The Development of an Inclusion Health Integrated Care Programme for Homeless Adults in Dublin, Ireland

Abstract

Introduction: Since 2013, the number of homeless adults in Dublin has doubled. Homeless people have higher morbidity and mortality, use a disproportionate amount of healthcare resources and generate a large volume of potentially preventable healthcare and other costs compared to more privileged individuals. Homeless people frequently need the input of multiple health and social care providers. We sought to develop and pilot a person-centred, multi-disciplinary approach to care delivery through an Inclusion Health Integrated Care Programme for homeless people attending St James’s Hospital. Methods: Action research approach: a programme was developed, and iteratively used and evaluated by the team at a weekly quality-improvement QI team meeting. Routinely collected administrative data was utilised to capture hospital presentations and length of stay for homeless individuals and the number of homeless people in the hospital catchment area. A survey was carried out to determine the views of hospital staff on the programme. Results: The Inclusion Health team, based in St James’s Hospital SJH, Dublin, was piloted from August 2016- August 2017. The team consisted of a part-time consultant physician and a full- time nurse manager funded by the National Nursing and Midwifery Planning and Development Unit. Patients were referred to the team by community-based health and social care providers or by hospital staff. The team reviewed patient cases during their inpatient admission, and continued to be involved in care co-ordination after discharge through a weekly inter-agency integrated care meeting. The team provided input to 360 homeless admissions during the one-year pilot. The approach was feasible and acceptable, with on-going engagement and attendance at weekly meetings by hospital and NGO staff. Feedback from community-based agencies and hospital staff was that the Programme delivered “a more coordinated approach to patient care, improved discharge planning with homeless services and streamlined admissions all of which have resulted in more positive patient outcomes.” During the pilot period, the number of homeless admissions to SJH fell from 0.03 to 0.017 per capita of homeless adults in Dublin per quarter. The mean length of stay for homeless adults in SJH fell from 16 days S.D 7 days to 7 days S.D. 2.5 days. The estimated bed days saving over the one-year pilot was 3,668. Limitations: A randomised controlled trial of integrated care versus no integrated care would enable more thorough assessment of intervention causality. A RCT design suitable for assessment of a complex intervention e.g. stepped wedge may be required. Conclusion: An Inclusion Health Integrated Care Programme is feasible and acceptable and offers benefits to patients and health care providers, with evidence of reduced need for costly unscheduled healthcare during the pilot programme.