Strengths-based, low caseload approach to integrated health, housing and practical support for people experiencing homelessness with multiple complex needs in temporary shelters (hostels): a cluster randomised controlled trial [REACH trial]

Residents of hostels for people experiencing homelessness (PEH) are some of the most clinically and socially vulnerable persons in society. However, there is no national guidance or standards to inform the delivery of health, housing and practical support for PEH in hostels. Stays between 5-10 years and beyond is common as residents struggle to receive tailored support. Lack of opportunities for skills development, isolation and boredom can increase substance use and resident conflicts, leading to many returning to the streets. Informed by our successful pilot study, and through engagement with PEH and stakeholders, we have co-designed the ‘Reach, Engage and Recovery’ (REACH) model of care in which mental health nurses work alongside a named care navigator to provide intensive outreach to PEH with multiple complex needs in hostels. Using a trauma-informed, strengths-based and low caseload model, REACH will offer focused support to residents for 12 months to diagnose, treat and refer people to improve their physical and mental health, wellbeing, practical skills for recovery and employment. Intervention team will accompany participants to appointments where needed, attend multi-agency meetings and systematically work to address mental health and practical barriers to disengagement from care. REACH will facilitate skills (e.g. volunteering, gardening, arts/crafts, employment training), address occupational deprivation, loneliness and promote PEH wellbeing through partnership with local voluntary and community organisations. A multi-centre cluster-randomised controlled trial will evaluate the effectiveness and cost-effectiveness of REACH. A total of 18 hostels in four UK settings will be randomised to receive REACH versus usual care 2:1 (426 participants, 213 in each arm). Primary outcome will be changes in ED visits at 12 months (intention-to-treat and aligned with a treatment policy estimand). Secondary outcomes include mortality (all cause), quality of life, alcohol and substance use, overdose, self-efficacy, resource use, housing status, criminal justice encounters and employment status. A 12-month longitudinal ethnographic study will explore individual PEH perspectives, hostel staff and wider stakeholder views on REACH, and wider implementation beyond this study. Economic evaluation will include cost-effectiveness analysis from NHS and societal perspectives, cost-benefit analysis and a 5-year budget impact analysis for scale-up and population health impact modelling. We have partnered with key national providers of hostels, NHS Mental Health Trusts and voluntary organisations to enable testing and future roll out of REACH. Pathway and Homeless Link will lead dissemination activities to care network, PEH, Government Departments, NHS and wider stakeholders. Interim learnings and knowledge mobilisation will be supported by joint interpretive forums. We will publish results in scientific journals and via accessible animations for public use. Our lived experience advisory group informed key elements and duration of REACH. We will be guided by their advice throughout the study. Inclusive research principles will be followed e.g. sampling (e.g. Women only hostels) and analysis (how intervention works in different people) as we seek to improve outcomes for the most marginalised populations in the society.