Guidance

Discharging people at risk of or experiencing homelessness

Published 26 January 2024

Applies to England

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About this guidance

This guidance is for staff in care transfer hubs and others involved in planning discharge of patients (including NHS, local authority, housing and other partners).

It includes examples of best practice, including step by step guides and example pathways, which can be adapted to suit local practices, for discharging patients:

  • at risk of or experiencing homelessness
  • with safeguarding concerns
  • with no recourse to public funds (NRPF)

Further guidance

This quick guide builds on the Home First: Discharge to Assess and homelessness guidance produced by the Local Government Association (LGA) and Association of Directors of Adult Social Services (ADASS).

Background

Homelessness is a health issue

Homelessness is not just about housing. People at risk of or experiencing homelessness often have physical and mental ill health including high levels of frailty, brain injury and disability.

These long-term conditions interact with each other (so called ‘multimorbidity’) and are often exacerbated by:

  • poverty
  • psychological trauma
  • drug and alcohol use
  • self-neglect

People at risk of or experiencing homelessness die at a much younger age on average than the general population. These premature deaths could be prevented with better access to healthcare.

The discharge system needs to better meet the needs of people from inclusion health groups to reduce avoidable delayed discharges, as highlighted in NHS England’s (NHSE’s) framework on inclusion health.

The guidance on this page follows on from NHSE’s guidance for emergency departments on Supporting people experiencing homelessness and rough sleeping.

Admission to hospital should be seen as a ‘window of opportunity’ to address these complex needs including obtaining consent for the duty to refer: referral form where required and support a move out of homelessness.

In line with the principles of discharge to assess, NHS and local authority partners should ensure that people with complex needs receive appropriate care in community settings (including specialist intermediate care where available). This should allow time for health, housing, social care and voluntary, community and social enterprise (VCSE) services to undertake a comprehensive multidisciplinary assessment of patients’ longer-term needs.

Ensuring people get the right support to be safely discharged in a timely manner is important both for them and for the health and care system. It can help individuals rebuild their lives and reduce pressures on health and care services caused by repeat attendance, readmission and delayed transfers of care.

In addition, patients at risk of or experiencing homelessness typically have much longer stays in hospital after they become medically fit than other cohorts. Continuous improvement of the processes around discharge of people at risk of or experiencing homelessness therefore has significant benefits for both the individuals and the wider health and care system.

Intermediate care

People at risk of or experiencing homelessness should not be denied access to intermediate care. There is strong evidence (supported by the National Institute for Health and Care Excellence (NICE) that specialist intermediate care services for people at risk of or experiencing homelessness are effective and cost-effective.

NHSE’s Intermediate care framework for rehabilitation, reablement and recovery following hospital discharge recommends consideration of specialist intermediate care pathways for groups such as those at risk of or experiencing homelessness.

The guidance on this page relates to the existing Hospital discharge and community support guidance, which reflects recognition of the specific needs of certain groups and the importance of reducing health inequalities as part of wider work to tackle delayed discharge.

There is no single ‘blueprint’ for specialist homeless intermediate care services. They should be developed in response to need and integrated so that ‘mainstream’ and ‘specialist’ services work seamlessly together. Bespoke services are needed to ensure people at risk of or experiencing homelessness are not excluded from short-term, post-discharge recovery and support because of their housing status.

Duty to refer 

Under the Homelessness Reduction Act 2017, NHS trusts have a statutory duty to refer, which includes referring admitted patients at risk of or experiencing homelessness to a local housing authority within 56 days.

For more information, see Chapter 4 of the Homelessness code of guidance for local authorities.

Assessing patients for safeguarding and care needs

Unsafe discharge can trigger a safeguarding concern linked to:

  • neglect or self-neglect
  • acts of omission (failure to provide access to appropriate health, care and support)

Multi-agency adult safeguarding has led to increased scrutiny of poor hospital discharge practices highlighted by Safeguarding Adult Reviews (SARs) into the deaths of people at risk of or experiencing homelessness.

The Care Act 2014 contains duties on local authorities to:

  • carry out assessments where it appears someone needs care and support (section 9)
  • consider someone’s wellbeing as part of that assessment (section 1)
  • involve patients and carers in planning discharge where someone is likely to require care and support after discharge (section 74)

If the local authority suspects someone has needs for care and support which place them at risk of abuse, neglect or self-neglect, it must carry out enquiries to enable it to decide whether any action should be taken in that adult’s case (section 42).

Local authorities carrying out these functions must:

  • promote the person’s personal dignity, and the control they have over day-to-day life
  • consider:
    • the suitability of their living conditions
    • their emotional, social and economic wellbeing
    • their contribution to society

A person’s ‘ordinary residence’ or ‘local connection’ is only relevant after the person has been assessed as eligible for accommodation and/or social care support. It should not prevent a local authority from:

When to make a referral: step by step guide

Use this step by step guide to assess whether you should refer a patient to the local authority for a needs assessment or with a safeguarding concern.

Section 9 assessment

If the patient appears to have care and support needs, you should make a referral for a Care Act 2014 section 9 assessment with the patient’s consent.

Section 11 referral

If the patient refuses a needs assessment, you should make a referral to the local authority citing section 11 of the Care Act 2014 if the responsible clinician believes the patient to either:

  • lack mental capacity to refuse the assessment
  • be at risk of neglect or self-neglect

Section 42(1) referral

If the patient meets the full criteria for section 42(1) of the Care Act 2014, you should make an adult safeguarding concern referral to both:

  • the local authority
  • your NHS trust’s safeguarding representatives

The patient meets the full criteria for section 42(1) if all the following are true:

  • they have needs for care and support
  • they are experiencing or are at risk of abuse or neglect
  • as a result of those needs, they are unable to protect themselves against the abuse or neglect or the risk of it

Further guidance

See:

Assess which pathway best meets your patient’s level of post-discharge care and support

All patients at risk of or experiencing homelessness have unmet need and therefore require involvement of the care transfer hub.

The care transfer hub should hold local information on available services and accommodation for patients at risk of or experiencing homelessness.

There are 3 pathways and examples of services dedicated to supporting these patients.

Pathway 1: discharge to usual place of residence (including temporary accommodation) with health and/or social care and support

Patients at risk of or experiencing homelessness should receive a welfare check on the day of discharge and settle-in support (especially where hotels are being used for discharge).

Example of specialist provision

In south-east London, the Red Cross homeless settle-in service works with local authority reablement teams to provide short-term floating support for up to 6 weeks to patients at risk of or experiencing homelessness who are discharged to hotels and other temporary accommodation.

Pathway 2: community bedded setting with health and/or social care and support

Step-down support continues until longer-term accommodation is in place. Local system partners take action to coordinate move-on.

Examples of specialist provision

Oxfordshire Step Down Houses provide homely (non-Care Quality Commission registered) accommodation in 3 houses with case workers on site part of the day and local authority reablement in-reach as required.

Mildmay Mission Hospital in London provides 24-hour step-down nursing care to patients at risk of or experiencing homelessness leaving London hospitals. This is sometimes called ‘medical respite’.

Pathway 3: care home placement for those with the most complex needs who are likely to need residential or nursing care on a longer-term basis

Long-term care services may be required where chronic homelessness has led to early or complex health and care needs.

Examples of specialist provision

The North Central London Specialist Homeless Intermediate Care Team provides in-reach support to patients at risk of or experiencing homelessness who enter nursing homes and other bedded rehabilitation facilities that work mainly with older people.

When to assess

Best practice is for these assessments to be done in a person’s home after a period of recovery and rehabilitation. For people at risk of or experiencing homelessness, the local authority has responsibility to provide temporary accommodation for this assessment.

As an exception to the general principle of discharge to assess, it may be necessary to carry out an assessment before discharge from hospital where it is considered that discharging someone without such an assessment would cause a safeguarding risk.

Continuous evaluation and monitoring

Monitoring and evaluation from care transfer hubs should be integrated into wider intermediate care governance. Integrated management dashboards specifically on homelessness are available to collect and analyse data by site, service and location.

Assessing patients with no recourse to public funds (NRPF)

Anyone who is subject to immigration control (meaning they need permission to enter or remain in the UK) will usually have NRPF. This means they cannot claim benefits or housing assistance unless an exemption applies.

See Public funds guidance to identify whether an individual’s immigration status has an NRPF condition attached.

On discharge, a patient with NRPF will have no access to:

It is the local authority’s responsibility to consider whether duties and powers apply under the Care Act 2014 to provide accommodation.

Where a local authority may not have responsibility for housing assistance due to NRPF, the local authority may have a responsibility to assess and meet an adult’s need for social care under the Care Act 2014, and accommodation and subsistence support can be provided as part of the Care Act response. If the patient is ineligible for support from their local authority, they must still be provided with information and advice to help prevent their homelessness (see ‘If the patient is not eligible for care and support’ below).

For certain groups such as those ‘in breach of immigration laws’, care and support can only be provided where this is necessary to avoid a breach of the person’s rights under the European Convention on Human Rights - that is, because it is not practically or legally possible for the person to return to that country, or doing so would breach their human rights (see schedule 3 to the Nationality, Immigration and Asylum Act 2002).

It is good practice for the NHS and local authority to establish referral pathways and consider commissioning services to help patients access immigration and welfare rights advice prior to discharge or while being accommodated. Local authorities should establish protocols setting out who has responsibility for case management and strategic oversight if there is no designated NRPF team.

NRPF guidance and resources

The NRPF Network produces resources around NRPF and social care guidance endorsed by ADASS and LGA. It can also provide advice about the NRPF Connect service, which can assist with status checking and case management.

Assessing patients with NRPF and homelessness pre-discharge: step by step guide

Use the guide below to determine the steps required to discharge a patient with NRPF at risk of or experiencing homelessness.

Refer for care and accommodation assessment

Regardless of the patient’s immigration status, you should refer them to the housing authority for a care and accommodation assessment as early as possible, to comply with the duty to refer (see section 213B of the Housing Act 1996.

Establish the patient’s immigration status

You should also identify the patient’s immigration status as early as possible.

If you do not have sufficient information to do this, check their immigration status using the Home Office’s Status Verification Enquiries and Checking (SVEC) service. You should do this with the patient’s consent.

See Forms for NHS staff: NHS visitor and migrant health charging.

You should flag a patient as an overseas visitor on your hospital systems.

Once immigration status confirmed, contact the local authority

Once you’ve confirmed the patient is subject to immigration control and has NRPF, notify and obtain advice from the local authority’s specialist NRPF team or social worker.

The local authority can help the patient to access advice on immigration, welfare rights and legal issues.

Free of charge services

The following services must be provided free of charge to a person with NRPF:

  • continuing NHS healthcare to meet long-term complex health needs (can include accommodation)
  • section 117 mental health aftercare to meet a need arising from or related to the person’s mental disorder (can include ‘supported’ accommodation arranged and provided by NHS and local authority)

If the patient is eligible for care and support

If the patient is eligible for care and support post-discharge under the Care Act 2014 (section 18, section 19(1) or section 19 (3)) this means:

  • the person is eligible for local authority funding
  • their NRPF status is not relevant

Note: the patient may also be subject to a human rights assessment if they are in certain groups such as those ‘in breach of immigration laws’.

If the patient is not eligible for care and support

If the patient does not meet the Care Act 2014 threshold for onward residential care post-discharge, the local authority should look at other accommodation options, such as:

  • night shelters (see a list of night shelters on the Pavement magazine)
  • NRPF specific accommodation providers (part of NACCOM (No Accommodation Network))
  • Home Office support for people seeking asylum, via Migrant Help
  • children’s services: these can provide accommodation and support when a child is in need
  • VCSE sector support (provision is limited)

See also Homeless England’s database of all homelessness organisations.

Whether or not the patient is eligible for care and support under the Care Act 2014, you should help the person to achieve a sustainable pathway out of destitution.

Preventing delays in discharge for people at risk of or experiencing homelessness:  best practice

All patients at risk of or experiencing homelessness have unmet need and require referral to the care transfer hub to manage the complex discharge. This should take place regardless of whether there is a specialist homelessness health team in the hospital.

Early discharge planning

Clinical teams should identify patients at risk of or experiencing homelessness, including those with NRPF, at the earliest opportunity. Note: some patients may not wish to disclose this information due to stigma.

Homelessness checklist

Ward staff should start (or continue, if started in the emergency department) a homelessness checklist.

See the example checklist in NHSE’s guidance on Supporting people experiencing homelessness and rough sleeping).

Duty to refer

Ward staff should complete the duty to refer form. This is required by the relevant local authority homelessness or housing options teams.

See a list of email addresses for local authority duty to refer teams.

All ward staff should be trained in the duty to refer and trauma-informed practice (see NHSE training on homelessness and training on vulnerabilities and trauma-informed practice).

Register patients with a GP

If the patient is not registered with a GP, ward staff should support them to do so. No fixed address or immigration status is required.

See How to register with a GP surgery.

In hospitals that see more than 200 homeless patients per year, ward staff should have access to a specialist multidisciplinary homeless discharge team.

This team should provide clinical in-reach, such as mental health or drug or alcohol dependency to prevent early self-discharge, and use the opportunity to engage the patient with the healthcare they need.

See the charity Pathway for more information on clinical in-reach services for homeless people.

Understand the current housing situation and agree the support needed post-discharge

Do this through the multidisciplinary team working in the care transfer hub. You should consider:

  • responsibilities in section 117 of the Mental Health Act 1983
  • any issues related to safeguarding
  • the most appropriate discharge to assess pathway (see ‘Assess which pathway best meets your patient’s level of post-discharge care and support’ above)

Appropriate safeguards

Incorporate appropriate safeguards for people who require onward care and support and who are at risk of or experiencing homelessness, or living in poor or unsuitable housing.

Housing officers

Dedicated housing options officers should be attached to the care transfer hub, with in-reach to wards for early discharge planning and move-on support, with the benefit of access to NHS and local authority systems.

Designated lead for discharge of patients at risk of or experiencing homelessness

A designated lead for discharge of patients at risk of or experiencing homelessness should be appointed, regardless of whether there is a pathway team. The lead should either case manage those individuals or have oversight of those discharges. They should work with housing officers to support people along the appropriate pathway.

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