People experiencing homelessness

How can evidence optimise Out-of-Hospital Care for people experiencing homelessness?


In the precarious socio-economic context that the UK is currently facing, rates of homelessness have been on the rise. As such, Out-Of-Hospital-Care-Models (OOHCMs) have become increasingly important for tackling the multiple health and social care obstacles that people experiencing homelessness may face. But, how do we know which OOHCMs are most effective? This is a critical question for informing policy and practice, and has been a key focus on the work on homelessness that we have been conducting at the Care Policy and Evaluation Centre (CPEC) at the London School of Economics and Political Science (LSE), led primarily by Dr Michela Tinelli.

In 2022, England witnessed an alarming 26% increase in rough sleeping, signalling a reversal from prior declining trends. Homelessness isn't confined to housing issues alone; it intertwines with a myriad of physical and mental health challenges. These complexities, termed 'multimorbidity,' are often made worse by factors like poverty, substance abuse, and neglect. These factors contribute to a starkly shortened lifespan of people experiencing homelessness, who have a life expectancy of 42 years, primarily due to treatable conditions like cardiovascular disease. This highlights the pressing need for intervention.

Towards a framework for evaluating Out-of-Hospital Care Models

For the past ten years, there has been an increased focus on evaluating Out-Of-Hospital Care Models (OOHCMs) in England, to which researchers at CPEC, including Dr Tinelli, have contributed. The aims of this work are to provide an understanding of the most effective way of implementing out-of-hospital care; to describe how models are being integrated as part of Discharge to Assess (D2A); to identify the challenges to systems and service delivery; and to further test the key components of effective and cost-effective models.

In 2020, the UK Department of Health and Social Care (DHSC), Department for Levelling Up, Housing and Communities (DLUHC), and the Ministry of Justice collectively allocated £16 million in funding to 17 local authorities to establish and test models for OOHC tailored to people experiencing homelessness. The design of this programme was informed by the research on OOHCM evaluations from CPEC, as well as King’s College London (KCL), University College London (UCL), and other partners. The first evaluation of this programme, led by Dr Tinelli and Professor Cornes from KCL, collected data on service delivery costs and process, economic implications for the NHS, feedback from individuals on their health outcomes and experiences with care, preferences for service provision, and more.

Active involvement of individuals experiencing homelessness has been integral to the evaluation process. These individuals assumed roles as specialised advisors and peer researchers, offering invaluable insights into the programme's effectiveness. Their firsthand experiences provided an authentic perspective that was previously absent, significantly enriching our understanding of what works for OOHCMs. As well as this, representatives from local authorities, Integrated Care Systems, NHS England, DHSC, and other government departments, also guided and supported the study. This collective effort ensures that the evaluations are not only comprehensive but also inclusive and useful, reflecting real-life experiences and needs, thereby aiding the development of more impactful and relevant solutions to address homelessness.

Insights into action: Visualising findings with digital dashboards

A key outcome of this evaluation was that first-generation digital dashboards have been developed to collect, analyse, and compare metrics related to OOHCMs by site, location, type of service provision and more. These dashboards facilitate the routine assessment of trends for individual providers, local areas, and the entire nation, all while benchmarking against relevant standards.

The dashboards have already been used by service providers in London and Oxfordshire to obtain (collectively) funding exceeding £5 million, that will enable to sustain their service delivery for an additional three years. Additionally, NHS England has already incorporated dashboards into their Good Practice guidance for integrated care boards (including commissioners and providers) for intermediate care. They have also advertised the dashboards in the NHS Inclusion Health Framework.

Next steps for increasing data-driven decision-making

Following this evaluation of the OOHCMs and the development of the digital dashboards which have proven useful to both local authorities and national bodies, conversations currently underway with to potentially develop an automated version of the dashboards to ensure continuous monitoring of long-term service performance through data collection, analysis, and online visualisations. As well as this, Dr Tinelli is also contributing to a number of other projects related to data visualisation, homelessness and social care, including:

  • A NIHR School for Social Care Research (NIHR SSCR) grant to collaborate with the People’s Recovery Project to build capacity for future evaluation of residential treatment for people experiencing homelessness and addiction
  • An NIHR-funded project co-led by KCL and UCL, "Housing Model Evaluation (HOME) - Improvements in health associated with housing-led systems for people experiencing homelessness"
  • An NIHR SCCR Development Research Leaders Award fellowship, through which she is applying choice modelling to understand service user preferences of people experiencing homelessness

Through contributing economic and data-driven perspectives to OOCHMs, Dr Tinelli hopes to improve the effectiveness of such interventions and ensure people experiencing homelessness receive adequate support, As she states,

I see social care and healthcare systems as intricate puzzles, and am eager to tackle them -especially within the context of homelessness. My vision is that all stakeholders working for the delivery and implementation of care and support are connected through a continuous flow of information that can be analysed in real-time to support better decision-making. My work extends beyond research, aiming to make tangible improvements in the health and happiness of individuals, communities, and the betterment of society.