Author: Susan Uí Bhroin, Cliona Ní Cheallaigh / Editor: Lauren Fraser / Codes: CAP30, CC6, HAP30, MHC1, MHP5, SLO1, SLO2, SLO7, XC3 / Published: 19/04/2022
Inclusion Health is an approach which seeks to improve health outcomes of socially excluded people. People who are socially excluded are typically excluded from the social system and its rights and privileges, typically as a result of poverty or the fact of belonging to a minoritized social group. They have greatly reduced access to education, occupation, accommodation and healthcare, even if these services are available free of charge.
Socially excluded people experience extreme health inequality, increased morbidity and mortality and their life expectancy is shortened by 20-50 years. Socially excluded people frequently experience homelessness, incarceration and sex work. They may belong to minoritized groups such as Travellers, Gypsies, Aboriginal or First Nation and/or may be LGBTQI, have physical or intellectual disabilities and/or may be vulnerable migrants or refugees (1).
Various aspects of social exclusion may be experienced by the same person, and compound the harmful effects (this is called intersectionality). Levels of traumatic experiences in childhood and adulthood including sexual and physical violence and neglect are much higher in people who are socially excluded, and this results in much higher levels of mental illness, drug and/or alcohol dependence and poor physical health – this combination is known as tri-morbidity (1). Childhood abuse and neglect, in particular, have profound effects on how a person interacts with others and particularly with healthcare staff.
In 2020, RCEM highlighted the importance of inclusion health in the ED with the publication of both a best practice guideline and a policy briefing on homelessness in the ED (1,2). In part, this is to raise awareness of the statutory obligation on EDs in relation to the “duty to refer”. This relates to the Homelessness Reduction Act 2017 which states that EDs, Urgent Treatment Centres and hospitals providing inpatient care must notify a local housing authority if they believe a service user is homeless or are likely to become homeless in the next 56 days (3). There are over 280,00 people estimated to be experiencing homelessness in England alone (4). Multiple studies have shown that homeless people use EDs much more frequently than the general population, are admitted to hospital more often and stay much longer (2,5). In addition, people experiencing homelessness have greatly increased mortality; 7.9 times for men and 11.9 times for women (6). These patients often suffer multimorbidity and are at risk of fragmentation of care without anybody taking overall responsibility for the patients’ needs e.g. input from psychiatry, substance use teams, HIV team, social work etc. but nobody managing the patient holistically (7).
As well as social exclusion, sex workers face a particular set of challenges including sexually transmitted infections, violence, and mental illness. Despite this, studies have shown that they are reluctant to access healthcare, making them amongst the most marginal and vulnerable groups in society (8).
Gypsys and Travellers are a heterogenous group but they share poor health in terms of increased infant and child mortality, high levels of anxiety and lower life expectancy, all while facing discrimination and social exclusion (9). Although some travellers are settled, others remain transient. When they are moved on from camp sites to new areas, they suffer the loss of continuity of care and may become reliant on EDs for healthcare that would better be provided in the community (9).
Refugees and vulnerable migrants share this problem of moving frequently and not establishing a lasting relationship with healthcare services (10). In addition, many find it difficult to register with a GP or communicate with them due to language barriers, resulting in increased ED visits (10).
Bearing all of this in mind, it is imperative that we recognise the unique opportunity in the ED to assess the patient holistically; arrange appropriate accessible follow up and link the patient to the relevant services (1).
Every ED attendance “represents an opportunity to provide healthcare advice and offer information regarding accessing social and other support” (1).
Inclusion health involves the care of those who experience extreme health inequality such as homeless people, Gypsys and Travellers, sex workers and vulnerable migrants.
These patients have much higher morbidity and earlier mortality than the general population but despite this, can struggle to access appropriate care.
This is a social justice movement which aims to prevent and address health and social inequities through research, clinical service and policy (11,12). Excluded groups most at risk from extreme inequity include people experiencing homelessness, sex workers, prisoners, Gypsies, Travellers, other relevant minoritized groups (e.g. Aboriginal people in Australia) and migrants (11,12).
People experiencing homelessness are those without the legal right to occupy any accommodation or have accommodation which is unsuitable to live in (2). While rough sleepers may be the most visible people experiencing homelessness, they represent only one of the following four types of homelessness (2):
- Rough sleepers
- Often seen on sleeping on streets, in parks, train stations etc.
- Those in temporary accommodation
- Such as hostels, shelters, women’s refuges etc. (13)
- Those experiencing hidden homelessness
- This cohort forms the largest group of homeless people but they do not appear in statistics and are hidden from services (13).
- They include those who are staying with friends and family, those who are “sofa surfing”, those who are squatting etc.
- Those defined as statutory homeless
- People deemed in priority need after approaching local authorities for assistance. These are often families; single homeless people rarely qualify for statutory homeless status (14).
RCEM has designed the guideline in the format of fundamental, developmental and aspirational standards for inclusion health in the ED both in relation to organisational structures and documentation (1).
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 patient’s 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 patient’s 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.
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.
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 patient’s 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.
The following should be recorded by each ED:
- The number of homeless ED attendances in the previous 3 months.
- The number of homeless patients leaving ED prior to being seen by a clinician in the previous 3 months.
Documentation in Patients’ Notes
- Drug and alcohol history
- Past medical history, allergies, and medication
- Social history including how long they have been homeless, which homeless services they use, where they sleep, if they have a key worker
- Method of attendance e.g., ambulance, police, self and if by ambulance, the location where they were picked up
Standards in Relation to Discharge
- The patient should only be discharged for GP follow up if they are registered with one.
- Discharge plan for homeless people should be documented including how the decision has been affected by homelessness e.g., isolation, follow up etc.
- Follow up plan for any of the vulnerable groups should be documented in the patient notes.
- If sleeping rough, the patient should be referred to an outreach team.
Standards Which Apply to Drugs, Alcohol and Mental Health
- The patient should be referred for specialist assessment if alcohol or drugs were the direct cause of the ED presentation.
- If attending secondary to an alcohol related cause, a CIWA score should be documented before the patient leaves the department.
- Homeless patients attending with alcohol as a cause of presentation should be given IV Pabrinex if indicated.
- If there is an acute mental health problem identified, there should be a risk assessment documented and the patient should be referred to the mental health liaison team.
RCEM have developed a guideline which outlines several standards for the care of homeless and other vulnerable patients in ED. The fundamental standards relate to the duty to refer, providing patients with information and obtaining up to date contact details for patients.
Barriers to the provision of holistic care to marginalised patients in the ED include (16,17):
- The episodic nature of the care
- Difficulty addressing medical needs while social needs are unmet
- Failure to recognise the patient’s housing situation
- Lack of timely involvement of the appropriate ancillary staff
- Staff attitudes toward homeless patients
- Lack of staff time and/or competency in working with people who have experienced complex psychological trauma
Homeless people, and those in other marginalised groups, also face a number of barriers to primary healthcare including (18):
- Stigma (both social stigma and self-stigma)
- Low literacy levels
- Cognitive deficits (including intellectual disability, acquired cognitive impairment, ADHD and autism spectrum disorders)
- Competing priorities (e.g. sourcing food, shelter, money, substances to prevent withdrawal)
- Language and/or cultural barriers
- Mental health problems
- Substance use disorders
- Practical issues including transience, inability to register with a GP and having pets to take care of
- Not being aware that primary care is free of charge
- Long waits for appointments
- Being unable to afford to call the surgery to make an appointment
- Lack of trust in health and social care professionals (may be due to experiences of institutional care in childhood, prison or having children removed in to institutional care)
Homeless people face many obstacles to accessing healthcare, not least of all the stigma associated with their housing status.
When assessing a patient from a socially excluded group, it is important to remember that this may be an opportunity to build trust and to intervene and link the patient to appropriate services. The patient may not be registered with a GP, may not be receiving follow up for chronic conditions and may not be taking prescribed medication. They may have complex medical and/or mental health problems and are seeking help so these patients are deserving of your time. Even those who are frequent attenders are repeatedly visiting the ED because they have unmet needs despite many encounters with healthcare professionals (19).
Since many of these patients have a complex combination of poor physical health, mental health problems and alcohol and/or drug dependence, it is often difficult to distil an ED attendance into a single presenting complaint and the patient may not be able to articulate their needs. While the presenting complaint may initially seem like a simple limb injury, for example, there may be psychosocial factors contributing to the presentation which may need to be explored and there may be other ongoing health problems requiring treatment. Check in with them in terms of their overall health, participation in screening programs etc. Standard follow-up and treatment plans may not be suitable e.g. advice regarding weight-bearing, diet and/or ability to engage with medication or follow-up appointments may not be achievable.
When taking the history, ask about previous medical history and medications. Bear in mind that they may not be taking prescribed medicine for several reasons (chaotic lifestyle, financial difficulties, poor understanding etc.) but they may be taking medications which have not been prescribed for them. This will only become evident if the history-taking is done in a non-judgemental manner.
Brief Alcohol Assessment
NICE Guidelines state that “staff working in services provided and funded by the NHS who care for people who potentially misuse alcohol should be competent to identify harmful drinking and alcohol dependence” (13). They suggest that this should be done using a formal assessment tool such as AUDIT (Alcohol use disorders identification test).
AUDIT enquires about alcohol intake, potential dependence, and alcohol related harm (14). Questions are multiple choice, and this could be completed quickly in the ED, indicating whether the patient may have an alcohol use disorder and may benefit from referral to appropriate services.
For patients with an alcohol use disorder, a thorough risk assessment should be completed including risks of acute intoxication, acute withdrawal, or suicide. Patients in withdrawal with, or at high risk of, complications such as delirium tremens or seizures should be offered admission to hospital for medically assisted alcohol withdrawal (20). Severe alcohol withdrawal has a significant mortality rate if unmanaged.
RCEM recommends documentation of a CIWA score for homeless patients presenting to ED as a result of alcohol. The CIWA-Ar (Clinical Institute Withdrawal – Alcohol, revised) scale is a validated 10 item assessment tool used to measure the severity of alcohol withdrawal and monitor patients through treatment (20). It assesses the following domains to generate a final score: nausea and vomiting; tactile disturbance; tremor; auditory disturbance; paroxysmal sweats; visual disturbance; anxiety; headache or fullness in head; agitation; and clouding of sensorium.
Brief Drug Assessment
Ask patients the drug(s), route(s) of administration and how often they use it/them (21).
It is of paramount importance that this assessment should be non-judgemental, respectful and proportionate to the patients vulnerabilities (21). Enquire about the safety of the patient, particularly in terms of acute withdrawal, comorbid mental health issues, needle use etc.
Homeless patients have complex needs which they may not be able to articulate easily. Seek out other health problems, drug and alcohol use, mental health issues and safeguarding concerns.
Investigations should be led by the presenting complaint and any other underlying issues uncovered during assessment. It must be kept in mind that homeless and vulnerable patients are often not appropriate for ambulatory pathways e.g. returning for doppler to investigate for DVT, and so investigations should be expedited where possible (1).
RCEM suggests that routine ED HIV testing should be considered in areas where the local HIV prevalence is 2/1000 or greater as long as appropriate systems and funding are available to support the programme (22).
Given the high levels of morbidity and mortality in this group, it is likely that the homeless person attending ED has ongoing health conditions which require treatment, even if they do not state that this is their priority (18). In parallel to managing the presenting complaint, attempts should be made to address psychosocial issues and refer to the appropriate services if the patient agrees. Rather than being judgemental or dismissive, staff must be understanding of the social determinants of health and the role of the ED in population health (2).
Managing difficult behaviour
Owing to high rates of adverse childhood events, complex trauma and PTSD, homeless patients may struggle to trust others, develop relationships, manage stressful or difficult situations and wait for treatment (18). This can often lead to patients in genuine need of medical care, escalating and being removed by security or discharging themselves (18).
Bear in mind that these patients have attended the ED due to a genuine need and try to show empathy. Try to understand why they are behaving in a particular way, provide information, develop trust and provide practical solutions (18). Common triggers for challenging behaviour are hunger (patients may not have money for food), shame about themselves (particularly if they are dirty or malodourous), perceived judgement or stigmatisation from hospital staff and drug or alcohol withdrawal. These patients frequently experience dismissal, disapproval and unfriendly behaviour throughout their life and are often primed to perceive interactions in a negative way. Often introducing yourself with a smile, and demonstrating that you see them as a person and recognise the challenges they are facing (e.g. by providing them with a cup of tea and sandwich) can go a long way in deescalating a patient and keeping them in ED for treatment. If their primary reason for wanting to leave is that they are entering withdrawal from alcohol and/or drugs, this should be managed appropriately as quickly as possible.
Discharging Patients from ED
Unfortunately, sometimes homeless patients must be discharged from the ED onto the street. In this circumstance it is of particular importance to ensure that the patient has capacity (especially for patients who want to self-discharge) and that there are no safeguarding concerns (18). While homelessness is not an indication for admission, bear in mind that these patients may warrant a lower threshold for an inpatient admission. The following may be barriers to safe discharge in this population:
- Inability to comply with close follow up
- Inability to afford or access prescribed medication
- No facilities to isolate if required
When discharging these patients, ensure you have referred them to relevant services and checked that you have up to date contact information (1).
The Care Act 2014 states that vulnerable people must be adequately safeguarded from abuse and self-neglect, therefore safeguarding concerns must be actively ruled out for every homeless person attending the ED (18). A safeguarding issue may arise where there is a patient who clearly cannot adequately take care of themselves, or a patient is being abused by another person. This must be raised with the safeguarding lead (18) and required referrals made to social care.
Often it can be helpful to signpost the patient to local community services which may be of assistance to them. Each ED should have a pack with this information readily available (1). In addition, the Homeless Link website is useful for sourcing up-to-date information on local services (18). Types of services available include (18):
- Specialist homeless primary care services
- Housing services
- Homeless day centres, night shelters and soup kitchens
- Homeless and mental health charities
- Mental health crisis supports
- Sexual health services
There can be many reasons for difficult behaviour in the ED but often being patient and empathetic can defuse the situation.
When discharging homeless patients, ensure they have the means to attend for follow up, obtain medication etc. and if not, reconsider the plan and whether or not the patient can be safely discharged.
Because of the complex nature of their needs, some homeless people attend ED frequently, leave the ED prior to seeing a doctor or before their treatment is complete and/or re-attend shortly after discharge. Up to 41% of ED visits by homeless people ended in the patient leaving before completion of treatment in one study (5). It is believed that some patients may register simply to seek shelter in the ED waiting room, however other patients who may require medical attention leave before they are seen due to withdrawal from alcohol and/or drugs (5). Similarly, homeless medical inpatients are also much more likely to self-discharge than housed patients (5). These patients may then re-present to ED later which can develop into a pattern of frequent attendance at EDs.
Patients who attend frequently should be treated with the same respect and care as other patients and ED physicians must speak out against the stigma associated with frequent attenders, especially given that this group has such high morbidity and mortality (23). All frequent attenders should be considered to be vulnerable and screened for drug and alcohol use, safeguarding issues and domestic violence each time they are seen in ED (23). It is useful for departments to identify their frequent attenders and develop strategies to better meet the care needs of this group such as ED care plans, MDT involvement and primary care involvement (19). Patients who frequently attend the ED should have clear boundaries put in place which are explained clearly to both them and to staff and these boundaries must be upheld at each encounter (18).
Patients who attend frequently are doing so because they have unmet needs and should be treated with the same respect as other patients.
Stigma is dangerous and should be challenged.
- Failure to identify that the patient is from a marginalised group
- Frustration at a perceived hopeless case or lack of progress
- Missing an opportunity to intervene for vulnerable patients
- Stigmatising homeless or other vulnerable patients and allowing this to affect their treatment
- Focusing only on the presenting complaint as opposed to taking a holistic approach
- Arranging follow up the patient is unlikely to attend
- Discharging the patient with a plan that they cannot comply with e.g., isolation
- Not referring patients to Local Housing Authority despite the statutory obligation to do so
- Discharging patients in acute alcohol withdrawal with red flags for, or a history of, complicated alcohol withdrawal
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- Ministry of Housing Communities and Local Government. A Guide to the Duty to Refer [Internet]. 2018.
- Shelter. This is England : A picture of homelessness in 2019 The numbers behind the story. 2019.
- Cheallaigh CN, Cullivan S, Sears J, Lawlee AM, et al. Usage of unscheduled hospital care by homeless individuals in Dublin, Ireland: A cross-sectional study. BMJ Open. 2017;7(11):1–7.
- Aldridge RW, Story A, Hwang SW, Nordentoft M, et al. Morbidity and mortality in homeless individuals, prisoners, sex workers, and individuals with substance use disorders in high-income countries: a systematic review and meta-analysis. Lancet [Internet]. 2018;391(10117):241–50.
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- Royal College of Physicians. Inclusion Health Designing Services [Internet]. 2021.
- Crisis UK. Types of Homelessness [Internet]. 2021.
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- Homeless Link. SWEP Guidance 2020-21. 2020;(1089173):2–5.
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- National Institute for Health and Clinical Excellence. Alcohol-use disorders: diagnosis and management of physical complications NICE Guideline [CG100]. 2017;(June 2010).
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- The Royal College of Emergency Medicine. Frequent Attenders in the Emergency Department [Internet]. Best Practice Guideline. 2017.