Integrated pharmacist and third sector outreach support for people experiencing homelessness: a synopsis of the...

People experiencing homelessness face up to 12 times higher mortality rates than the general population. People experiencing homelessness have multiple, unmet health and care needs, including poor physical and mental health, substance use disorder and lack of stable and safe housing, yet they do not find services accessible or tailored to their needs.

The aim of this study was to assess the feasibility of conducting a larger, definitive trial evaluating an integrated clinical pharmacist/homeless third-sector support (Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx) for people experiencing homelessness, in a community pharmacy setting.

Randomised, multicentre, open, parallel group external pilot trial with parallel economic and qualitative process evaluation.

People experiencing homelessness ≥ 18 years were recruited from community pharmacies in Glasgow and Birmingham, United Kingdom. Participants were randomised 1 : 1 to receive Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx intervention in addition to usual care or usual care only. The Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx intervention is a collaboration between National Health Service pharmacist independent prescribers and third-sector homelessness charity workers offering weekly community pharmacy and/or outreach-based consultations for people experiencing homelessness to address health (e.g. health screening, treatment and prescribing), housing and social needs (e.g. welfare benefits, housing support). A range of health, social and care outcomes were evaluated at baseline, 3 and 6 months from both usual-care and intervention participants. The primary outcome was to evaluate the feasibility of a subsequent definitive randomised controlled trial according to pre-specified progression criteria classified as green (go ahead), amber (minor amendment in procedures required for definitive trial) and red (substantial changes needed). These related to recruitment; retention; intervention adherence; and collection of clinical and social outcomes data, including emergency department visits, rough sleeping and criminal justice encounters.

Progression criteria were met (4 green and 1 amber) as follows: (1) recruitment (target 55% conversion rate): 100 people experiencing homelessness were recruited as planned from 5 community pharmacies, 100/183, that is, 55% eligible consented to participate - green; (2) retention (target 60%): 72 (72%) participants remained in the study at 6 months - green; (3) collection of routine healthcare utilisation data (target 60%): 91 (91%) had emergency department visit and mortality data available at 6 months - green; (4) completion of questionnaire booklet (target 60%): 72 (72%) completed the booklet at 6 months - green; (5) intervention adherence (target 60%). Twenty-six (53%) participants had over half of the planned weekly contacts with the Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx team - amber. Signals of improvements were observed, as there were fewer ambulance call-outs, fewer emergency department visits and hospitalisations; fewer nights slept rough; and improved health-related quality of life in Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx participants compared to the usual-care group at 6 months' follow-up. Qualitative interviews conducted with participants and stakeholders. Participants suggested the Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx intervention was characterised by holistic approach, comprehensiveness, consistency and care. Challenges identified included resource constraints, integration with existing services and concerns about long-term sustainability.

Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx community pharmacy pilot randomised controlled trial successfully achieved key progression criteria. If found to be effective and cost-effective in a subsequent definitive randomised controlled trial, it offers promise as an adaptable (United Kingdom and internationally) model of integrated care provision for people experiencing homelessness.

While small sample size limits generalisability of the, it fulfils the purpose of a pilot study. Temporary absence of intervention worker in one of the study settings constrained intervention delivery. Future trials should plan for contingency measures.

Future research should seek to test and evaluate care models integrating health and voluntary sector care for people experiencing homelessness in various settings, including community pharmacy, street outreach and temporary accommodations.

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR133060.