Integrated health and social care for people experiencing homelessness
Exam Tips
- In UK exams, explicitly state that lack of fixed address or ID is not a valid reason to refuse GP registration.
- Use the triad of inclusion health risk: physical illness + mental illness + substance misuse (trimorbidity).
- Prioritise immediate risks first: suicide/self-harm, overdose, withdrawal, safeguarding, and acute physical illness.
- Describe management as multidisciplinary and trauma-informed, with active re-engagement rather than discharge for non-attendance.
- Mention high-yield epidemiology: very high emergency care use and markedly premature mortality in people experiencing homelessness.
Definition
Integrated health and social care for people experiencing homelessness is a coordinated, trauma-informed model that delivers primary care, mental health, substance misuse, and housing/social support together for people aged 16 years and over who are homeless or at high risk of repeat homelessness. In UK practice, this includes people sleeping rough, living in temporary or insecure arrangements, and those with severe and multiple disadvantage, with the aim of reducing exclusion from routine healthcare and preventable morbidity and mortality.
Pathophysiology
Homelessness is driven by interacting structural determinants (poverty, inequality, unaffordable housing, unemployment, discrimination) and individual vulnerabilities (adverse childhood experiences, trauma, mental illness, substance use, neurodiversity, brain injury, criminal justice involvement). These factors create a reinforcing cycle of allostatic stress, poor access to preventive care, delayed presentation, and "trimorbidity" (coexisting physical illness, mental illness, and drug/alcohol misuse). Repeated crisis care use, poor continuity, stigma, and disengagement further worsen disease burden, functional decline, and early mortality.
Risk Factors
- Poverty, deprivation, and housing unaffordability
- Unemployment, social exclusion, and discrimination
- Lack of family or community safety net
- Psychological trauma and adverse childhood experiences (neglect/abuse)
- Pre-existing mental health disorders
- Drug or alcohol misuse
- Neurodiversity and acquired brain injury
- History of local authority care or imprisonment
- Family conflict or relationship breakdown
- Exposure to violence, abuse, harassment, or hate crime
- Refugee status or immigration-related exclusion
- Criminal justice system involvement
Clinical Features
Symptoms
- Low mood, anxiety, insomnia, emotional dysregulation, or trauma symptoms (including PTSD features)
- Substance dependence symptoms, withdrawal symptoms, and recurrent overdose risk
- Poorly controlled long-term condition symptoms (breathlessness, chest pain, seizures)
- Frequent unscheduled care attendance and difficulty engaging with booked appointments
- Dental pain, poor oral intake, food insecurity, and fatigue
- Social care distress: unsafe accommodation, safeguarding concerns, inability to navigate services
Signs
- Evidence of multimorbidity at younger age than housed peers
- Physical signs of malnutrition, poor dentition, skin infestation/infection, or chronic respiratory/cardiovascular disease
- Signs of intoxication, withdrawal, self-neglect, or cognitive impairment
- Untreated severe mental illness signs (psychosis, severe depression, suicidality, agitation)
- Repeated missed appointments linked to access barriers rather than lack of need
- Communication barriers (low literacy, language mismatch, no phone/internet access)
Investigations
Management
Lifestyle Modifications
- Register with GP regardless of fixed address or ID; do not exclude for missed appointments
- Use trauma-informed, non-judgemental communication; offer private reception discussions and flexible contact methods
- Provide longer/double appointments and rapid access to a named clinician for continuity
- Coordinate multidisciplinary care (primary care, mental health, addiction, social care, housing, outreach, voluntary sector)
- Actively re-engage people who disengage; involve advocates/support workers when communication is difficult
- Address practical enablers: translation, Easy Read formats, appointment reminders, help with NHS cost forms, digital access support
- Health promotion: smoking cessation, nutrition support, oral health referral, vaccination catch-up, sexual health and contraception support
Pharmacological Treatment
Alcohol-related harm prevention and treatment
- Thiamine 100 mg orally 2-3 times daily (prophylaxis in harmful/dependent drinkers)
- Pabrinex Intravenous High Potency: 2 pairs of ampoules IV three times daily for 2-3 days if suspected Wernicke encephalopathy
- Acamprosate 666 mg three times daily (maintenance of abstinence, after withdrawal)
- Naltrexone 50 mg once daily (relapse prevention in abstinent patients)
Give thiamine before carbohydrate loads when deficiency risk is high. Naltrexone is contraindicated in current opioid use/dependence and acute hepatitis/liver failure. Acamprosate requires renal dose adjustment; avoid in severe renal impairment.
Opioid dependence and overdose risk reduction (specialist/shared-care protocols)
- Methadone oral solution 10-30 mg once daily initial supervised dose, titrated cautiously
- Buprenorphine sublingual 4 mg initial dose, titrate to typical maintenance 8-16 mg daily
- Naloxone 400 micrograms IM, repeated every 2-3 minutes in opioid overdose until response
Initiate opioid substitution treatment with addiction specialist input; overdose risk rises after reduced tolerance. Methadone can prolong QT interval and interacts with sedatives. Avoid co-prescribing benzodiazepines/opioids unless essential, with clear risk mitigation.
Common comorbid mental disorders
- Sertraline 50 mg once daily initially (usual range 50-200 mg daily) for depression/anxiety
- Mirtazapine 15 mg at night initially (usual range 15-45 mg nightly) if insomnia/poor appetite coexist
- Olanzapine 5-10 mg daily (titrate to response) for psychosis/acute severe disturbance when indicated
Select once-daily regimens where possible to improve adherence. Monitor suicide risk early after antidepressant initiation, metabolic effects with antipsychotics, and interactions with alcohol/opioids. Use depot antipsychotics only after specialist assessment and consent/shared decision-making.
Smoking dependence treatment
- Nicotine replacement therapy patch 21 mg/24 h daily plus short-acting gum/lozenge as needed
- Varenicline 0.5 mg once daily for 3 days, then 0.5 mg twice daily for 4 days, then 1 mg twice daily
Assess neuropsychiatric history and renal function for varenicline dosing. Smoking reduction can alter metabolism of some antipsychotics (notably clozapine/olanzapine), so review doses if smoking status changes.
Complications
- Markedly increased all-cause mortality and premature death
- Drug-related poisoning deaths, alcohol-specific deaths, and suicide
- Delayed diagnosis due to barriers to primary/preventive care
- High emergency department use and prolonged hospital admissions
- Greater burden of chronic physical disease (cardiovascular disease, COPD, asthma, stroke, epilepsy)
- Persistent trimorbidity with functional decline and social exclusion
- Oral health deterioration and untreated dental disease
- In young people: poorer mental health, developmental and educational harms, and increased safeguarding risks
Prognosis
Without integrated, flexible, and continuous care, outcomes are poor with recurrent crisis presentations and high early mortality. Prognosis improves when trauma-informed primary care is linked to housing support, addiction services, and consistent mental healthcare with assertive follow-up.
Sources & References
✅NICE Guidelines(1)
📖Textbook References(6)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 212)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 191, 192)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 190, 191)[context]
- [Oxford Medical Handbooks] Ian Wilkinson, Tim Raine, Kate Wiles, Anna Goodhart, Catriona Ha - Oxford Handbook of Clinical Medicine (2017, Oxford University Press) - libgen.li.pdf(pp. 867)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 168)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 168)[context]