Nurse‐led mental and physical healthcare for the homeless community: A qualitative evaluation

Abstract Increased morbidity and mortality rates are prominent issues among homeless individuals. To help reduce these health inequalities, dedicated senior mental and physical health nurses have been deployed to work within and alongside local statutory and voluntary organisations. This qualitative evaluation examined the impact of nurse‐led homeless healthcare in Warwickshire, United Kingdom. During January and February 2021, online semi‐structured interviews were conducted with 17 professionals including the mental and physical homeless health nurses (n = 4), statutory health and local authority professionals (n = 4), and voluntary and community sector professionals (n = 9). Interviews were qualitatively analysed using inductive, reflexive thematic analysis. Data analysis identified three overarching themes related to the meaning, impact and future development of nurse‐led homeless healthcare: (1) Nurse‐led homeless healthcare and health inequalities, (2) The multi‐agency approach of nurse‐led homeless healthcare, and (3) Future development of nurse‐led homeless healthcare. The findings confirm the benefits of homeless healthcare in reducing health inequalities and promoting a more accessible, flexible and person‐centred approach to holistic care. Yet, prevailing organisational and system‐level barriers were also identified as currently limiting the capacity, provision and practicalities of delivering nurse‐led homeless healthcare. Recommendations were identified with international relevance and included: (i) continued implementation of person‐centred healthcare for homeless individuals, (ii) strengthening of organisational collaboration and communication pathways to improve coordinated care, (iii) development of the managerial and structural aspects of provision, (iv) addressing limitations associated with scope and capacity to ensure that delivered healthcare is adequately intensive, (v) increased availability of clinical or therapeutic spaces, and (vi) implementation of long‐term plans supported by evaluation and commissioning.


| INTRODUC TI ON
Health inequalities are prevalent among homeless individuals.
Increased morbidity and mortality are associated with accident and injury, suicide and long-term conditions including infectious and cardiovascular diseases Fazel et al., 2014;Field et al., 2019;Queen et al., 2017). Poverty, trauma, substance misuse and mental illness also contribute Fazel et al., 2014;Field et al., 2019;Queen et al., 2017). Barriers to accessing healthcare include stigma, social exclusion and unsuitable communication pathways (Elwell-Sutton et al., 2017;Gunner et al., 2019;Magwood et al., 2020), which can increase emergency care utilisation (Mitchell et al., 2017;Rae & Rees, 2015). Individuals may also experience co-occurring mental illness and substance misuse, referred to as 'dual diagnosis' (Cream et al., 2020), however individuals may be ineligible for specialist services because of these comorbidities (Carrà et al., 2015).
Additional provisions have been designed to better care for homeless individuals (Bryar, 2020;Gunner et al., 2019). Projects have utilised community spaces such as libraries to deliver healthcare (Mariano & Harmon, 2019) and observed increased engagement with primary care when in contact with a community health nurse (Su et al., 2015). Positive implications for identifying and treating health issues and reducing emergency care have also been identified (Bryar, 2020;Cream et al., 2020). Homeless healthcare, however, can be restricted by temporary commissioning, and only half of homeless projects (e.g., hostels) in the United Kingdom (UK) are linked to specialist health services (Crane et al., 2018). Less than 50% of UK mental health services report dedicated resources for homeless patients, and staff training in homelessness is limited (Lucas et al., 2018). The development, implementation and evaluation of homeless healthcare is therefore ongoing.
Authorities in the UK have implemented guidance and strategies to reduce homelessness and improve health (Public Health England, 2019). Central to this is multi-agency partnerships between statutory services (services provided by local and national government, including health and social care) and voluntary and community organisations, which are purported to improve holistic and coordinated healthcare and subsequently reduce inequalities (Cream et al., 2020;Luchenski et al., 2018). The voluntary sector have traditionally played a significant role in supporting homeless individuals, using more flexible methods than those observed in statutory healthcare (Flanagan & Hancock, 2010), offering opportunities for developing homeless healthcare.

| Context for this evaluation
This study evaluates nurse-led homeless healthcare delivered in Warwickshire, UK, a rural county that reports increased rates of homelessness and recent counts of 47 individuals rough sleeping (e.g., on the street or in tents) (Public Health England, 2021;Warwickshire County Council, 2021). Rural homelessness poses challenges for reaching more isolated individuals, delivering specialist services over greater distances and implementing effective commissioning (Snelling, 2017).
In 2019, mental health nurses (experienced in psychological therapies and motivational interviewing) were seconded into a voluntary organisation delivering community-based housing support ( Figure 1). This structure aimed to develop street-based and outreach approaches to homeless healthcare for individuals rough sleeping (in year one of the pilot) and those vulnerably housed (from year two). General nurses have delivered physical health provision (e.g., wound care, blood-borne virus treatments) since 2020 and remained employed by the National Health Service (NHS). The full-time homeless health nurses are senior and have specialist expertise in their respective fields, where prior experience with homeless patients was only that gained from working in public healthcare. Akin to 'street medicine', where healthcare is delivered in locations more accessible to prospective patients (Stefanowicz et al., 2021), the nurse-led homeless healthcare pilot aimed to deliver person-centred care to improve health, strengthen system-wide partnerships and disseminate professional knowledge across the multidisciplinary team. In this article, 'clients' is used to denote individuals who may access homeless healthcare.

| Aims
The specific aims of this evaluation were to understand (i) how the mental and physical health of clients was supported by nurseled homeless healthcare, including via access to other services and (ii) professionals' experiences of collaborative working and What is known about this topic • Mental and physical health inequalities among homeless individuals have been internationally evidenced.
• National policies and local homelessness prevention strategies aim to reduce health inequalities and improve health through integrating health, care, and support services.

What this paper adds
• Nurse-led homeless healthcare was indicated to increase access to mental and physical healthcare and may reduce health inequalities.
• Effective support for homeless individuals is strengthened by multi-agency partnerships across statutory and voluntary and community organisations.
• Strong referral pathways and structures at organisational and system levels were important in building client engagement with both homeless healthcare and wider services and to ensure a professionally coordinated approach.
whole-system outcomes, including the impact of nurse-led homeless healthcare on organisational partners.

| Design
In this qualitative study, semi-structured interviews were conducted with professionals working with homeless individuals in Warwickshire. The design was discussed with key professionals to ensure appropriateness. Ethical approval was received from Coventry University (p110165). This evaluation is written according to COREQ requirements (Tong et al., 2007).

| Sample and recruitment
In North and South Warwickshire, nurse-led homeless healthcare was delivered by one mental health nurse and one general nurse (four nurses in total across Warwickshire). Via joint casework and multi-agency meetings, the homeless health nurses worked alongside statutory services (e.g., housing, health, police and probation) and the voluntary and community sector (e.g., housing support and drug and alcohol services), as depicted in Figure 1. Eligible participants contributing to this evaluation therefore included professionals working for or alongside nurse-led homeless healthcare in Warwickshire.
During COVID-19, interviews were conducted remotely between January and February 2021. Relevant gatekeepers disseminated Participant Information Sheets to key organisational contacts, and snowball sampling identified further participants. Interested individuals contacted the research team, and all participants provided informed consent using survey software (Qualtrics). No participant withdrew, however with this recruitment approach response rates are unknown. We also intended to interview clients. Regrettably, clients were not interviewed due to challenges accessing confidential spaces during COVID-19.

| Reflexivity
Interviews were conducted by a Research Assistant with a public health research interest and experience conducting research interviews. Participants were informed that the research institution was not involved in the design or delivery of the homeless healthcare pilot, and that participants would not be explicitly identified alongside quotes. However, participants were from a limited potential pool, and this was recognised as a factor that could influence responses. Analysis therefore applied a critical realist perspective, whereby participants were assumed to present meaningful and individual experiences and perspectives, though participant responses may be filtered or modified in the interview context (Fletcher, 2017).

| Data collection
Only the interviewer and participant were present during interviews. Participants chose where to complete the interview, such F I G U R E 1 Structure of the nurse-led homeless healthcare and types of partner organisations working in national and local strategies. Note: National Health Service (NHS)

Warwickshire homelessness strategy
Commissioning and strategizing towards mulƟ-agency partnerships. Aims to improve health and reduce inequaliƟes via increased healthcare access and partnership working. as their home or workplace. According to a semi-structured schedule, participants reported their perceptions of nurse-led homeless healthcare and its impact on clients, organisational collaboration, knowledge-sharing, referral pathways and recommendations for homeless healthcare. Follow-up questions sought clarification and in-depth understanding. All interviews were audio-recorded with consent. Field notes were not produced and interviews were not repeated. Participants were not invited to comment on transcripts.

| Data analysis
Audio recordings were transcribed verbatim and identifiable information removed. Participants were informed that quotes would be presented with pseudonyms and their own pseudonym could be chosen. Quotes are not presented with participants' professional roles to support anonymity. Verbatim quotes have been modified to aid readability (e.g., removing word repetitions and hesitations).
A reflexive thematic analysis was conducted according to a sixphase approach (Braun & Clarke, 2006, 2020. After data familiarisation, LB assigned codes to all transcripts inductively (i.e., data driven) and without automated software. A second researcher (MB) examined three transcripts to offer alternative interpretations, codes and to support reflexivity. LB organised codes into candidate themes, which were then collaboratively refined among the researchers. Themes and definitions were revised throughout the writing process, and quotes were chosen to illustrate patterns and represent the range of participants. Independent coding and saturation were not concepts aligned with the chosen reflexive approach (Braun & Clarke, 2021).

| Participants
A total of 17 professionals (see Table 1) participated in interviews that lasted M = 38 min (range 20-67 min).

| Qualitative findings
Thematic analysis identified three master themes: (1) Nurse-led homeless healthcare and health inequalities, (2) The multi-agency approach of nurse-led homeless healthcare, and (3)  The consensus was therefore to redevelop the referral process to fulfil reporting needs while maintaining a flexible approach.
Finally, relationships between some organisations in the system were perceived to be currently underutilised, which could hinder information-sharing and referral opportunities. Increased and formalised integration between primary and secondary healthcare and the homeless healthcare provision, particularly at the point of hospital discharge, was also likely to improve care continuity: ''people go into [intensive care], come round and they self-discharge and they come out and they're literally back on the street…it's hearsay that I find out, but there should be some pathway.'' (Barney).

Subtheme 3B: Ongoing organisational and structural challenges
Organisational and structural challenges were identified in relation to the current nurse-led provision, notably regarding the secondment of the homeless mental health nurses into a voluntary organisation (as illustrated in Figure 1). Differences between the voluntary organisation (and wider voluntary sector) and the statutory sector (i.e., the NHS) were found in the availability of training and supervision, which did not always match professional registration require- "where we could just say to people 'just pop in the back for a minute and let's have a look at that that wound or that foot' to give people back their privacy and dignity." (Sharon).

Subtheme 3D: Generating and measuring long-term impact
The need to evidence the impact of nurse-led homeless healthcare was identified. However, an acceptable measure of mental wellbeing was not identified, and quantitative scales used routinely in statutory healthcare were perceived to be less appropriate for use in homeless healthcare: "the people we work with may not wish to be answering a set of questions every time." (Adrian).

| DISCUSS ION
This evaluation interviewed a range of professionals involved with nurse-led homeless healthcare in a UK county. The findings reported how the homeless health nurses, specialising in mental or physical healthcare, responded to existing health inequalities, improved health outcomes and offered a novel contribution to a strengthened multi-agency approach. Challenging areas needing further development largely related to prevailing system and organisational-level barriers and, if addressed, could lead to enhancements in the delivery of nurse-led homeless healthcare.

| Strengths and outcomes of nurse-led homeless healthcare
The findings contributed additional evidence for the benefits of nurse-led homeless healthcare in improving health and reducing health and social inequalities for people who are homeless (Bryar, 2020;Ungpakorn & Rae, 2020). The nurses delivered personcentred care aligned with a biopsychosocial model likely to support clients' interacting and diverse unmet needs (Omerov et al., 2020).
Positive implications for health extended from aspects of psychological wellbeing, (e.g., improved self-esteem, confidence, motivation and worry) to physical health outcomes (e.g., symptom alleviation, screening attendance and treatment uptake), including via increased medication adherence and help-seeking by clients.
Instead, nurse-led homeless healthcare appeared to increase accessibility to testing, therapies and treatments owing to full-time provision that prioritises and advocates for the homeless community (Davies & Wood, 2018;Harney et al., 2019;Su et al., 2015).
The nurses' compassionate approach counteracted clients' previous negative healthcare experiences, and their compassion was successfully combined with expertise in mental illness and physical health.
Multi-agency working between the homeless health nurses and voluntary and statutory sectors was successfully aligned with national strategies to integrate health and social care services (NHS England, 2021). Partnership working via case work and multi-agency meetings supported professionals to exchange knowledge, build client pathways and overcome usual issues with dual diagnosis (Carrà et al., 2015;Gunner et al., 2019). By building on the relational partnerships and collaboration that had developed, the findings also identified ways in which organisational and system-level factors could be developed to strengthen homeless healthcare.

| Moving nurse-led homeless healthcare forward
Areas requiring further development were associated with contextual and structural factors of homeless healthcare. In particular, a secure shared system between the mental health and general nurses could improve safeguarding of clients and professionals, avoid unnecessary repeated history-taking, and promote care continuity (Mathioudakis et al., 2016 The mental health nurses' secondments into the voluntary organisation were beneficial in implementing the flexible, streetbased approach already adopted by the voluntary sector. However, conflicting practical and cultural approaches between the sectors were also reported, consistent with wider evidence about such differences in organisational norms, practice, knowledge and outcome measurements (Renedo, 2014). In addition, participants raised the importance of improving capacity in the nurses' roles, particularly in the context of a larger and more rural county. Because of the complexities associated with homelessness, appropriately low caseloads (resulting from appropriate referral criteria) are likely to be important in ensuring care continuity and intensive provision (Ponka et al., 2020). Assertive community treatment approaches are characterised by multi-disciplinary working and low caseloads offering community-based, intensive support (Coldwell & Bender, 2007).
Evidence has supported this approach for homeless individuals because of improved housing stability, mental health and psychiatric outcomes (Moledina et al., 2021). Advances in nurse-led homeless healthcare must therefore adopt structures that support professionals with diverse roles and responsibilities, and facilitate intensive and multi-agency support to clients (Parsell et al., 2020).
Finally, participants indicated that inequalities in healthcare access could prevail while adequate clinical and therapeutic spaces were lacking. Participants advocated for mobile transport or increased utilisation of community spaces to enhance client privacy and confidentiality (Kiser & Hulton, 2018). Similarly, understanding of the longer-term commissioning plans would assist stakeholders to plan and prepare adequately in relation to local homeless healthcare.
As well as forming a standard part of implementation and evaluation efforts, it is crucially important to optimise the role that nurses play to support and sustain nurse-led healthcare for the homeless community. A summarised list of recommendations is provided in File S1.

| Potential limitations
Due to challenges acquiring confidential spaces for client interviews during COVID-19, this evaluation did not directly incorporate the voices of clients. While professionals agreed about how nurse-led homeless healthcare had positively affected clients, it is not known how far professional perceptions align with client experiences, and this work is ongoing by the research team. Though beyond the scope of this study, examination of the impact of homeless healthcare on outcomes such as hospitalisation and rough sleeping would contribute beneficial evidence.
Participants from a range of organisations contributed constructive thoughts to this evaluation. However, it was recognised that the interview context may have influenced participant's contributions, and some stakeholders (such as police and probation services) were not successfully recruited. The findings also do not intend to be applied to other homeless health services, particularly where local systems and infrastructure may differ.
Considerations should also be granted to the context of COVID-19. The homeless community, including professionals, were impacted by closures of community spaces, routine disruption and changed formats of support services (Kaur et al., 2021;Parkes et al., 2021). These contexts shaped the roles of the nurses during this time, as they increased accommodation visits, facilitated support between clients and other services, and attended online multiagency meetings. Therefore, while nurse-led homeless healthcare was operational prior to the pandemic, there were multi-faceted implications of COVID-19.

| CON CLUS ION
This qualitative evaluation reinforced the benefits of dedicated homeless healthcare in reducing health inequalities through accessible, flexible and person-centred care. Multi-agency partnership working was essential to holistically support clients and professionals. Important organisation and system-level recommendations based on the findings included developing robust organisational pathways, structural considerations related to scope and capacity, and increasing availability of clinical spaces, with these recommendations expected to further enhance access to healthcare and health promotion for individuals experiencing homelessness.

ACK N OWLED G EM ENTS
The authors would like to thank the participants and organisations who took time to share their experiences of nurse-led homeless healthcare in this evaluation.

CO N FLI C T O F I NTE R E S T
The authors do not declare any conflict of interest for this work.

AUTH O R CO NTR I B UTI O N
EF, DL and LB contributed to the study design. Interviews were conducted by LB. Analysis was conducted by LB and MW. All authors interpreted the findings and contributed to manuscript drafts and revisions.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data are not publicly available to preserve participant anonymity.