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Discharge Programmes

strength of evidence

Some reliable evidence

Cost effectiveness

Insufficient evidence available

Impact

Multiple high quality studies show a positive impact

What is this intervention?

Discharge programmes coordinate services for people at risk of homelessness who are being discharged from institutional settings such as hospital, prison or the military.

Common elements of discharge programmes are: (1) identification of a person as homeless or at risk of homelessness while in the institutional setting; (2) measures taken to address any complex needs while the person is in the institution; (3) collaboration between health, social care and housing agencies and other relevant bodies to formulate a discharge plan; (4) safe discharge to appropriate accommodation and services.


What is its goal?

The main goal of discharge programmes is to ensure that when people are discharged from institutional settings they have accommodation and services in place to help them avoid homelessness.

For individuals being discharged from hospital or prison, support and care before and after discharge is intended reduce the risk of readmission or reoffending.

People who experience homelessness are more likely to have psychiatric or medical needs that require periods of inpatient care in institutions such as psychiatric hospitals, general hospitals, or rehabilitation centres. People who are homeless are also more likely to have spent time in prison. Without coordination between relevant bodies such as social care providers, housing agencies, police and mental health teams, there is a risk of people being discharged from these institutions into homelessness and without the necessary services in place. This in turn increases the risk that they will end up being rehospitalised or back in prison. People in the armed forces are also at risk of homelessness on discharge from military service.

This intervention ensures that individuals are discharged into appropriate accommodation with access to support services. This means they are less likely to become homeless in the future and have a better chance of complete recovery from both physical and mental illness. These programmes also promote a more individualised approach to clinical practice to ensure that the individual’s specific, and likely complex, needs are addressed fully. If people being discharged from prison have the right support and accommodation in place they are less likely to reoffend.


What does the evidence tell us?

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Discharge programmes seem to produce positive effects on outcomes related to housing stability and health. These findings were consistent at both a 12-month and an 18-month follow-up.

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Future homelessness was reduced in all the studies that measured this outcome; these results were consistent at an 18-month follow-up.

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When measuring the risk of future hospitalisation, two studies demonstrated reductions in readmission for participants involved in a discharge programme.

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Discharge interventions did not improve community integration or the rate of emergency department and outpatient clinic visits in participants across two studies.

Where does the evidence come from?

Of the studies summarised here, 11 were conducted in the US and one in the UK. They consist of a range of study designs including:

  • one systematic review including data on 29 studies (4 RCTs, 4 quasi-experimental, 13 prospective cohort, 2 retrospective cohort, 6 cross-sectional)
  • six RCTs (n= 908)
  • four cohort studies (n=15,186).

The US studies all relate to discharge from psychiatric hospitals and general hospitals. The UK study is on discharge from prison.

Which groups does it affect?

The majority of studies measured the impact of this intervention on participants who were hospitalised for mental illness (six studies), three studies included participants suffering from a physical illness, and two included veterans who had substance dependencies and were being discharged from the US Department of Veterans Affairs transitional housing intervention programmes. All participants were homeless.

Which outcomes does it affect? 

The 12 studies included in the review considered a range of outcomes. Seven studies considered housing stability, seven looked at health outcomes, two considered outcomes associated with capabilities and wellbeing, two looked at the participants’ access to services, two studies considered the impact on community integration and the rate of emergency department and outpatient clinic visits, one study considered justice and criminal outcomes, and one looked at outcomes associated with employment or income.

Housing stability

Future homelessness was reduced in all the studies that measured this outcome; these results were consistent at an 18-month follow-up.

Health and wellbeing

When measuring the risk of future hospitalisation, two studies demonstrated reductions in readmission for participants involved in a discharge programme. One of these studies demonstrated a 50% reduction compared to the control, while the other showed consistent reductions at a 12-month follow-up.

Social Connectedness

Discharge interventions did not improve community integration or the rate of emergency department and outpatient clinic visits in participants across two studies.

Criminal Activity

One study presented information about the participants’ previous involvement with the criminal system. Participants who had committed a crime within six months were more likely to suffer continued homelessness and require further psychiatric hospitalisation. This finding was consistent at one, two, and three-year follow-ups. This study suggests that additional factors should be considered when evaluating discharge interventions.

considerations for IMPLEMENTATION

Collaborate with other agencies

If you are implementing a discharge programme, establish effective coordination between different agencies to enable your team to:

  • Access service users within institutions as early as possible before their release (e.g. discharge housing options should be considered on entry for short term prisoners)
  • coordinate personalised, and potentially long-term support and packages
  • Ensure robust data monitoring and sharing arrangements.

Partnerships linking service users directly with housing are paramount, providing both motivation for participation and stability for service users to engage with non-housing support.

Invest in maintaining a skilled workforce

Ensure your staff have the skills to work effectively with a range of service users and other agencies, from technical knowledge to emotional intelligence. Ex-prisoners may benefit from peer-support/workers. Equip your staff to be able to navigate complex systems and barriers, and offer proactive advocacy to service users and supporting agencies.

Design support package around users’ needs

Ensure your service offers a wide range of support alongside housing to promote success and housing stability. Staff should work closely with service users when planning support. Such support includes healthcare, welfare access, employability training and employment support, financial management and planning, childcare and support, legal advice, and support with social and familial relationships. Small amounts of financial support such as for bus fares can also enable service users to participate more effectively.

Secure long-term leadership buy-in from all agencies

If you are a policy maker or funder, be aware that discharge programmes require robust partnership working with discharging institutions (particularly hospitals as evidence suggests they are hardest to engage), which needs to be facilitated by strong leadership and buy-in from the top. Many implementing agencies require guarantees that service users will receive housing. These commitments should be reflected in contracting arrangements. Policies and guidelines should also be context specific and include good practice examples.

Enable access to welfare support for housing costs

Shortage of suitable and affordable accommodation creates major barriers to discharge programmes. Try to ensure service users can access to welfare support to help them secure housing; larger, upfront sums may also be required to help service users afford rent deposits. If this is rationed or access requirements change during a programme, services can fail in their objectives.

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