The Pathway model offers a new way to help people who are homeless. It trains NHS staff to help patients access the accommodation, care and support they need to recover and get life onto a better pathway after their stay in hospital.

Pathway teams are led by specialist GP’s who bring their experience caring for homeless people in the community, as well as expertise in methadone prescribing, personality disorder, and chronic disease management.

Nursing staff manage the team caseload and bring vital clinical experience in homelessness, addictions and/or mental health.

Housing specialists bring their expertise to the service and help build links with voluntary sector services in the community. Some Pathway teams also include Care Navigators who have personal experience of homelessness, and larger teams also include occupational therapists, social workers and mental health practitioners.

Teams work with patients to create bespoke care plans for their support, including referrals to addiction services, ongoing treatment for health issues such as hepatitis C and tuberculosis, and community services offering social care. Coordinating input from housing departments, mental health and addictions services, social services, community and charity sector partners, Pathway teams provide empathetic, patient-centred, recovery-focused care.

Based in the hospital, Pathway teams:

  • Provide expert advice and clinical advocacy around homeless and inclusion health issues (such as substance misuse and substitute prescribing) for inpatients, improving care and treatment outcomes
  • ensure patients with complex needs are able to engage with health and other services through holistic inpatient support and care, thereby reducing rates of early self-discharge
  • help homeless patients find somewhere safe and appropriate to stay on discharge, taking into account their needs around health, care and general support
  • support patients with financial issues, welfare entitlement and to access specialist legal help where possible
  • help to replace lost ID documents
  • ensure patients are registered with a GP for ongoing care
  • refer and signpost to specialist community services to help with a variety of social, mental and physical health, and addictions issues
  • reconnect patients to family and social support networks on discharge