Homeless Health Inclusion Team

What does this service provide?

Who we are

We are an award-winning specialist homeless health inclusion team.

The team consists of nurses, health care assistants, a nurse prescriber, an occupational therapist, an associate therapist, and a physiotherapist.

We have a full-time homeless in-reach nurse at the hospital as part of a wider multi-agency team, including colleagues from ARCH Healthcare, Justlife and Housing.

What we do

We work in a trauma informed way with patients with tri-morbidity, (3 or more chronic health conditions). Our goal is to help patients who struggle to engage with primary and secondary healthcare to manage their health needs.

Many of our patients really struggle to engage with services, and will often disengage with healthcare and social services. This lack of trust is often caused from previous difficult experiences with healthcare professionals and other agencies.

Homeless and vulnerably housed people are a marginalised group. Many have multiple compound needs, addiction issues, and are very disadvantaged. They often feel judged by the health and adult social care system, and struggle to access standard NHS services without support, from the multi agencies involved in this citywide issue.

We outreach to people living in emergency, temporary and supported accommodation, those who are of no fixed abode, and those who are sofa surfing. This group often have problems with physical, psychological, and mental health issues and substance misuse. Our patients often have social care needs and are deteriorating with early onset frailty and ageing.

As a team we provide outreach, home visits, and run clinics in the city providing multi-disciplinary care in the community.

We understand complex needs and help to create realistic solutions to help support patients to trust and engage in services. We work collaboratively with other agencies, and our partners. The hospital-based pathways team help our patients to feel reassured that they have a point of contact if they are admitted into hospital.

We work collaboratively with our third sector colleagues, St Mungo’s and Change Grow Live, who outreach and support people who are street homeless and vulnerably housed. This includes support and solutions around substance misuse and helps to rebuild lives.

We help advocate for patients who have challenging behaviours, and who can be judged and not fully understood. This may be because of an abusive and traumatic childhood, or violent adult experiences, trauma, and PTSD.

Many of our patients chose to use illegal substances and have entrenched addiction. The route is usually intravenous, subcutaneous, or smoked. The drugs commonly used are crack, cocaine and heroin.  The effects from illicit substance misuse, are used to block out and symptom manage the pain associated with past traumatic experiences.

We holistically assess the individuals care needs, working in a solution focused way to support harm-minimisation if they wish to continue to use illicit substances safely.

We collaborate with other services, working towards detox and rehabilitation to help them focus better on other aspects of their lives.

Our patient group has multiple compound needs and are multiple disadvantaged. We work as part of a wider multi-agency team that includes, GPs, housing, adult social care, mental health, substance misuse services and third sector colleagues to best support the needs of all our patients.

How can I access this service?

To access our service, can be referred by a health care professional, who will need to complete our referral form. This will need to be emailed to the address mentioned on the form.

Alongside the referral form we have a team landline and mobile number. These can be found in our contact details at the bottom of this page.

You can self-refer at one of our drop-in clinics at Off the Fence or First Base Day Centre, or ask a member of the team there to refer for you. See the bottom of the page for clinic details.

We take referrals from high/medium support hostels in the city (also known as supported accommodations) and can take direct referrals from keyworkers and patients through our clinics and online using the referral form.

We are not commissioned for low support accommodation but will support patients on a transitional care plan who are moving on from higher support and refer on to the community nursing team (integrated primary care) if appropriate, for continuing care.

Any frontline staff working in the community can make a referral into the team for people who are rough sleeping, in emergency or temporary accommodations, or sofa surfing, who they are concerned about.   

Where can I access this service?

Let's get social

You can also get involved by engaging with our service's social media accounts by helping with the latest fundraisers and events.