The Homeless and Health Inclusion team is a citywide, multidisciplinary service dedicated to supporting individuals at risk of or experiencing homelessness across Leeds. Our team provides integrated medical and psychosocial care through the following key functions:

• Hospital in-reach: We conduct assessments within Leeds hospitals for patients identified as homeless or at risk of homelessness.
• Discharge planning: We collaborate with hospital teams to develop safe and sustainable discharge plans.
• Community placements: We facilitate access to 11 out-of-hospital placements to support recovery and further assessment within the community.
• Post-discharge case management: We provide up to six weeks of case management following hospital discharge to ensure continuity of care, address health needs, and reduce the likelihood of unplanned readmissions.
• Healthcare advocacy: We advocate for equitable access to healthcare for all individuals we support.
• Community outreach: We engage with Gypsy and Traveller communities through site visits and roadside encampments, assessing health needs and working alongside community members and third-sector partners to identify and address barriers to healthcare access.

People we serve

Our service supports individuals who may be:

• street homeless, living in tents, sofa surfing, or residing in temporary accommodation
• experiencing housing instability due to previous tenancy breakdowns or current tenancy challenges
• at risk of exploitation or harm from others
• women engaged in sex work, vulnerable migrants, or individuals admitted to Leeds hospitals from other parts of the UK without a discharge destination
• living with substance dependencies, disabilities, or long-term health conditions.

We provide open, honest, and person-centred support, empowering individuals to make informed decisions about their health and wellbeing.

Team composition

Our multidisciplinary team includes:

• Registered nurses and mental health nurses
• Occupational therapists
• Care navigators
• General practitioners from Bevan Healthcare, a specialist GP practice, who conduct assessments both in hospital and within our community placements.

Referral pathways

Referrals to our service are accepted from:

• healthcare professionals
• third-sector organisations
• individuals via self-referral