Housing, Health & Wellbeing Hospital Discharge Support Service

The service is to prevent individuals aged 18 and over from being discharged from hospital into street homelessness, and to support safe, timely, and sustainable discharges through coordinated in-hospital intervention and time-limited post-discharge support. The service will provide proactive, responsive, and coordinated support through: •Early identification of individuals who are homeless or at risk of homelessness; •In-hospital assessment, advocacy, and discharge coordination; & •Time-limited post-discharge support to sustain accommodation and reduce the risk of readmission.

The service will specifically support individuals who: •Are homeless or at risk of homelessness; •Have support needs relating to drug and alcohol use; and •Are known to Adult Social Care services, including those with assessed care and support needs, those open to Adult Social Care teams, and those requiring coordinated discharge planning. The service is commissioned in recognition of the significant risks associated with hospital discharge into homelessness, and the adverse impact this has on individual health and wellbeing, as well as system pressures across health, housing, and social care.

The Council is committed to ensuring that no individual aged 18 and over is discharged from hospital into street homelessness, and that all discharges are safe, timely, and supported by appropriate accommodation and care pathways. The service will operate within the framework of statutory duties under the Care Act 2014, including the duty to promote individual wellbeing, prevent, reduce, and delay the need for care and support, and ensure the integration of services where this contributes to improved outcomes.

The service will also support the Council in meeting its responsibilities under the Homelessness Reduction Act 2017, including duties to prevent and relieve homelessness and to work collaboratively with partner agencies through the Duty to Refer process. The service will deliver an integrated model of support spanning in-hospital intervention and time-limited post-discharge assistance, ensuring continuity of care for individuals with complex and multiple needs.

It will form a key part of a wider system approach to discharge planning, working in close partnership with Adult Social Care, housing services, health providers, and other relevant stakeholders to facilitate coordinated and person centred outcomes. A core feature of this integrated approach is the requirement for the provider to work proactively and collaboratively with Transfer of Care Hubs, clinical teams, and wider hospital-based staff to identify individuals who are homeless or at risk of homelessness at the earliest possible stage of admission.

The service will accept and respond to referrals from Transfer of Care Hubs, hospital wards, Emergency Departments, and clinical teams, ensuring timely engagement and intervention to support discharge planning processes. A requirement of the contract is that staff work flexibly and may need to align as part of a hospital discharge pathway resulting in the need to be co-located from time to time within other relevant commissioned services and embrace opportunities for alignment with the National Health Service Neighbourhood Hubs Programme and integrated working with health, housing and adult social care partners