Homeless hospital discharge nursing

homeless discharge nurses












Pathway were recently awarded 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 short report can be found here. The full report and resources developed on the project will be published and shared soon.


‘A Second Class Ending’

CQC and Faculty paper highlights ways to improve end of life care for homeless people

An image of a shadowy bed, with half light from a windowA report released today by the Care Quality Commission, drawing upon research from the Faculty for Homeless and Inclusion Health, raises concerns that homeless people are struggling to access the care they need as they face the end of their lives.

People whose needs are the most overlooked are often those who are least able to advocate for themselves. A Second Class Ending highlights problems including fragmented support, inadequate services and few genuine options for homeless people in their last weeks and days of life, leaving many without the support they need.

However it also highlights numerous examples of good practice, where health and social care providers, palliative care specialists and homelessness staff have worked together to meet the significant needs of people facing this situation.

Dr Briony Hudson, Pathway Fellow and Research Associate at Marie Curie Palliative Care Research Department at UCL, comments:

“Enormous pressure is currently being placed on hostels who struggle to support people with very poor health, due to a lack of alternatives. Options for place of care and multidisciplinary working are key to improving quality of life for people experiencing homelessness, especially towards the end of their lives. We’re delighted to see the examples of good practice and joint working highlighted in this report, and there are many lessons to be learned from them.”

Stan Burridge, Pathway’s Expert by Experience Lead, was homeless for almost 20 years. He recently documented his experience of trying to see a GP whilst he was homeless for the BMJ. Stan said:

“Seeing a GP who understood homelessness was the first step to getting my life back on track. Without him, I think my health would have continued to the spiral out of control, and I could have ended up as one of the many homeless people who die an early death.”

Read the CQC report

Is Your Surgery ‘Homeless Ready’?

Pathway in the BMJ

Pathway’s Expert by Experience Lead, Stan, has been making waves with his latest article in the British Medical Journal (BMJ). Entitled ‘Three forms of ID and a Letter from God‘. His piece outlines the struggles faced by people who are homeless, who need to see a GP.

The majority of people who are homeless have a physical or mental health problem, but incorrectly enforced regulation around proof of address prevents many from accessing support. Possibly as a result, people who are homeless use A&E 6 times more than people with a home.

Stan’s passionate article is based on his own experiences of life on the streets, and his subsequent recovery, assisted by a specialist homelessness GP. The article is part of Pathway’s ongoing work to help GP receptionists to support registration for people who are homeless.

Access free homelessness training for GP receptionists
Download the Faculty of Homeless and Inclusion Health National Standards for GP Receptionists

Homeless Patients Are Dying Without Support

Research published today reveals that homeless people who are terminally ill are falling between cracks in services, and not able to access the same level of support as others.

Researchers from Pathway, Marie Curie Palliative Care Research Department at University College London (UCL), St Mungo’s and Coordinate My Care worked with homeless people and care professionals and found that many homeless people who may be approaching the end of their lives are living in homeless hostels.

The study is the largest of its kind and the first to describe the lack of appropriate services for homeless people in the UK, from the perspectives of homeless people and those supporting them.

It showed that hostel staff often end up caring for some of the sickest homeless people, despite not having the palliative care training or support to do so.  As a result, huge burdens are placed on hostel staff who do their best to manage with minimal support and very limited resources.

One hostel staff member commented:

“At least three times a shift we check she’s okay.  It’s hard … particularly on weekends and nights when we only have two staff … it’s a big hostel … you really can only do so much … this isn’t an appropriate environment, but it’s the best we have”

Dr Caroline Shulman, Pathway and Marie Curie Palliative Care Research Department, UCL, who led the research, said:

“Hostels provide temporary accommodation. They are not designed to meet the needs of seriously or terminally ill residents. Hostel staff often struggle to secure additional support from social services or palliative care services for their residents who have complex problems.”

Many homeless people die young from conditions such as advanced liver disease, often complicated by mental health problems and/or drug and alcohol issues. There are differences in the type and amount of support available for this group across London, with some innovative attempts to deal with this extremely challenging problem. However the researchers found that overall, homeless people with advanced ill health rarely receive adequate care and support in the community. This results in repeated unplanned and emergency hospital admissions in the last months, weeks or days of life, which can be very distressing.

One of the participants with experience of homelessness commented:

“There’s been a few guys that were in hospital, told they were dying …. They didn’t want to go to any hospice, they didn’t want to … stay in hospital, they wanted to die in the homeless hostel”

The research calls for urgent action to improve collaboration between health, housing, social services and the voluntary sector, with extra support for hostel staff. It also makes recommendations for a specialist health hostel, with staff that not only understand the complex needs of homeless people but can also offer adequate 24-hour support for people with serious illnesses, including those who are dying.

As one of the hostel residents observed: 

“You’ve got to walk past those people.  They half block the stairwell, you have to edge your way past.  It’s kind of … in your face.  Erm, yeah, it becomes part of the furniture.  But it disturbs me as a person…”

Professor Steve Field, Chief Inspector of General Practice at the Care Quality Commission, said: 

“As a GP I have seen how the lack of appropriate and sensitive services can mean that homeless people are denied the compassionate healthcare, dignity and respect that they deserve at the end of their lives.

“This research makes it clear that by working together, healthcare services and the wider system – such as housing, social services and the charity sector – have a vital role to play in improving the quality and co-ordination of care for homeless people as they reach the end of life. Everyone has the right to safe, high-quality, and compassionate health and social care. Through our inspections we have seen services that are providing outstanding care to people who do not have secure housing but it takes strong, responsive leadership and dedicated staff.

“In the coming months CQC will be publishing a detailed report making recommendations on how we as a society can meet our responsibility to the most vulnerable people in our communities who are currently being let down at a time when they need help and support the most.”

The research, published in the journal Palliative Medicine, was funded by the Oak Foundation and supported by Marie Curie, Pathway and Coordinate My Care.

Click here to download the paper from Palliative Medicine (free).


Notes to Editors

Case studies and interviews available on request.

Additional quotes:

Alex Bax, Chief Executive at Pathway, sad: “Pathway is delighted to support this ground breaking research. We knew that homeless people’s experience of care at the end of their lives was often poor, but this new study shows how all parts of the system working together could make things much, much better. The voices of homeless people and the staff who work with them come through loud and clear. Towards the end of life everyone wants to be treated with dignity, respect, kindness and compassion. And homeless people are no different.”

Simon Jones, Director of Policy and Public Affairs at Marie Curie, said: “The majority of people tell us that they wish to be cared for and die in comfort, where they normally live and surrounded by their loved ones. For most people, this means their own home. This important study highlights that for homeless people, home represents something completely different – a hostel, or on the street.  Everyone deserves compassionate care and a dignified death, regardless of where they normally live, or their personal circumstance.”

Niamh Brophy, Palliative Care Coordinator at homelessness charity St Mungo’s, worked on the research. She said: “People who are homeless do not gain access to palliative care until very late in their illness, if at all. Often their choices for care are limited, and their death is more likely to be perceived as sudden, untimely and undignified.

“In recognition of this complexity, St Mungo’s provides the unique service of having a dedicated Palliative Care Coordinator. My role centres around giving our residents with serious health concerns the opportunity to choose their treatment, the chance to reconnect with loved ones, and the possibility to die in a dignified, comfortable way in a place of their choosing.”

The Oak Foundation said: “We are pleased to support the research to improve end of life care for people who are homeless or vulnerably housed. This work is key to strengthening the links between the homelessness sector and health providers.”


About the research

  • Homelessness includes not only people who are sleeping on the streets, but also those in insecure or temporary accommodation such as hostels.
  • Participants were recruited across three London boroughs, Lambeth, Hackney and Westminster, selected for their high volume of both homeless people and homelessness services.  Frontline homelessness providers and health and social care professionals were recruited through the research’s team existing connections.
  • 127 participants took part. Over a third (n=39%) of the homeless participants had been homeless for more than five years; 86% reported having slept rough and 71% reported currently sleeping in hostels, most of the time.

recent CQC report acknowledged that people from certain groups in society, including homeless people, experience poorer quality care at the end of their lives and that more must to done to tackle the problem.

Key findings

  1. In London, appropriate services for homeless people with advanced ill-health are lacking. Facilities that can meet the physical and emotional needs of homeless people with advanced ill health, who may continue to misuse substances, are needed.
  2. There is currently a large emotional, and practical burden on hostel staff in supporting homeless people with advanced ill-health due to lack of appropriate alternatives. Homeless people, and those supporting them struggle to access the services required.
  3. There is a conflict between the recovery-focused nature of many services and the realities of health and illness for homeless people that creates a lack of comprehensive person centred care.
  4. Collaboration between health, housing and social services, the promotion of multidisciplinary working including hostel in-reach and greater training and support are urgently needed for professionals and those working with homeless people as their health deteriorates.

About the partners

Marie Curie – care and support through terminal illness

Please note – we are now called ‘Marie Curie’ (not Marie Curie Cancer Care)

Marie Curie is the UK’s leading charity for people with any terminal illness. The charity helps people living with a terminal illness and their families make the most of the time they have together by delivering expert hands-on care, emotional support, research and guidance.  Marie Curie employs more than 2,700 nurses, doctors and other healthcare professionals, and with its nine hospices around the UK, is the largest provider of hospice beds outside the NHS.

For more information visit www.mariecurie.org.uk
Like us at www.facebook.com/mariecurieuk
Follow us on www.twitter.com/mariecurieuk

The Marie Curie Palliative Care Research Department at UCL is an internationally recognised centre of research with a team of over 20 full-time researchers. The department receives core funding from Marie Curie and also undertakes research funded by the National Institute for Health Research (NIHR), the Alzheimer’s Society and other research funders. The department has particular research strengths in the areas of palliative care for people with dementia, prognostication in advanced cancer and the management of cancer-related fatigue.


Pathway works to improve healthcare for homeless people. The charity has helped the NHS to create 11 homelessness teams in hospitals across England, supporting over 3000 patients every year. Pathway also develops models to facilitate improvements in patient care, carries out research in new and developing areas, provides training for healthcare professionals and supports specialist commissioning. Pathway hosts The Faculty for Homeless and Inclusion Health, a network of over 900 health and social care professionals providing support for homeless people, vulnerable migrants, gypsy and traveller communities and people in the sex industry.

St Mungo’s

St Mungo’s provides a bed and support to more than 2,600 people each night who are either homeless or at risk of homelessness. As a charity and housing association, we work to prevent homelessness, through more than 250 projects including emergency services, supported housing, specialist physical and mental health services and advice, skills and work services. We believe everyone should have a place to call home and be able to fulfil their hopes and ambitions. www.mungos.org

St Mungo’s Palliative Care Service started in 2007, and since then we have

  • Provided more than 190 residents with end of life care support including bereavement support
  • Delivered training about homelessness and end of life care to more than 300 staff
  • Developed an online Resource packaimed at supporting staff working with people who are homeless
  • Forged greater links and partnership working with services such as a multidisciplinary working group set up to identify earlier on those residents whose health may be deteriorating
  • Partnered on collaborative research and training development with UCL, Marie Curie and Pathway

Coordinate My Care (CMC) 

Coordinate My Care is an NHS urgent care clinical service developed from the concept of a multidisciplinary digital end of life care plan to an urgent care plan for all vulnerable patients. CMC was established in May 2012 to address the need for patients to have integrated, coordinated and quality care. The CMC service is implemented successfully across the 32 London CCGs where it has provided quality improvements and a reduction in unnecessary hospital admissions. As of June 2017, 41,565 care plans have been created.

Palliative Medicine

Palliative Medicine s a highly ranked, peer reviewed scholarly journal dedicated to improving knowledge and clinical practice in the palliative care of patients with far advanced disease. It reflects the multidisciplinary approach that is the hallmark of effective palliative care. http://journals.sagepub.com/home/pmj

Well done Tim!

tim accepting award
“We are delighted to add our congratulations to Dr Tim Robson and all his staff at the Meadowell Practice in Watford on his winning the Mayor of Watford’s Audentior Award.  Tim personally was recognised in the award citation for his incredible commitment to services for homeless people, and his long-term leadership of the specialist Meadowell Homeless Health Practice.  For the last three years Tim has also been the lead team GP working with the Pathway homeless team at UCLH so we know him very well, and value him as an exceptional colleague.  So beyond Watford there are hundreds of homeless patients, admitted to UCLH from the streets of London, who have benefitted from his professional knowledge, wisdom and compassion.


Brighton & Sussex University Hospital

Pathway’s team in Brighton Hospital started work in spring 2012. Prior to launching the service Pathway carried out a needs assessment of homeless health in the hospital gathering baseline data about homeless admissions and talking to staff involved with homeless patients.  This report is available on the publications page.

Our team in Brighton Hospital are delivering the Pathway service as part of a two site randomized controlled trial funded by an NIHR Research for Patient Benefit grant.  Fifty percent of homeless patients admitted to the hospital are randomized to standard care, and fifty percent received enhanced care co-ordination from the Pathway team.

If you are a Brighton Hospital staff member and would like to refer a patient the team’s contact details are on the staff internal directory. If you work for a partner agency and would like to contact the team about a patient please email info@pathway.org.uk and the team will call you back.


Pathway + Brighton

Justlife manages the Pathway+ project, operating in Brighton and Hove. Working in partnership with Pathway, St. John Ambulance and Brighton Homeless Healthcare, Justlife provides support to patients who live in unsupported temporary accommodation when they are discharged from hospital. The team work to ensure that client’s health recovery is sustained and that they receive relevant assistance with their broader needs, linking in with the wide range of services which are available in the city.

This project was initially funded by the Department for Health as a six month pilot (October 2013 – March 2014). Following the success of the pilot, which included improved health and significant reductions in A&E and ambulance use following Pathway+ interventions,Brighton & Hove Clinical Commissioning Group have commissioned Pathway+ for a year. During this time Justlife and the other partners are involved in the development of an integrated care system for the homeless community in Brighton with a view to the creation of future services within the city.

Referrals from Pathway team within the hospital are received, appropriate care plans are established and the Justlife team provide non-clinical floating support to individuals who live in temporary accommodation. Staff will also be involved in the wider work of Justlife inBrighton and Hove providing support to people who live in unsupported temporary accommodation.

Justlife is only of the only organisations in the country working with single homeless residents of unsupported temporary accommodation and is recognised, within the sector, as experts in this area of homelessness.

For more information about Justlife visit: www.justlife.org.uk


Barts Health

Pathway’s team in the Royal London Hospital started work in autumn 2011.  The team consists of Dr Peter Buchman, specialist homeless GP from Health E1, the homeless primary care practice on Brick Lane in Whitechapel; and Pathway Nurse Jeflyn Musariri-Nzara.  Prior to launching the service Pathway carried out a needs assessment of homeless health in the hospital gathering baseline data about homeless admissions and talking to staff involved with homeless patients.  This report is available on the publications page.

Our team in the Royal London Hospital are delivering the Pathway service as part of a two site randomized controlled trial funded by an NIHR Research for Patient Benefit grant. Fifty percent of homeless patients admitted to the hospital are randomized to standard care, and fifty percent receive enhanced care coordination from the Pathway team.

If you are a Royal London Hospital staff member and would like to refer a patient to the team Peter and Jeflyn’s contact details are on the staff internal directory. If you work for a partner agency and would like to contact the team about a patient please email info@pathway.org.uk and the team will call you back.


University College London Hospitals NHS Foundation Trust

Pathway’s first team was developed in University College Hospital in 2009 by Dr Nigel Hewett and Nurse Trudy Boyce.  The team been working with homeless patients at UCH since autumn 2009.  The team now consists of Pathway homeless health nurse practitioner, Flo Cumberbatch and Care Navigator Co-ordinator Trudy Boyce, Josie Mavromatis, Pathway Senior Care Navigator, and Dr Tim Robson, Pathway homeless health GP.

The BMJ published a ‘Quality Improvement report’ showing the value of the work of our UCLH team in September 2012: ‘A general practitioner and nurse led approach to improving hospital care for homeless people’, available on the Pathway publications page. Professor Michael Porter of Harvard Business School has also reviewed the work of the team, judging the Pathway approach ‘a great example of value based healthcare.’  Both these papers are available on the Pathway publications page.

If you are a UCLH staff member seeking to refer a homeless patient the team are based in the discharge lounge (details on the intranet) or can be paged on pager number 5800.  If you work for a partner agency and would like to contact the team about a patient please email info@pathway.org.uk and the team will call you back.



Bradford Bevan Healthcare


Bradford Bevan Pathway Team

With a grant from the Department of Health Innovation, Excellence and Strategy Development Fund we have launched a new Pathway team in Bradford. The team is hosted by specialist primary care service Bevan Healthcare. A practice GP, nurse, and a specialist housing worker from Horton Housing Association make up a Pathway team working with patients in Bradford Royal Infirmary. The team works not only with homeless patients but with other complex and vulnerable adults and the service went live in November 2013. The funding will allow the pilot service to run for 12 months during which time we hope a detailed evaluation will persuade local commissioners of the value of the service.

If you want to find out more about the service or a particular homeless patient you can email pathway@bradford.nhs.uk


If you are in the Bradford area, or just want to find out more about Bradford Bevan Healthcare click the logo

bradford bevan




Patient stories continued (Video Chest)

Patient stories continued (Video Chest)

Some of the most powerful messages Pathway have to offer comes from our patients. Often the story of their lives, damaged, ignored, disengaged will slowly unravel when they arrive at one of the hospital sites and begin getting healthcare, sometimes for the first time in many years.

Pathway have produced this series of short films with our hospital team members describing their work with homeless patients, and how our teams work with partners inside and outside hospital. We hope they are useful for colleagues introducing new teams in other partner hospital trusts.

Click the links to watch:

Pathway’s Chairman Professor Aidan Halligan describe the foundation of Pathway
Dr Tim Robson talking about a number of components of the service, and his experience of joining the UCH Pathway team
David Robertson, a Westminster community drugs worker recounting the case of a particularly complex patient
UCH Pathway nurse Florence Cumberbatch talking about working with housing departments and other colleagues, and dealing with challenging patients
Trudy Boyce, Senior Care Navigator Co-ordinator and Pathway’s first nurse, talking about bringing compassion to patient care and the realities of working with the most excluded in our society
Pathway Senior Care Navigator Josie Mavromatis talks about escorting patients out of the hospital, and tells her own remarkable story of recovery from many years living on the streets


For the full list of al of our videos please follow this link