Hospital InReach - Falkirk

Forth Valley Hospital InReach is a specialist homelessness prevention and discharge-planning service delivered by Cyrenians as part of the Scottish Government-funded Ask and Act pilot in Forth Valley. The service embeds a Hospital Link Worker within the acute hospital setting to identify and support patients at risk of homelessness, unsuitable discharge arrangements or delayed discharge due to housing issues.

Working closely with clinical teams, the Link Worker provides holistic, person-centred support throughout admission and discharge planning. Key interventions include preventing self-discharge among patients with complex needs, securing appropriate accommodation prior to discharge, supporting the retention of temporary accommodation during admission, facilitating home adaptations where required and improving engagement with both acute and community-based services.

The service is designed to reduce homelessness on discharge, minimise delayed discharges linked to housing issues, improve continuity of care and reduce the risk of repeated cycles of hospital admission and homelessness.

Hospital In Reach is particularly suited to patients experiencing homelessness, housing insecurity, substance use issues, complex health needs or other circumstances that may compromise safe discharge planning and long-term recovery. It provides an important bridge between healthcare, housing and community support systems, helping patients achieve better health and housing outcomes.