Pathway hospital teams try to deliver compassionate, integrated, patient-centred care. Often our patients’ emergency admission to hospital is the last episode in a downward spiral of events. Pathway teams work with homeless people in hospital to piece together what has happened and try to find each patient a safe place to go when they leave. The short patient stories below are based on admissions to University College Hospital in London and they help to illustrate the kinds of issues Pathway teams have to face every day.
Each individual part of these stories is true, but we have mixed together incidents from two or three individuals lives to project patient anonymity.
Eddy, male 40
Eddy has had prolonged treatment in intensive care for alcoholic cardiomyopathy, liver and renal failure. He accepts the need to stay off drugs and alcohol. The Pathway team negotiated a placement at a “dry” hostel for patients recovering from dependency, and supported him on each subsequent planned admission for treatment of ascites. He remains off drink and drugs in the community, and has re-established a relationship with his father.
Vince, male 59
A self employed electrician for 40 years, Vince has no family or savings and lived in B&B. Once out of work he rapidly became unable to pay for a room and took an overdose in despair. On ward he was discovered to be diabetic. The Pathway team befriended him and supported him to approach Camden housing for help. They negotiated return to his B&B with backdated housing benefit to pay his arrears. After discharge there was a delay in getting his benefits. He returned to hospital and was supported by the Pathway team in getting a crisis loan and was also given a small cash support grant from the hospital Samaritan fund to buy food. With this support another overdose and admission were prevented.
Dave, male 54
Admitted for surgical drainage of infected leg and hand, Dave was an alcohol dependent intravenous drug user on methadone, who had poor engagement with community services, and no local GP. He required repeated surgical drainage over several days. He had difficulty with pain control due to high opiate tolerance, and this caused friction with ward staff.
The Pathway ward team befriended him and provided liaison with ward staff, pain team and drug treatment team to ensure adequate pain relief. A hostel key worker was invited into hospital to discuss a possible rehabilitation placement on discharge. Dave was supported with his benefits claim.
He became abstinent from drugs and alcohol on ward, but finally decided against rehab placement. Negotiation with the community drug team and GP ensured that he had methadone and stable opiate analgesia prescribed on discharge for daily collection to minimise risk. He stayed out of hospital for a year after discharge.
Jim, male 48.
Jim collapsed in A&E at UCH with alcohol withdrawal seizure and malnutrition. Paramedics had found him incontinent from urine and faeces in the ground floor common room of his hostel. He had been unable to climb the stairs to his room for two days.
Upon admission, it was discovered he also has alcoholic fatty degeneration of liver, cerebral atrophy and symptoms of cerebellar ataxia and peripheral neuropathy due to brain and nerve damage. And, he had scars of self-harm.
Since 1995, Jim has attended A&E at UCLH 155 times; has been admitted to hospital 11 times; and spent a total of 62 days as an in-patient. Usually, this has been related to self-harm or alcohol-related damage. He has been on the homeless circuit for the last seven years, with periods of rough sleeping. However, he has never been deemed to have support needs and medical care has been reactive. Any mental and physical health problems were considered alcohol-related.
Following assessments by an occupation therapist, physiotherapist, and a report from the Pathway team it was finally agreed that he has long-term care needs. We found a placement for him in a residential unit.
Peter, male 63
Peter is a very frequent attender at A&E for treatment of chronic obstructive pulmonary disease. He used to work as hospital porter, but has been sleeping rough for about 20 years. He attends hospital A&E in the night and then spends the next day dozing in the pharmacy queue, saying he is waiting for his inhaler prescription. He also sleeps on buses and the tube. Pathway befriended him in the hospital and built a relationship with him. We helped him apply for benefits and supported him in getting emergency accommodation in Westminster. His benefits cheques were delivered to the hospital and he was supported in applying for a post office account. He was accompanied to register with a GP and to keep appointments for neurology assessment of poor short term memory. The Social Services safeguarding procedure was triggered when it was discovered that housing benefit was being claimed in his name in another Borough. Peter revealed that he was driven out of a flat with threats of violence many years ago, and this is why he was still rough sleeping. He is now safely supported in residential care.
Sue, female 33
Sue has a long standing heroin dependency with groin injecting and alcohol dependency. She was admitted with a chronic leg ulcer and a bleeding duodenal ulcer. At first she was reluctant to stay. She had a history of repeated admissions, premature self-discharge, poor engagement with support services and steadily deteriorating health.
The Pathway team befriended her on the ward, following which she stayed long enough to see improvements in leg ulcer, stabilise on methadone and complete alcohol detoxification. During this time, she revealed a wish to return to her family in Scotland. The Pathway team liaised with Scotscare and identified a means of funding the move home. A local drug treatment agency was identified and the current GP prescriber in London agreed to provide a script to facilitate the handover.
Sue stayed in London for 3 days after her hospital discharge in order to collect a benefits cheque; she remained in touch by telephone. At the last minute, funding for the return home was problematic because Sue needed to travel by train in order to take her dog with her. A medical letter was emailed to Scotscare confirming that her leg ulcer required her to have the leg room afforded by train travel. After arriving in Scotland further liaison was needed between the local pharmacy and the prescribing GP over the methadone script.
Sue settled back with her supportive family and her dog. She remains drug and alcohol free and has started visiting a dentist to get her smile restored.
Bart, male 34
Bart is a security guard admitted with acute myeloid leukaemia. He had no savings and was on the minimum wage. He was staying with a friend, but could not return because his friend believed that he might “catch” the cancer. Bart had prolonged and repeated admissions for chemotherapy. There were difficult negotiations with the impoverished outer London borough, that was reluctant to accept a duty to house him. These prolonged negotiations were supported by medical reports.
The Pathway team finally helped to find a private let accommodation with housing benefit.
Pathway have also produced a 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 with the sole aim of doing our very best for the patent.
We hope they will also be useful for colleagues wishing to introducing new teams in other partner hospital trusts.
- 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