospital. (Edited publisher abstract)
The Care Act 2014, personalisation and the new eligibility regulations: implications for homeless people
- Authors:
- CORNES Michelle, et al
- Journal article citation:
- Research Policy and Planning, 31(3), 2016, pp.211-223.
- Publisher:
- Social Services Research Group
This paper explores the implications of the Care Act 2014 for ‘homeless people, a group that was defined as ‘ineligible’ for publically funded care and support under the previous community care legislation. The paper describes how the Supporting People Programme evolved to fill this gap, providing what was termed ‘housing related support’ to meet the needs of homeless people and other excluded groups. It then describes how the austerity measures have eroded this support, and the evidence for a retrenchment of the welfare state. The second part of the paper explores the changes that have been introduced as a result of the Care Act 2014 and in what circumstances they might be used to access personalised support for ‘homeless people’ (including housing related support). It draws highlights evidence that necessitates a reconceptualisation of homelessness as a ‘health risk’ that extends beyond the low level preventative agenda making the case that many ‘homeless people’ will now fulfil the new eligibility criteria for publically funded care and support. It also highlights the barriers which may hinder awareness raising and the implementation of these changes thereby limiting opportunities to enhance choice and control for some of the most severely and multiply disadvantaged people in England. (Edited publisher abstract)
The Care Act, personalisation and the new eligibility regulations: a discussion paper about the future of care and support services for homeless people in England
- Authors:
- CORNES Michelle, et al
- Publisher:
- King's College London. Social Care Workforce Research Unit
- Publication year:
- 2015
- Pagination:
- 21
- Place of publication:
- London
As the law currently stands 'homeless people' as a service user group are not eligible for community care assessment, though people who are homeless and who fall into one of the 'eligible groups' by virtue of having a mental health or drug and alcohol problem may be. The Care Act 2014 removes reference to 'eligible' and 'ineligible' groups so that any adult with any level of need will have a right to an assessment. Exploring some of the ways in which homeless people have been excluded from care and support in the past, this discussion paper outlines how homeless organisations can work with local authorities to ensure fairer and more consistent access and in so doing, potentially secure their own futures in the face of fewer 'block contracts' and open-up access to personal budgets and more individualised forms of commissioning. (Edited publisher abstract)
Not just a talking shop: practitioner perspectives on how communities of practice work to improve outcomes for people experiencing multiple exclusion homelessness
- Authors:
- CORNES Michelle, et al
- Journal article citation:
- Journal of Interprofessional Care, 28(6), 2014, pp.541-546.
- Publisher:
- Taylor and Francis
Within homelessness services recent policy developments have highlighted the need for integration and improved collaborative working and also, the need for “Psychologically Informed Environments” (PIES) in which workers are better equipped to manage the “complex trauma” associated with homelessness. Drawing on the findings of an evaluation of a multi-site development programme, this paper demonstrates how both these policy aspirations might be implemented through a single delivery vehicle (a community of practice). The paper describes how organisational, educational and psychosocial theory was used to inform programme design and reflects on the utility of these approaches in the light of the evaluation findings. It is reported that communities of practice can deliver significant performance gains in terms of building collaborative relationships and opening-up opportunities for interprofessional education and learning. Filling an important knowledge gap, it also suggested how (professional) participation in a community of practice might work to improve outcomes for service users. Most likely those outcomes are seen as being linked to tackling exclusion by sustaining the workforce itself, that is in motivating workers to remain engaged and thinking positively in what is an emotionally challenging and stressful job role. (Edited publisher abstract)
Little miracles: using communities of practice to improve front line collaborative responses to multiple needs and exclusions
- Authors:
- CORNES Michelle, et al
- Publisher:
- Revolving Doors Agency
- Publication year:
- 2013
- Pagination:
- 12
- Place of publication:
- London
This report summarises the learning from a development programme which established six ‘communities of practice’ in different locations across England whose aim was to improve front line collaborative responses to people facing multiple needs and exclusions. The overall aims of the programme were to explore if communities of practice might provide a vehicle for building networks and improving and sustaining relationships between different agencies and professions; lead to improvements in front line service responses through knowledge brokerage and opportunities for interdisciplinary education and learning; and provide shelter and space for reflective practice and interdisciplinary group supervision with opportunities for mutual (collegiate) support. The report, which draws on a small scale evaluation comprising a questionnaire survey and a focus group with each community of practice, outlines participants’ perception of the benefits and challenges associated with the programme and concludes that given a relatively small financial investment, considerable gains can be achieved through communities of practice in terms of building collaborative relationships, opening-up opportunities for interdisciplinary education and learning, and potentially improving certain kinds of outcomes. (Edited publisher abstract)
Reconciling recovery, personalisation and Housing First: integrating practice and outcome in the field of multiple exclusion homelessness
- Authors:
- CORNES Michelle, et al
- Journal article citation:
- Health and Social Care in the Community, 22(2), 2014, pp.134-143.
- Publisher:
- Wiley
‘Recovery’ is a key concept in the organisation and delivery of interdisciplinary support for people experiencing multiple exclusion homelessness (MEH). MEH are situations where homelessness overlaps with a range of other complex problems such as mental health issues and drug and alcohol dependencies. At the level of individual support planning, practitioners are expected to ‘work together’ to motivate service users to make positive changes to their lives and to secure outcomes (results) such as employment and permanent accommodation. Drawing on the accounts of 34 (n = 34) people with first-hand experience of MEH in England, the authors outline some of the limitations of ‘recovery-orientated practices’, namely the exclusion of people with unresolved needs and the implications this may have for continuity of provision. It is argued that there is a need for a more personalised and inclusive practice model, which can accommodate ‘recovery’ (change outcomes) alongside those for maintenance and prevention. In proposing one such model, the authors show how this might also take forward the principles of ‘Housing First’ (a US blueprint for tackling entrenched homelessness), which has already begun to challenge the orthodox view that permanent accommodation should be provided only when recovery has been achieved. (Edited publisher abstract)
The experiences and perspectives of agency social workers in England: findings from interviews with those working in adult services
- Authors:
- CORNES Michelle, et al
- Journal article citation:
- Social Work and Social Sciences Review, 16(1), 2013, pp.67-83.
- Publisher:
- Whiting and Birch
One of the solutions to the shortages of social workers in England has been to employ social workers on a temporary or locum basis, often these social workers are called agency social workers as their contract of employment is with a employment agency rather than the social work employer. This paper explores the background to the use of agency social workers in the current context of government efforts to reduce the expenditure of public sector employers on agency staff. Data were collected through interviews with 40 social workers working with adults in England, in three diverse local authority settings; spanning those social workers whose careers in social work were in their early years; those with that were experienced and third group who while experienced and specialist were considering possible retirement or career moves. The aim of the interviews was to investigate motivations and experiences around this type of social work employment. The findings of the interviews are presented, with illustrations of ‘push and pull’ factors around agency working. The article concludes that agency working presents opportunities for social workers that may be within the power of social work employers to foster more generally, such as ways to minimise ‘office politics’ and to provide greater variety of work. (Publisher abstract)
Assessing the effectiveness of policy interventions to reduce the use of agency or temporary social workers in England
- Authors:
- CORNES Michelle, et al
- Journal article citation:
- Health and Social Care in the Community, 21(3), 2013, pp.236-244.
- Publisher:
- Wiley
There has been growing concern that English local authorities are over reliant on temporary staff to meet the shortage of social workers. This has been criticised as inefficient and costly while leading to problems of continuity and consistency for people using social work services. Focussing on recent policy and the implementation of new administrative procedures for the procurement and management of temporary or agency staff, this article explores progress being made towards achieving the previous government’s policy goal that by 2020 local authorities will no longer need to rely on agency workers to carry out tasks that would normally be carried out by a permanent social worker. The article draws on the findings of an exploratory study (2007–2010) commissioned by the Department of Health which comprised of the following: a survey of local councils in England with adult social services responsibilities; case studies in three different localities; and qualitative interviews with stakeholders (n = 93). The findings suggest that while local authorities have reduced the costs of employing temporary staff through the setting up of intermediary control mechanisms, agency social workers continue to play important roles in teams and services. (Publisher abstract)