Integrated care: starting with housing advice on hospital wards

Long before COVID-19, the delayed discharge of individuals who are medically fit enough to leave acute settings was a long-term problem for the NHS. But in these extraordinary times, and as the winter months approach, reducing the number of people who are ready to leave hospital, but unable to move on due to a lack of agreed further care or home to return to,  is going to be an even bigger priority. 

In its recent health and social care bill, the government demonstrated its commitment to person-centred integrated care. Indeed, we believe it will take health, social care, housing and other public services all working together to properly address this challenge for patients and healthcare professionals, and to ensure that vital inpatient beds are available for people who need them, when they need them.

Common barriers

We know that there are plans and funding to do this, and were pleased that last month the Better Care Fund policy framework (2021/22) was updated, with funding available this year to support early discharge from hospitals. This £6.9 billion fund requires clinical commissioning groups and local government to agree a joint plan for achieving integrated care.

This is why our organisation is sponsoring the online event, Integration and innovation: Supporting the mental health system through community-based solutions. I will be joined by some distinguished speakers, including Angus Gartshore, director of delivery improvement and interim community mental health director at Camden and Islington NHS Foundation Trust, to talk about our joint work.

We will highlight two of the most common barriers preventing patients from being able to leave mental health units: the need for specialist housing advice and the ability to access appropriate community-based support.

Together, we will outline how Look Ahead and Camden and Islington NHS Foundation Trust have worked together to remove these barriers, developing a model that could be replicated up and down the country. Patients with complex housing or social care needs do not need to remain in hospital if the right help is made available to them. 

Specialist housing and social care knowledge

In Camden and Islington, Look Ahead’s specialist support and housing staff are co-located with the trust’s discharge teams to ensure patients are able to enter community-based settings directly from inpatient wards.  

The project began as a six-month pilot during the pandemic when the trust, like many others, was under a huge amount of pressure. During the pilot – which has since been extended – the team of three experienced housing staff and a part-time manager supported more than 130 patients. 

Using their specialist housing and social care knowledge, they worked with the wider NHS team – including social workers and psychiatrists – to reduce the delayed discharge of patients from an average of 50 days to 42 days. 

Individuals are not on acute wards for longer than they need to be, thus freeing up beds sooner than would otherwise have been the case

Almost three-quarters (72 per cent) of patients were discharged to suitable accommodation, and only 3 per cent have since been readmitted to hospital – the previous readmission rate was 10 per cent.

With shared access to patient records and the ability to hold collaborative meetings with NHS community and in-house colleagues, it has been possible for the Look Ahead team to help address complex issues as they arise. 

As a result, individuals are not on acute wards for longer than they need to be, thus freeing up beds sooner than would otherwise have been the case – more than a week earlier in most cases.

Longer-term outcomes for patients

At Look Ahead, we believe our work with Camden and Islington NHS Foundation Trust is just the tip of the iceberg. There is so much more we and other supported housing providers can do to help the NHS. At specialist supported housing provider Look Ahead, we’ve been able to demonstrate the value of integration. Through our work with Camden and Islington NHS Foundation Trust, we’ve shown how investing in making it possible for supported housing professionals to work alongside NHS clinical staff while patients are still on hospital wards not only leads to positive, longer-term outcomes for individual patients – it also saves public money.

In February this year, we published a report written by Europe Economics. It found that if the integrated mental health and supported housing systems we have established in parts of London and the South East were implemented across the rest of the country, the NHS could save approximately £950 million per year.

In terms of community mental health services, we have five key housing models:

• crisis and recovery houses
• rehabilitation services
• forensic step-down
• housing and advice workers
• community-based support. 

But at the Mental Health Network webinar on 27 September, we’ll be focusing on the outcomes achieved by the Camden and Islington service. 

With new government funding available for integrated care, it is now time for health and wellbeing boards to embrace new methods for providing community-based care and support such as the ones developed by Look Ahead. If you need support in your trust to help delayed discharge, please do get in touch. 

Rosa Napolitano is executive director of business development and innovation at Look Ahead. Follow the organisation on Twitter @lookaheadtweets