Case Study:
OOHCM Programme Evaluation
Introduction
Evaluation of the Out-of-Hospital Care Models (OOCHM) Programme for people experiencing homelessness
Timescale: 1 September 2021 - 31 October 2023
Funder: Department of Health and Social Care
In 2020, the Department of Health and Social Care (DHSC), Ministry for Housing and Local Government and Ministry of Justice, allocated £16 million through the Shared Outcomes Fund (SOF), to roll out and robustly evaluate out-of-hospital care Models (OOCHM) for people experiencing homelessness.
As part of this initiative, funding and improvement support were provided to 14 local authority test sites and four sites working across London by the DHSC. The aim was to test how successful models can be scaled across a wide range of areas and adapted to new contexts and circumstances post Covid-19.
In August 2020, a new hospital discharge operating model was implemented across England to manage the increase in hospitalisations due to the pandemic: Discharge to Assess (D2A). D2A aims to transfer people as soon as it is clinically appropriate to do so. The programme will provide short-term support to enable assessment for longer-term care and support to take place out-of-hospital and in a range of settings, including people’s own homes, care homes and hotels. A key objective of the Out-of-Hospital Care Models programme was to explore how support for homeless patients can be integrated as part of the new D2A operating model.
In September 2021, King’s College London, The London School of Economics and Political Science, and Expert Focus were commissioned to undertake a 24-month evaluation of the OOHCM programme. The overall aim of the evaluation is to capture the learning from the test sites and to evidence the outcomes that are being achieved.
Objectives
The main objectives of the Out-of-Hospital Care Models programme are:
Scaling Out-of-Hospital Care
Provide an understanding of the most effective methods for implementing and scaling out-of-hospital care across a wider range of areas, including the conditions needed to maximise the effectiveness and sustainability of the services.
Integrating Care Models
Describe how models are being integrated into the evolving health, housing and social care system, supporting the D2A hospital discharge operating model, the NHS Long-Term Plan and Covid care and recovery.
Identifying Challenges
Identify the challenges within systems and service delivery that necessitate changes beyond the direct control of local organisations.
Testing Effectiveness
Further test the key components of (cost-)effective models, particularly those that have not yet been integrated into a unified system.
Methods
The evaluation adopted a mixed methods approach comprising 4 work packages:
Work Package 1
WP1 supported the DHSC with designing and implementing a robust audit framework to capture the outcomes being delivered across the test sites.
Work Package 2
WP2 was a qualitative study of ‘what works’ regarding the successful roll out of models across different areas.
Work Package 3
WP3 was an economic evaluation.
Work Package 4
WP4 was a choice modelling study, analysing data collected with a Discrete Choice Experiments (DCEs) survey to establish service user preferences and utility scores for different types of out-of-hospital care.
Alongside the delivery of the work packages, the evaluation team actively participated in all aspects of the programme (e.g., contributing to webinars and events and attending quarterly monitoring meetings where test sites report their progress to the DHSC).
Performance data is now accessible through a series of dashboards that visualise key metrics with clear labelling, configured in line with existing NHSE integrated care and health inclusion frameworks. These resources include static reports and presentations, as well as interactive digital dashboards designed for various stakeholders at national and local levels. The interactive dashboards allow users to explore relationships between variables and drill down into subgroups. Findings are shared promptly, supporting the programme to achieve maximum impact throughout its lifetime and beyond.
Findings
OOHCM Programme Impact
The OOHCM Programme has delivered numerous new services, influenced significant practice changes and enabled areas to test new ways of collaborative working.
Patient Outcomes
The Programme worked with 1,254 homeless patients, with data available for analysis. Many patients reported improvements in their quality of life and positive experiences with the services, feeling treated with dignity and respect. Only a small percentage (7%) returned to rough sleeping after hospitalisation or step-down, a significant decrease from earlier reports indicating around 77%.
Metrics Standardisation
Beyond the performance analysis aligned with the DHSC business plan 2020, this programme represents the first effort to standardise over 50 metrics. These metrics cover individual demographics, process outcomes (e.g., care flow, staff composition, workload), economic impacts on the NHS and public budgets, investment costs, health and housing outcomes, care experiences, and preferences for various care models.
Automated Dashboards
Aligned with NHS England, the future automation of the integrated management dashboards aims to enhance data quality and coverage swiftly, embedding real-time data into daily operational practices at local, regional, and national levels.
Sustaining Impact
There is a risk that the Programme's impacts may be short-lived unless a method is found to sustain the momentum of the Programme’s delivery, along with its ongoing monitoring and evaluation. Additionally, a leading homeless health charity has highlighted that substantial work remains to change practices beyond the test sites.
Dashboard Workshops
The evaluation team has held workshops to demonstrate the full potential of the dashboards and discuss the roadmap for their adoption by local sites, commissioners, and national stakeholders. This roadmap is now in use. If you are interested in participating, please contact the team.
Stakeholder Feedback
Stakeholder feedback was overwhelmingly positive, with the Programme praised for creating new opportunities and improving local relationships. As one stakeholder noted, "There is nothing like a million pounds to get people round the table". However, stakeholders are aware that for sustainability issues to be addressed, effective government action is needed.
Service User Feedback
Qualitative feedback from service users was highly positive regarding the value and life-changing potential of these specialist services. One service user shared, “I was not allowed to go back to my own flat and I had nowhere to go. I remember laying in my hospital bed sobbing, then I was told about step-down and that I could go there, just till I was able to look after myself and that they would help me get the help I needed, and believe me, they did just that.”
Evaluation Findings
Overall, the evaluation aligns with the Hewett review, which notes that Integrated Care Boards (ICBs) do not routinely address health inequalities as part of their broader transformation efforts concerning delayed discharges and other persistent issues. Specialist out-of-hospital care services for individuals experiencing homelessness are still viewed as a "nice to have," with commissioners prioritising more immediate pressures on the NHS before considering funding these services.
Service User Preferences
Planning for future service developments should consider that discrete choice experiment (DCE) preference data reveals service users strongly oppose returning to rough sleeping after hospital stays and highly value alternative options. Ideal models include longer-term accommodation (minimum of 10-12 weeks) with multidisciplinary teams offering consistent support (3-4 times per week) without imposing behavioural restrictions.
Conclusion
The OOHCM Programme has delivered various new services and significantly impacted practice changes, allowing areas to experiment with innovative collaborative methods. Aligned with NHS England’s frameworks on intermediate care and health inclusion, the future automation of integrated management dashboards is set to enhance data quality and coverage. This will integrate real-time data into daily operations at local, regional, and national levels, thereby improving healthcare management.
Jo Coombes
Research Fellow, King’s College London
