Organisational Standards

Fundamental Standards

All care provided by all individuals at all levels must comply with these standards and there should be zero tolerance of breaches. The fundamental standards of Inclusion Health in the ED include:

• ED staff should comply with the statutory duty to identify and refer homeless patients, and those at risk of becoming homeless.
• Patients who are homeless or at risk should have a discharge letter sent to their GP which includes information about their housing status.
• If the patient is not registered with a GP, they should be provided with information about accessing health care. In the ED, a social worker may be able to help them register with a primary care provider.
• EDs should obtain and record up to date contact information for patients who are homeless or at risk of homelessness and provide these patients with information about homeless services in the area. For example, leaftlets with information on hostels, soup kitchens, homeless cafes etc may all be very beneficial to these patients and having them printed in a range of languages would be even more helpful.
• All homeless patients and patients at risk of homelessness should have an opportunity to discuss issues related to drug or alcohol misuse. When taking the patients social history these issues can be explored and help provided if necessary. In relation to alcohol, the CAGE questionnaire or AUDIT-C may be helpful to identify those with alcohol dependence or harmful drinking.
• A homelessness staff information pack should be available and reviewed yearly.
• EDs should have processes to ensure staff can arrange emergency accommodation for homeless patients both in and out of hours.
• The ED should have processes in place to ensure staff are aware when the Severe Weather Emergency Protocol (SWEP) is activated.
  • Each local authority should have a SWEP which is used when severe weather is forecast (15). This includes extreme cold, strong winds, heavy or prolonged rain and heatwaves. While the main aim is to give rough sleepers shelter from the extreme weather conditions, it may also provide the opportunity to engage with hard to reach groups who may be more likely to seek help or shelter during severe weather (15).
• When discharging a patient who is homeless or at risk of homelessness, staff should consider the impact and feasibility of the discharge plan. For example, if the patient needs to isolate, rest, return for ambulatory care, etc. this may not be feasible depending on the patients circumstances.
• EDs should have a process to ensure staff know who they should inform when a homeless patient or patient at risk of homelessness is admitted to the hospital. Some trusts and hospitals have Inclusion Health Teams who may be involved during the admission.

Developmental Standards

These are set requirements which go beyond the fundamental standards and include:

• Pathways should exist for high risk groups who should be prioritised to prevent them missing their follow up appointment and reattending ED e.g., homeless people who inject drugs and are attending with suspected DVT but are unlikely to return the following day for doppler.
• The ED should have processes to identify groups at high risk of health inequality.
• The ED should have a lead nurse and consultant lead for homelessness +/- other vulnerable groups.
• There should be ED alcohol and drug assessments with brief advice and referral.
• A multidisciplinary forum should be regularly organised to discuss homeless frequent attenders with community support service.
• The ED staff should have access to regular educational updates on Inclusion Health.
• The ED should have a system in place to identify patients from Inclusion Health backgrounds and the waiting room should have information readily available to inclusion health groups, informing them of their rights and services available.

Aspirational Standards

These standards set longer term goals.

• The trust should have a homelessness officer who liaises directly with the ED as well as access to an Inclusion Health team.
• The ED staff should be aware of the services available to patients in the inclusion health categories and how to access them.
• The ED should make efforts to communicate in the vulnerable patients language through translator or language line.
• The ED should have processes in place for referral to specialist services tailored to the needs of their local population e.g., HIV testing.