Improving hospital discharge arrangements for people who are homeless: A realist synthesis of the intermediate care literature

4.1 Scoping the literature

In undertaking this review, we applied the same methods and search strategy as outlined by Pearson et al. (2015), but extended the scope of the search to include “homelessness”. While Pearson's search strategy used what they believed to be a comprehensive list of phrases relating to intermediate care, we extended the scope of this search to encompass [‘medical respite’] and [‘homelessness AND ‘hospital discharge’ (schemes)] and [‘homelessness AND ‘delayed discharge’.] This is because the term intermediate care is not widely or consistently used in the homelessness sector. The search terms used are shown in Figure 1.

4.2 Searching processes

Electronic searches were carried out for peer-reviewed articles published in English from 2000 to 2016 in the Medline, Medline in Process, Embase, Social Policy and Practice, HMIC, British Nursing Index, The Cochrane Library, CINAHL and Assia. We searched the “grey” literature through relevant websites (e.g. Department of Health; Homeless Link), as well as through the Internet using the Google search engine. We also contacted over 52 intermediate care services for homeless people in England seeking copies of any local evaluations and project reports.

4.3 Selection and appraisal of documents

Intermediate care is a complex term that can encompass a wide range of different service configurations and functions. In selecting material for inclusion in the review, Pearson et al. (2013) helpfully distinguish between conventional “hand-overs” of care between providers and interventions that have been specifically designed to support service users’ transitions (p26). The inclusion criteria for this present review was that articles and reports should describe specific interventions to support homeless service users in transition and that the intervention should encompass most of the key characteristics of intermediate care (see Figure 2). A small number of additional articles was included which considered homeless health or hospital discharge more generally, but only where they raised issues about the need for intermediate care (see e.g. Medcalf & Russell, 2014; Parker-Radford, 2015).

Each source was read by at least two members of the research team. Papers were assessed based on the same realist “quality” criteria utilised by Pearson et al. (2015). This makes distinctions between those that are “conceptually rich” (with well-grounded and clearly elucidated theories, ideas and concepts), “thick” (a rich description of a programme, but without explicit reference to theory underpinning it) or “thin” (weaker description of a programme, where discerning a programme theory would be problematic).

4.4 Data extraction, analysis and synthesis process

The literature was synthesised with regard to how it addressed Pearson et al.'s (2015) conceptual framework. When reviewing the literature, we sought to identify programme theories that were both explicitly argued and those that were tacit or implied, making it clear which was the case. A data extraction pro forma was designed to allow the evidence to be carefully mapped against each of the three programme theories. This included space for identification of any new programme theories. The final stage of the synthesis was to take the evidence as a whole and to reflect on the overall utility of Pearson et al.'s (2015) conceptual framework, highlighting where any changes or refinements could be made.

5.1 Document characteristics

Table 1 (online resource) summarises the articles and reports (n = 47) that were included in the review, the methods they used, their “richness rating” and to which programme theories they aligned. Most of the literature fell into the “thick” category, with few papers including a theoretical perspective. Most of the empirical evidence was from the USA which focused on medical respite. The UK evidence comprised mainly local grey literature reports and was focused mainly on the hospital discharge schemes that had been set-up with the HHDF funding.

5.2 Main findings

5.3 Engagement as a distinct mechanism

Tomita and Herman (2012) carried out an RCT which evidenced reduced hospital readmission rates and other positive outcomes for 150 homeless psychiatric patients receiving a care co-ordination intervention (compared to usual care). It was suggested that the relationship with the social services worker may be as equally an important mechanism in delivering these positive results as securing housing tenure and stability.

5.4 Tackling stigma and discrimination

Pearson et al.'s (2015) review highlights the training of staff in the specific skills needed to deliver person-centred care as an important mechanism in the delivery of successful intermediate care. However, in homeless intermediate care, “cultural distance” emerges as a complicating factor. Drury (2008), for example, describes how the daily lives of healthcare providers and homeless people are so different that they may become cultural strangers, fearfully avoiding contact with each other. Cultural distance often creates the “gaps” which specialist intermediate care is then expected to fill. In their study of continuity post hospital discharge, Whiteford and Simpson (2015a) for example, describe how some community nurses will not provide care inside hostels because they are perceived as “dangerous places”.

5.5 Place of care

The strongest correlate of hospital readmission among homeless people is discharge location (Kelly et al., 2013). Kertesz et al. (2009) showed discharge to a medical respite facility was associated with significantly lower odds of readmission than discharge to “own care” (including homeless shelters). Discharge to supportive housing has similar benefits (Sadowski et al., 2009).

The notion that intermediate care might itself fill some of these gaps raises questions about scope and remit and how far this should extend into the territory of longer term care. According to Van Laere, De Wit, and Klazinga (2009), the high mortality rate among users of a Dutch medical respite scheme might be explained by the fact that the homeless population in Amsterdam most commonly comprises people with mental health challenges and long-term opiate users and alcoholics who are not able to live independently and depend on fragmented services. Many intermediate care schemes for people experiencing homelessness currently provide palliative care to compensate for the lack of provision elsewhere (Hendry, 2009; Van Laere et al., 2009; Whiteford & Simpson, 2015a).

5.6 Generic or specialist?

It is suggested that mainstream intermediate care facilities do not currently meet the needs of people who are homeless (Dorney-Smith, Hewett, & Burridge, 2016). The argument for “specialist” provision stems in large part from the challenges of co-housing people with different challenges and vulnerabilities (Lephard, 2015). For example, Lane (2005) charts the advantages and disadvantages of admitting people who use substances and are experiencing homelessness to mainstream intermediate care. On the one hand, it is considered that when someone is in recovery, they should not be exposed to the hostel environments in which drug and alcohol use is commonplace. On the other hand, it is recognised that people who use substances may have ways of being that are problematised by health providers and other uses of intermediate care services (Lane 2015).

Rather than being understood in the context of patient choice and the need for person-centred care planning, debates around “place of care” may be conflated with potentially discriminatory assumptions about the characteristics of different user groups. For example, Lane (2005) reports how some GPs and hostel managers he interviewed expressed concerns that “homeless people” would not mix well with other users of intermediate care who “tend to be elderly and extremely fragile both emotionally and physically” (p44), thus overlooking the potential for complex and unique behaviours related to a variety of life chances and conditions (e.g. dementia).

5.7 Safe spaces for women

A study of early exit from medical respite reported that “respite structure” (rules and regulations) could make some service users feel unsafe, and may account for why up to a third of people leave medical respite earlier than planned (Bauer et al., 2012). Women in this study were significantly more likely to leave respite before discharge completion than men. According to Bauer et al. (2012) gender-specific treatment models or women-only spaces could enhance safety and consequently retention outcomes.

5.8 Reablement and physical rehabilitation needs

A feasibility study reviewed the caseload of a specialist homeless primary healthcare team in Ireland to assess the need for a specialist homeless intermediate care centre (O'Carroll, O'Reilly, Corbett, & Quinn, 2006). It found that 15% of homeless people on the caseload had mobility and disability challenges attributable to healthcare needs such as stroke, hip replacement, fracture or amputation.

In the literature on homeless intermediate care, “re-enablement” or “reablement” were not mentioned. Many studies reported difficulties collaborating with adult social care which may indicate that local authority reablement services are not easily accessible to people who are homeless (Dorney-Smith & Hewett, 2016; Hewett, Halligan and Boyce, 2012; Homeless Link, 2015; Lewis, 2014; Whiteford & Simpson, 2015a).

Indeed, there is a recognised need for improved disability access in many UK homeless hostels (Dorney-Smith & Hewett, 2016).

5.9 “Reablement” environments

Mainstream residential intermediate care facilities in care homes or in hospitals often provide access to specially adapted environments, such as a “training kitchen”, in which people can practice the activities of daily living. A complaint arising from service users in one (specialist homeless) hostel-based intermediate care facility was boredom due to the lack of any kind of structured daily activity (Hendry, 2009). More recently, Pathway teams in London have employed occupational therapists to address this risk by promoting meaningful activity (Dorney-Smith, Hewett, Khan, et al., 2016).

5.10 Recovery

There is emerging consensus in the intermediate care literature specific to people experiencing homelessness that to stop the “revolving door” of hospital readmissions, support needs to extend beyond the discharge process itself, and into the community either by means of a residential “step down” facility or “floating support” arrangement (Charles et al., 2015; Dorney-Smith & Hewett, 2016; Gillespie, 2016). However, what is less clear is the ideal timeframe for such arrangements which may be termed intermediate care.

5.11 Resettlement

In Pearson et al.'s (2015 p9) review, it is noted that one drawback with (mainstream) intermediate care is that it has tended to prioritise a desire for service users to attain certain functional goals within a specified time period over service users’ self-knowledge and desire to reach a wider set of goals over longer, less clearly defined time periods.

5.12 Multidisciplinary team skill mix

An early evaluation of the HHDF concluded that those schemes taking a multidisciplinary team approach were more effective in delivering improved health and housing outcomes than those which provided access to housing in isolation (Albanese et al., 2016; Homeless Link, 2015). Without the benefit of a nursing post, some of the housing link worker projects described difficulties in engaging with what they described as the “medical model” (SERI, 2014). A nurse link worker role is mainly focused on case management rather than the delivery of clinical interventions (Dorney-Smith & Hewett, 2016).

The “skill mix” also appeared indicative of different “occupational lenses” or types and levels of comprehensiveness around how homelessness might be addressed. While the focus of the Housing Link Worker schemes was often on housing and benefits advice with “referrals on” to primary care and other agencies, Hendry (2009) describes how staff in one medical respite scheme provided a full assessment under one roof, including a full screen blood test, screening for sexually transmitted diseases, medication compliance work, pre-detox work, smoking cessation, mental health, social services, occupational therapy referrals, benefits advice and chiropody.

5.13 Involving carers and family members

In none of the material reviewed was there explicit reference to family members and carers being involved in discharge and intermediate care support planning. However, there was an account of one discharge scheme which focused specifically on linking people who were experiencing homelessness back to their country of origin or their home town where they may have a “local connection” and therefore a better chance of securing housing and social care support (Lewis, 2014).

5.14 Mechanisms for integrating services

For many of the HHDF projects, integration into the hospital setting was described as challenging (Homeless Link, 2015). Formal protocols were important, but the main problem was sustaining them (Housing Learning and Improvement Network, 2009). Successful ways of doing this and raising awareness about the schemes more generally included having the scheme championed by senior hospital staff and actively promoting the scheme through posters, leaflets and contact cards (Albanese et al., 2016 p10). Co-location and being “a face” on the ward was thought to help ensure the flow of referrals and ease of communication (Charles et al., 2015; Housing Learning and Improvement Network, 2014). Participating in ward rounds, attendance at weekly hospital staff meetings to discuss patient discharge planning, and running reflective practice and training sessions for hospital staff on the subject of homelessness were also considered helpful.

5.15 Advocacy as an additional key mechanism

6.1 Summary of findings

The additional evidence presented above does then broadly support the validity or usefulness of Pearson et al.'s (2015) conceptual framework for understanding “what works and why” in intermediate care. This is with regard to three key programme theories: the importance of consulting with service users (PT1), working in ways which are enabling (PT2) and ensuring integrated professional working (PT3). However, it might be suggested that these three “programme theories” are likely to be implicated in the successful delivery of many other health and social care services. Herein, lies a potential limitation of the current framework in that it may not answer some of the more complex or nuanced questions relating specifically to the development of intermediate care services.

The first challenging question to emerge from this review is how to maintain the integrity of intermediate care as a “time limited” intervention. This issue arises where there is a need to encompass multiple and overlapping rehabilitative and resettlement goals which may require housing solutions underpinned by much longer term or continuing health and social care support. Indeed, the issue of “timeframe” and scope is relevant to commissioners of intermediate care for both older people and people who are homeless. It is acknowledged that the rehabilitation of older people has sometimes fallen short because it has often prioritised short-term reablement goals linked to “physical functioning” over and above those for inclusion and citizenship. Meanwhile, intermediate care for people who are homeless has reversed the “occupational lens” prioritising longer term resettlement and recovery outcomes over and above those for reablement. How to encompass these different needs and vulnerabilities under a single service banner is a significant additional challenge, with the danger that “specialist” provision starts to confirm cultural distance (e.g. “elderly people” are quiet and frail, “homeless people” are challenging and disruptive).

These issues are compounded in times of austerity, when the integrity of intermediate care is further compromised by the need not just to “fill the gaps” in local provision but on occasions to substitute for the widespread loss of longer term support services. As Backer et al. (2007) suggest, discharge planning and intermediate care will have little impact unless housing and other services are available. It is recognised that this poses perhaps the most serious threat to the viability of intermediate care as a service organisation and delivery construct. If the boundaries with longer term care start to blur, then intermediate care risks quickly becoming “blocked” (Dorney-Smith, Hewett, Khan, et al., 2016; Poymow et al. 2006).

In CTI, “scope” is clearly defined as being about the management of transitions rather than specific kinds of “needs” or “gaps” in existing provision. It is thus generic in that it can be applied to all client groups and can potentially be operationalised in any given local context as the aim is to “weave together” the resources and infrastructure that are already in existence. The “timeframe” for the intermediate care intervention is also determined not by any rigid “service led” criteria but by the adaptive capacity of the local context to meet the person's needs. It might be added that where CTI becomes “blocked” (i.e. there are no appropriate services to take over responsibility) then this should ring alarm bells for commissioners that there are “cracks” in local provision.

Indeed, CTI also seems to encapsulate the “how to” of what Parker-Radford (2015) terms a “transition of care approach”. This has the additional advantage of shifting the focus of the “organisational lens” from the acute sector to the management of a much wider range of transitions (e.g. “prison-to-community” and “armed forces-to-civilian”). It is therefore potentially key to continuity and seamless care as seen from the perspective of people who use services.

7.1 Limitations

The limitations of the review are that while we have outlined our search strategy judgements have been made about the interpretations of the findings. Identifying programme theories and mechanisms from sources that are not explicitly theory driven, or do not provide adequate descriptions of the services, is also problematic. Nevertheless, using realist synthesis to build “conceptual frameworks” which can guide future intervention development about ‘what works’ for whom and in what circumstances may be an important step in complementing more traditional evidence-based approaches which often leave these questions unaddressed.