The Queen's Nursing Institute

The Queen's Nursing Institute works with the public, nurses and decision-makers to make sure that good quality nursing is available at home for everyone when they need it.

Healthcare at home

Hospital Discharge

QUESTION: Do any of your members have some advice about hospital discharge relevant to homeless people?

ANSWER: I put into place about four years ago a discharge protocol for our local acute psychiatric hospital which is working well.  I followed the guidelines from the DOH Best Practice guidelines for those being Discharged NFA/near homeless from hospital.   It enabled better communication between wards and the loose knit team of homeless agencies on behalf of the client, along with improved and timely discharges.  This led to the PCT commissioner organising meetings to produce discharge protocols with the two major local General Hospitals, Bournemouth and Poole.

ANSWER: St John Ambulance Homeless Service (SJAHS) has a partnership with the Conquest Hospital, and is included in the local discharge protocol, so that all homeless patients attending A&E and homeless inpatients on the wards are (or should be) referred both to the Local Authority (Hastings Borough Council) Housing Services and to SJAHS. For us (SJAHS) that also includes vulnerably housed, as well as street homeless people.

Our role with regard to inpatients, who are referred by the discharge nurses to us, is to assess them on the ward as soon as possible after referral – usually within 1-2 working days – to assist with discharge planning, to ensure they get the all the necessary support and care on discharge – and rehoused if at all possible. Our role is primarily one of support and advocacy, and linking the patient and the hospital staff (including ASC - Adult Social Care) with community agencies. We’ll usually visit the patient on the ward several times before their discharge, depending on how long they’re on the ward and what the needs are. Some of this work is done by a SJAHS volunteer, but the assessment and most of the advocacy is done by a nurse on the SJAHS team.

Patients referred by A&E are fewer and tend to be discharged at the same time as referral – so the patients are signposted to services including ours in the community but they don’t necessarily attend those services.

The service has developed since the attached report was written – referrals are pretty frequent and the work can be very time-consuming. It mostly works very well, especially because of our working links with other community agencies that the Hospital / ASC staff don’t always have very good knowledge of – and because of our assertive advocacy during and after the discharge planning process.

Sometimes the system breaks down and we recently had to write a formal complaint jointly to ASC and the hospital trust over two very poor discharges of the same client. However, this complaint has led to positive changes, with closer inter-agency working and further development of communication channels to prevent the same problems recurring.

Roger Nuttall, Nurse Co-ordinator, St John Ambulance Homeless Service 


Supporting Carers

Transition to Community

Homeless Health