Hospital readmission reduced by two-thirds by Cyrenians pilot project

16 August 2022
Western General Hospital

The Cyrenians Hospital InReach service has reported a reduction in readmission rates of over two thirds, representing a significant reduction in pressure on NHS services.

Within the first 18 months of the pilot project, over 300 patients at risk of homelessness have been supported to maintain or access accommodation upon discharge. These patients were 68 per cent less likely to be re-admitted to hospital compared to the 12 months prior to their referral to the project.  

Homeless men and women have an average life expectancy of just 47 and 43 years respectively, and on average experience hospital admission 3.2 times more often than non-homeless patients. Furthermore, these admissions last on average three times as long, driving up unscheduled secondary care costs. Cyrenians Hospital InReach team works alongside clinicians to identify patients experiencing homelessness and support them to access appropriate housing, food and ongoing support on discharge from hospital.  

The Scottish Government recently consulted on proposals to extend homelessness prevention duties to public bodies, including integration authorities and health services. Cyrenians Hospital In-Reach service directly demonstrates how health services and the voluntary sector can work together and take a prevention-led approach to improving outcomes for people at risk of homelessness. 

Cyrenians Chief Executive, Ewan Aitken, said,

“A vicious combination of inadequate shelter and pre-existing physical and mental health conditions, makes accessing appropriate healthcare and maintaining a healthy lifestyle exceptionally difficult for this vulnerable population group. These issues drive increased need for acute and emergency healthcare among people experiencing homelessness."

"Our hospital in-reach service has been integral to securing better long-term health outcomes for those who have interacted with our team."

“Alongside the improved health outcomes we have seen a significant reduction in readmission and therefore reduced pressure on NHS services showing how valuable projects between the third sector and public sector are. We are hopeful that we can secure the necessary support to maintain and grow the project.” 

Dr Claire Mackintosh, Clinical Director Regional Infectious Disease Unit, NHS Lothian, added,

“The Hospital In-Reach Team provides invaluable support to patients during their inpatient stay through what can be a very stressful, difficult and disorientating experience."

“The relationships this team forges with patients lead to trust and understanding and clinical teams are hugely helped by the knowledge this team carries with regards to safe discharge and available support. They have very quickly established the service as a crucial aspect of safe and compassionate care for patients suffering complex medical and social needs.” 

Gavin, a beneficiary of the Hospital In-reach Team’s support, said,

“I was admitted to the Western General Hospital on New Year’s Eve - I met Chris when he came to see me in hospital. I didn't have any clothes with me and he got me new ones, he made sure I had everything else I needed whilst I was in the ward. I had no one else who could do this for me, I was totally on my own in hospital.

“Chris has been great and nothing is too much trouble for him. Out of all the support workers I've had he's the only one I've been able to talk to and tell things that I wouldn't tell anyone else."

"The attention and practical support I got was way more than I expected or have had from other support workers.” 

Find out more about the results of this ground-breaking project: Hospital Inreach evaluation summary 2022, or read the full report here.