The project is led by the housing charity Trident Reach, covering three Birmingham trusts and three local authorities. The team consists of a GP, a registered mental health nurse and a hospital navigator (housing specialist).
The pathway uses a multi-morbidity assessment approach to the multiple needs of patients admitted homeless or vulnerably housed, and allows for seamless transition of care into the community.
The 24 KPIs address issues unique to the homeless population such as mental health, blood borne viruses, harm reduction, alcohol and housing. Each patient on the pathway is allocated six months of key worker support to ensure they re-integrate into society.
RCGP president Professor Mike Pringle presents the award
The vast majority are now discharged to suitable accommodation with intensive support when medically fit for discharge, rather than occupying acute beds. Readmission rates have dropped significantly and 93% of patients have registered with a GP after discharge.
One rough sleeper with hepatitis C, who was a drug misuser and alcohol-dependent, had attended A&E 25 times last year. Following intervention they have not attended A&E once and have settled in housing with key worker support.
Lead GP Dr Muninder Lotay said: 'When patients present, we take the opportunity to do everything we can for them, with a multidisciplinary approach to their care. Integration of health and social care is the new buzzword and although we do have different remits, I can see how important it is that we work together.'
THE JUDGES SAID:
This GP-led initiative brings together lots of different organisations, in a priority area, to provide comprehensive and compassionate care
The GP Enterprise Awards are organised by GP magazine and GPonline, in association with the RCGP and sponsored by the MDU. Each of the six category winners receives £1,000 and has the chance to become the overall winner in a vote by the profession - and win a further £4.000.
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