Spreading the Pathway model of homeless health

• The Pathway model of enhanced care coordination improves the quality of hospital care for people who are homeless.
• Following a successful pilot in London, funded by the Health Foundation’s Closing the Gap through Changing Relationships programme, an independent charity was established to spread the model.
• The model has now spread to around ten sites with more in the pipeline.

Health care for people who are homeless

It’s not difficult to understand why homeless people need access to good quality, person-centred health care. People who are homeless often have mental health problems, physical health problems and drug and alcohol problems, with little social support or money. All of these things can be part of the reason why someone becomes homeless and can also be the result of being homeless.

People who are homeless face multiple barriers to health care, from administrative issues like not having a fixed address, to a lack of compassion from health care staff, who can struggle to deal with chaotic and challenging patients. All of these factors contribute to poor outcomes for people who are homeless – a recent study found the average age of death for someone who is homeless to be just 47.

In 2009, a small team at University College Hospital in London (UCLH) started to work on improving standards of care for homeless people admitted to hospital and better integrating hospital care with other services. Their successful model became known as Pathway, and an independent charity was set up to spread the model to other areas.

Pathway’s stated aim is to help the NHS transform the way it looks after people who are homeless.

A new way of working

The rationale for the Pathway model includes both compassionate person-centred care and economics. People who are homeless are usually sicker by the time they seek care, require longer stays in hospital (three times longer) and often visit A&E repeatedly (six times more often). They are frequently discharged without proper planning.

The Pathway model involves GP and nurse-led care coordination. When a homeless person is admitted to hospital, a specialist team works to build a relationship with them. The key is to understand the person’s situation and what can be done to improve outcomes for them, supporting and advocating for them during their stay. The team works with ward staff and other agencies, liaising with other health specialties, statutory and voluntary sector services.

The first Pathway team was set up with funding from the Health Foundation’s Closing the gap programme. An early analysis found a 30% reduction in bed days, but the real benefit is in the improvement in quality of care. This is summed up in patient quotes included in the initial project’s final report:

‘[The team] have been very kind to me on several occasions, clothing me, cleaning me up and showing love, time and compassion.’

‘I’ve never stayed in hospital as long as this [two weeks] but I know you are really going to help me, I trust you, that’s why I’m staying.’

‘With me being so ill I was grateful there was someone to speak on my behalf when sorting out my housing; you always went that extra mile.’

For the Pathway team, there was never any question about whether to share their experience. Chief Executive Alex Bax explains, ‘If you identify a problem and begin to find a solution, it’s almost beholden on you, as a medical practitioner, to do something about that. And that does mean system change.’

Establishing an independent body to spread improvement

Alex believes that establishing the independent Pathway charity to spread the model was an important step. The model of medical practitioners working in NHS settings but aligned to an independent health charity is familiar to many people – Macmillan nurses are a good example of this. Having a separate identity and brand can be helpful on a policy level and on a patient care level. Alex says, ‘Sometimes the pressures on a hospital trust are not helpful for the patient. Our teams need to be powerful enough to talk back sometimes.’

As a charity, having capacity to apply for funding has helped to smooth the path into new areas. Being independent has also helped teams establish themselves and build relationships in new trusts.   

The project has spread to around ten sites and is receiving national recognition and support. It is now the recipient of a Health Foundation Spreading Improvement grant.

What has Pathway learned about spreading improvement?

Pathway is adapting to new challenges that come with growth. Having more teams means regular meetings with all practitioners is no longer possible. New models for communication and support are being considered and tested.

Several factors have contributed to the successful spread of the project. Early data were important in providing evidence – being able to measure and communicate need and impact. On the other side of the coin, communicating the human factor through stories has been very powerful.

Alex and his team have worked in various trusts and hospitals and in several different areas of the country. The context Pathway is working in varies from place to place, as each trust, hospital or team will have different strengths and weaknesses, so an element of flexibility is important. At the same time, the Pathway teams have tried to keep their objectives clear and focused. Perhaps above all, and in line with their organisational values, they approach each new partnership with humility and respect.

You can find out more about Pathway on their website: http://www.pathway.org.uk