Homeless Hospital Assessment Tool

clipboard checklist

Dr Bruce Taylor, from Gloucestershire Hospitals Foundation Trust, sets out why he’s helped to develop a hospital admissions assessment tool for those experiencing homelessness:

Until the day homelessness is solved, we welcome everyone, housed or not, into our hospital.

Our homeless patients are 6 times more likely to attend A&E and 4 times more likely to be admitted into hospital, with their admission being 3 times longer than that of our patients who have a permanent roof over their head. This is therefore a great opportunity to engage with our patient, treat them, and refer them on where necessary.

Our typical process in ED is to complete Duty to Refer applications; call the Housing Officer and Homeless Specialist Nurse; and contact the drug and alcohol teams . All this within a few hours. Our job (seemingly) done.

But, wait, surely there is so much more we could achieve in the short time we have?

Just as we have the one-hour window to recognise and initiate treatment for sepsis to avoid terrible morbidity, why not use this opportunity to undertake a comprehensive, global assessment of a homeless patient within their first hour of admission?

We realised that for certain patients, their admission to hospital was a golden opportunity to give more help. With input from Dr Pippa Medcalf, I designed the Homeless Assessment Tool (HAT).

On one side of A4, this Tool is a comprehensive checklist for every doctor and nurse to commence at admission and run through as an aide memoire when caring for our homeless patients. Blood borne virus screen? Check. Nutrition? Check. Sexual health issues? Check. The HAT has it covered.

We have begun educating our junior doctors working within the Trust on the HAT’s importance and how we will roll it out. We are now moving to have it embedded in our hospital IT system so the checklist appears and is activated automatically when a homeless person is admitted.

We have a wonderfully unique and opportunistic moment to really make a difference while homeless patients are under our roof. The HAT ensures we are truly addressing and managing the dynamic and complex care needs of our homeless patients, with a holistic and multi-disciplinary approach, aiming to streamline their admission and their discharge.


Download Version 1 of the HOMELESS ADMISSION TOOL. Any feedback or suggested improvements, please drop us a line at: info@pathway.org.uk

Street Outreach: New Annex to Faculty Standards

A new annex to the Faculty Standards has been drawn up by advanced nurse practitioner, Rosa Ungpakorn, winner of the  2020 RCNi Advanced Nursing Practice Award.

Rosa won her award last year for her nurse-led street outreach project in Westminster, which in turn led to the creation of this annex.

Rosa developed the “Guidelines for health related street outreach to people experiencing homelessness” while she was planning improvements in her own service. They are based on her research exploring the perceptions of people with experience of sleeping rough, and on consultation with health and social care workers providing street outreach around the UK.

Street outreach is an assertive strategy that aims to bring healthcare directly to people who are sleeping rough. The Faculty Standards state that specialist primary care services should provide street outreach, however there has previously been no guidance detailing how to deliver it.

The guidelines have been co-authored and published by the London Network of Nurses and Midwives Homelessness Group (LNNM). They are written for healthcare workers from any professional background working with people experiencing homelessness. The aim is encourage services to plan new health related street outreach projects, or to review their existing street outreach.

Homeless health services cover a range of locations, where the demographics and needs of people sleeping rough may differ widely. The guidelines are therefore designed as a flexible tool for sharing best practice examples and innovative ideas, allowing services across the UK to apply them as appropriate to their areas. They include practical advice on: the reasons to provide health related street outreach; the skills and training healthcare workers will need; the timings, locations and recommended approach of street outreach; and what items to provide to patients.

Rosa and the LNNM would like to thank the Faculty for endorsing the guidelines and including them as an annex to the Standards.

Pathway COVID19 reflections – London Hotels







By Samantha Dorney-Smith, Nursing Fellow, Pathway


My usual role is Nursing Fellow for Pathway, and the Homeless Health Programme Lead for the Queen’s Nursing Institute. I have also been working one evening a week since January 2020 for Doctors of the World undertaking medical outreach in the City of London.

On Saturday 20th March 2020 I arrived to volunteer at the MHCLG funded Limehouse Holiday Inn alongside volunteer GP Sophie Mylan. I had been asked that week by the Find and Treat Clinical Lead Dr Al Story to find volunteers through the LNNM network to help the COVID19 effort, and thought I should volunteer to be one of the first on scene.

The ‘Everyone In’ programme of hotels had only been finally agreed that week, and Limehouse was the first of these hotels to start taking clients from night shelters, the No Second Night Out projects and Heathrow airport. The day before, I had been sitting with Find and Treat and we had been assured everyone had been triaged to assess medical vulnerability, and to find out if they had symptoms – so I was initially volunteering to check in and see if any support was needed.

When I arrived, of the 37 clients already at the hotel, staff identified to us immediately three clients that they thought were medically vulnerable. After our clinical assessment, those three clients were medically vulnerable, and two had COVID19 symptoms.

We then started a pretty intensive period of triage and urgent support provided by multiple volunteers and self-redeployed staff to help get ‘Everyone In’ safely, and cohort them effectively.

I stayed supporting this 150-bed hotel and another 200-bed hotel, City Travelodge for 6 weeks. During that time we managed around 25 symptomatic clients, mostly on the floor we designated for symptomatic clients at Limehouse.

I had to source all our resources – staff, clinical equipment, PPE, locked cabinets etc over the initial few days, and develop messaging and procedures in the hotels to make them safe from a public health point of view.

All clients received a medical triage, and clients needing help with addiction and their mental health were plugged into emergency support to stabilise them and help them settle and self-isolate. The response was effective, and I believe, saved many lives; particularly if we look in comparison at other cities e.g. some cities in the United States of America.

Throughout this time I also provided telephone triage support to more remote outreach workers as part of a team, and also continued my own outreach in the City of London on Tuesday evenings, helping to bring people in.

Since this initial six weeks of emergency hotel outreach, I have moved for a few weeks to continue to support medical triage in the hotels in North West London.

Looking to the future, I am now discussing being part of a virtual Pathway team to support ‘move on’ from the hotels. Throughout this time I have also been supporting the Healthy London Partnerships Homeless Health COVID19 control in producing guidance to support the care of all the 4000 clients across London. Additionally, I have supported inclusion health nurses and Health Visitors around the country via the QNI by providing information, resources and networking platforms.

It’s been a busy time to say the least…but I have loved being back on the frontline. And I have loved being part of a system where it is possible to say yes.

Yes, we have accommodation. Yes, we can get you rapidly scripted. Yes, we can get you mental health support even though you have an addiction. Yes, to food, new clothes, a SMART phone, a TV in your room. Yes, to simple things like Language Line when you need it (although admittedly accessing services like GPs have been difficult so it hasn’t all been perfect). Yes, to sharing information sensibly to benefit people’s health.

I really, really hope the system learns from this unprecedented time, and doesn’t go back. But either way, it’s good to know we saved lives when it was needed.

COVID-19 (Coronavirus) & Homelessness








UPDATED 03.06.20

The COVID-19 (Coronavirus) outbreak presents specific risks to people experiencing homelessness. People rough sleeping or living in temporary accommodation are in a high risk group, many with long term conditions, that mean becoming infected with the virus could have severe consequences.

This resource article is regularly updated with practical information regarding COVID-19.

UK Government response

The Government has issued general advice regarding this virus and has published guidance for hostels and day centres. Hostels and day centres are currently advised to stay open and take precautions broadly in line with those for the general public.

The Government also

Pathway response

Pathway has been deeply worried that the Government’s general guidance failed to address many of the practical concerns raised by specialist homeless clinicians and the homeless charity sector across the country. This was our response.

Our charity, and many in the homeless charity sector, advocate the advice given by Dr Al Story at our Homelessness and Inclusion Health conference – it’s imperative to Test, Triage, Cohort, Care – here with COVID-19 clearly explained by Prof Andrew Hayward links to both presentations here. 

Pathway also published an OPEN LETTER from London Clinicians COVID-19 calling on NHS England, Public Health England and the Mayor of London, to help support a rapid COVID-19 response for vulnerable homeless patients.

The open letter was published alongside a COVID19 Homeless Sector Plan produced by Dr Al Story, Clinical Lead Find & Treat and Prof Andrew Hayward UCL Professor of Epidemiology and Inclusion Health. A further, revised version of that plan, updated on 14 April is now published here. We expect further revisions shortly, particularly to reflect the gradual improvement in the national situation with regard to testing.

Discussions have also begun with national partners about how the homeless sector will need to respond to COVID-19 management more long term. To feed into some of this thinking, Pathway carried out a health needs assessment of clients at two of the London Prevent hotels: Brief HNA Limehouse and City – 22 May 20.


Clinical protocols

Palliative Care and End of Life Care

Other organisations also calling for action and offering practical support:


  • Crisis is calling for emergency measures to accommodate and protect the homeless population, regardless of legal barrier and published an open letter to the Prime Minister, seeking facilities and support for people facing homelessness to be able to self-isolate and protect themselves from COVID-19. Crisis has also created an online open-access COVID-19 toolkit.



  • Homeless Link has also responded to the government guidance on COVID-19 for hostel and day centre services for people experiencing rough sleeping, and also has a useful COVID-19 resources page that is regularly updated.



  • FEANTSA, the European Federation of National Organisations Working with the homeless, an umbrella group working with NGOs committed to combatting homelessness in Europe, has organised self isolation spaces for people experiencing homelessness diagnosed with COVID-19 in 15 locations.



  • Maternity Action have highlighted the particular impact of COVID-19 on pregnant women in a letter to the Chancellor. Their website hosts a range of useful information, including the telephone number of their advice line which offers help to women at risk of exclusion.


  • Groundswellhave developed resources to support people experiencing homelessness during the current coronavirus (COVID-19) pandemic.



  • Medact has drawn up a petition calling on all party leaders and all MPs to radically rethink public health and work together to ensure legislation is passed that protects everyone’s wellbeing now and through the duration of the COVID-19 crisis. You can sign the petition here.




  • RCGP elearning is making its entire eLearning content freely available to support all returning GPs and primary healthcare professionals during the COVID-19 crisis. It has a useful resources hub.


  • The King’s Fund is producing materials and guides to help health and care leaders through COVID19.



The Doctor shines a light on the Pathway model







by Eva Morrison


Pathway teams have been profiled in the December 2019 and January 2020 editions of the BMA’s The Doctor magazine; illustrating the work of homeless health interventions in London and Brighton.


These articles are timely, as last year the BMA declared the homelessness crisis a ‘public health emergency’ at its annual representative meeting in June.


The Doctor talked to Pathway clinicians in London, Manchester and Sussex, and made visits to the Royal London Hospital and Brighton teams, witnessing homeless healthcare in action.


“A hospital admission is an amazing opportunity. Someone is in a place where you can help them and where they may want help also. It can be an opportunity to break the cycle,” said Dr Peter Buchman.








The Doctor documents the struggles of staff, patients, and the system – shadowing the work of our teams and other colleagues on the frontline. The demand, and complexity of patients, combined with the lack of ability to make a difference to their homelessness, is growing ever apparent to those working in primary care.


The January feature highlights the example that even though there are around ten emergency accommodation sites in Brighton, and The Doctor visited three, – it was clear that even with well-meaning staff, hostel and temporary accommodation is not necessarily suitable for vulnerable or ill patients.


Inclusion health teams across the country are working in less than ideal situations, often making the best of almost nothing, with whatever resources they have.


In most towns and cities across the UK housing is becoming near-impossible in most circumstances. Few houses are being built, and therefore supported accommodation is quickly filled with patients who are unable to move on.  Some of these sites, suitable in the past for emergency accommodation, are now being used for people staying for months or years at a time.


Homeless patients are complex, and vulnerable. It can take a long time to build up trust before a patient feels able to go to hospital, make GP appointments or engage with other services. Our colleagues try to do as much as they can, but this all puts a strain on health care professionals as well as patients.


Services themselves are chronically underfunded. Support services such as substance misuse, social care and mental health services have been cut back over the last decade. This has resulted in primary care having to fill in for gaps in services, and even picking up patients who really need specialist care – and specialist care is really what a lot of homeless patients need.


Pathway teams see the effects of childhood trauma, and austerity in many of their homeless patients daily. With the numbers of people experiencing homeless increasing, combined with a lack of accommodation, the UK is facing an ever growing problem.


The Royal London team, like the Pathway team in Bradford, is fortunate to have access to a six-bed respite facility. This makes a huge amount of difference to the patients they treat. It enables those who need more help to receive it in a supportive environment.


“It’s about celebrating your victories and not dwelling on the times when you aren’t able to do anything,” said Dr Chris Sargeant.

Homeless Hospital Discharge Nursing

The emerging discipline of homeless hospital discharge

Sam Dorney-Smith

by Samantha Dorney-Smith


Pathway were recently granted a 15-month leadership grant from the Burdett Trust for Nursing to identify, network and support all nurses working across the UK in the emerging discipline of homeless hospital discharge.

Homeless hospital discharge nurses work in partnership with patients experiencing homelessness to achieve timely, holistic and compassionate assessment, treatment and discharge plans that improve health and housing outcomes.

Most of these nurses work in hospitals, although in many cases this is an in-reach intervention from community-based services. Some nurses work in Pathway teams, but many others do not. A small number of nurses that work to achieve better discharges for people experiencing homelessness are entirely based in the community.

The first clear reference to homeless hospital discharge practice was in 2003. A Department of Health document ‘Discharge from hospital: pathway, process and practice’ stated that all acute hospitals should have formal admission and discharge policies to ensure that homeless people are identified on admission, and that the discharge of homeless people should be notified to relevant primary health care and homelessness services.

Fast forward to 2019, and there are now around 25-30 specialist nurses in the UK directly involved in homeless hospital discharge (nearly all of whom have been involved in this project), and the NHS Long Term plan cited homeless hospital discharge teams (in this case a Pathway model team) as an example of good practice to reduce health inequalities.

Additionally, since October 2018, the Homelessness Reduction Act (2017) has now conveyed a ‘duty to refer’ on Accident and Emergency departments and inpatient settings for patients identified as experiencing homelessness, or being at risk of homelessness within the next 56 days. This requires patients to be referred to a Local Authority for support (with their consent). The hope is to focus acute hospitals on their responsibilities for safe discharge in this group. It may also result in the recruitment of more nurses into specialist roles.

Our Burdett funded project has revealed that homeless hospital discharge nurses need to be experts in clinical advocacy, patient empowerment, motivational interviewing, and health and housing rights. In addition, they need a broad clinical background in physical health, mental health and addictions and a good understanding of public health, and the concept of ‘making every contact count’, as well as an ability to gradually chip away to deliver systemic culture change. Having said that, to a large extent best practice has been developed locally by expert practitioners ‘doing the job’, and the evidence base is still limited.

Through shadowing and observation, interviews, and group workshops, the project has attempted to define the homeless hospital discharge nurse role clearly, including providing a breakdown of the knowledge, skills and experience required for the role with specimen job descriptions. An early vision for best practice has been defined, and local innovations have been highlighted. Continuing professional development needs have been analysed, and voluntary standards for practice are being developed.

Finally, and perhaps most importantly the project has helped the nurses to develop a shared vision of quality, and has defined this in terms of the value of a safe, effective and compassionate discharge, rather than by cost reduction per se (although the need to deliver efficiency has been taken into account).

The full report and resources developed on the project can be found here.