• Ensure NFA status is clearly documented in the patient’s notes

• Offer referral to a GP, safeguarding team, and local homelessness support services

• Provide patients with information leaflets and care packs

• Aim for safe and supported discharge

This is a controlled document. If you are using a printed copy, check it against the guidelines site to ensure you are using the latest edition. Print copies must be destroyed after use.

Abbreviations

To ensure consistent, safe, and compassionate care for homeless (NFA) patients attending the Emergency Department, in line with local safeguarding and referral pathways.

1. Identification & Documentation

   • Record NFA status on arrival and in the clinical notes

   • Capture next of kin/contact details if available.

2. Referral Pathways

   • Offer/ Signpost regarding GP registration and/or referral

   • Safeguarding referral – with informed consent.

   • Screen for alcohol, drug, and mental health issues; offer intervention/ referral

3. Information & Care Packs

   • Provide information leaflets (GP access, shelters, housing, benefits, mental health, alcohol/ drug services if needed).

   • Provide care packs

4. Safeguarding & Vulnerability

   • Escalate to adult/child safeguarding teams as appropriate.

5. Discharge Planning

   • Aim for safe discharge to accommodation, shelter, or support service considering vulnerabilities.

   • Document the discharge plan clearly

Process Flow

Homeless patients (NFA) experience disproportionate health inequalities and higher mortality. Emergency Departments (EDs) are a frequent point of contact and an opportunity to intervene. This guideline sets out the minimum standards of care in line with RCEM Best Practice Guidance (2024).

To ensure consistent identification, support, and referral of homeless patients attending the Emergency Department, in line with national guidance and local safeguarding responsibilities.

NFA (No Fixed Abode):

A person is considered NFA/ homeless if:

• They do not have any accommodation which is available for them which they have a legal right to occupy; or,

• it is not reasonable for the person to occupy their current accommodation, for example, because they would be at risk of domestic abuse. (Homelessness code of guidance).

• Someone is defined as being threatened with homelessness where they are likely to become homeless within 56 days, or have been served with a valid notice under section 21 of the Housing Act 1988 by their landlord, which expires within 56 days.

Duty to Refer:

• All hospitals, emergency departments and urgent treatment centers in England have a legal duty to refer  someone who they believe to be experiencing homelessness, or to be threatened with becoming homeless within 56 days, to a local housing authority of their choice.

Care Pack:

A pack containing key contact numbers and support leaflets for housing, benefits, and substance misuse services along with basic toiletries and cloths.

ED Reception:

• Identify NFA status and activate Epic Flag for NFA patients.

• Obtain contact details, method of arrival and document accurately.

ED Clinician / ED Triage Nurse:

• Clarify and document housing status.

• Consider safeguarding and GP registration.

• Drug/alcohol and mental health screening including Audit C and escalate to liaison teams where indicated.

Identification & Documentation

• Record NFA status at booking in (will create an FYI flag)

• Explore and document NFA status at triage and in clinical notes.

  • Consider where sleeping, reasons behind NFA status (e.g. domestic abuse), support network, plans for housing

Assessment & Referrals

Alcohol & Drug Misuse:

• Screen for withdrawal and acute intoxication including Audit C completion

• Referral to Alcohol Liaison Nurse if indicated.

• Explore drug misuse and consider iAccess referral.

• Assess for any mental health concerns and refer to Psychiatric Liaison if concerns identified

Safeguarding:

• Adult safeguarding referral completed after every attendance, after gaining consent.

• Child safeguarding referral if dependent children affected

Frequent Attenders:

• Flag for review by multidisciplinary frequent attender group by email to ED Matron Lead.

Duty to Refer

• Offer patient the option to be referred to Local Housing Authority. Document the following:

  1. If they do / do not give consent for referral

  2. Which local housing authority they would like to be referred to

  3. That they give consent to their contact details being shared so the housing authority may contact them

• The referral will be done by the ED NFA Team within 56 days. You can also do the referral from the ED via Jigsaw - duty to refer. Kindly document in Epic if you have done the referral yourself.

Veterans / Armed Forces

• Contact the Armed Forces Covenant Lead if any veterans are in need of housing support.

• Link: https://ourplace.xfph-tr.nhs.uk/our-trust/armed-forces-covenant//

Discharge & Follow-up

Ensure safe discharge plan:

- Check for severe weather (SWEP activation – FHFT cold weather plan). If due to be discharged overnight, the patient can wait in the ED WR overnight if the temperature outside is < 0^o Celsius, but do not discharge them off of Epic until physically left the department.

- Ensure discharge letter is generated and GP follow-up if patient is registered. Be aware that the patient can use the GP Surgery’s address for registration at the GP as well as accessing any healthcare.

- Provide care packs/ information packs, with up to date guidance on where to access support, shelter and other services. The care packs are kept near the nursing station near Major B 1-5.

Kindly reach out to the NIC if the patient needs a spare set of clothes.

• Where discharge is unsafe or if the patient is likely to be non-compliant with follow up, consider short admission or alternative pathways and escalate to senior clinician

• Following discharge, the NFA ED Team will review all attendances for these patients and make relevant local housing authority referrals as appropriate, in line with the Duty to Refer, within a period of 56 days.