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Practice comment

We must tackle unsafe hospital discharge for homeless patients  

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Nurses need to resist the pressure to discharge homeless patients inappropriately, and must act to ensure better outcomes for them, says Samantha Dorney-Smith

Homeless people experience more health problems and have poorer access to healthcare compared with the general population. They also have a higher rate of attendance and admission to hospital, and once there, problems continue.

Homeless patients suffer a higher rate of inadequate inpatient management, and frequently experience unsafe hospital discharge, such as self-discharge, inappropriately early discharge, and/or discharge to inappropriate accommodation.

Hospital admission is often the only time a homeless person is free of substance misuse, well cared for, and in a position to talk coherently with healthcare professionals. It is also a time when there is potential for reflection, and life changes can be made. However, this opportunity is often missed.

A common reason for self-discharge relates to substance misuse treatment. Recently, an ambulance crew, when collecting a patient from one of our hostels, drove the patient to the pharmacist for his daily methadone dose, on the way to A&E.

This was an example of excellent, patient-centred practice, and demonstrated a clear understanding of that patient’s needs. A client drinking 15L of cider a day, or injecting £100 of heroin a day, will not stay long in hospital without the addiction problem being treated.

Failed discharges are common. Once in hospital, hostel dwellers often recognise that their hostel accommodation is unsafe, and decide they do not want to return. However, because they are perceived as having a “home”, their concerns are not heard.

In fact, homeless hostels can be extremely unsafe. Although the voluntary organisations that run them do an excellent job, these hostels are full of clients actively engaged in substance misuse, with a variety of mental health disorders. Health outcomes are often appalling. In one hostel last year there were seven deaths, at an average age of 38 years.

Clients requesting not to return to their hostel should always be referred immediately to a social worker, and need strong advocacy to fight their case.

Another common situation is where hostel clients are admitted to hospital, and are unable to articulate clear opinions about their future. For example, many homeless patients have cognitive deficits (secondary to alcohol misuse), or are severely depressed, and have mental capacity issues. These patients may not be able to conceptualise the risks of being placed in a hostel. Expert psychiatric opinion might be needed and a working knowledge of the Mental Capacity Act is required by all professionals involved in discharging homeless patients.

“Hospital admission is a time when there is potential for reflection, and life changes can be made. However, this opportunity is often missed.”

Some clients have not been “verified” as homeless, and may need to be discharged to a homeless persons’ unit. In these cases patient hotels and/or intermediate care settings should be considered. A welfare rights/benefits worker should also be involved.

Wherever homeless patients are discharged to, every effort should be made to ensure adequate follow up. Check whether they have a GP, and if not, try to register them. Refer them to the nearest homeless health team, and check they know how to access these services. Ensure you have active addresses for clients for any outpatient appointments.

There is often pressure to discharge homeless patients, and a feeling they will quickly become “bed blockers”. There is even sometimes a perception that other patients may be more “deserving” of these beds. Although evidence does suggest that homeless people stay in hospital twice as long as others, it also indicates they are generally twice as sick. There is no evidence they become “bed blockers” any more than the general population. However, if safer discharges do mean that clients end up staying in a bed longer, the trade off will be less readmission and much better outcomes for the most vulnerable patients.

So now I encourage you to ask yourself – are you discharging your homeless patients safely?

AUTHOR Samantha Dorney-Smith is nurse practitioner, Three Boroughs Homeless Team, south London, and co-chair, London Standing Conference on Nursing and Midwifery (Homelessness Group).

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