Background: Homelessness is associated with enormous health inequalities, including shorter life expectancy, higher morbidity and greater usage of acute hospital services. Viewed through the lens of social determinants, homelessness is a key driver of poor health, but homelessness itself results from accumulated adverse social and economic conditions. Indeed, in people who are homeless, the social determinants of homelessness and health inequities are often intertwined, and long term homelessness further exacerbates poor health. Aggregated health service data can mask this, and case histories thus provide important insights. Methods: This paper presents three case histories of homeless patients seen at an inner city public hospital in Perth, Western Australia. The case histories draw on several data sources: hospital data, information collected from rough sleepers and clinical observations. Estimates of the cost to the health system of the observed hospital usage by the three patients are included. Findings: The case histories illustrate the interplay of social determinants of health in homelessness that help explain the high level of hospital usage by rough sleepers. The cumulative healthcare costs for the three individuals over a 33 months period were substantial. Hospital attendance plummeted even in the short term when housing needs were addressed. Conclusions: Treating homelessness as a combined health and social issue is critical to improving the abysmal health outcomes of people experiencing homelessness. In addition, the enormous economic costs of hospital care for people who are homeless can be reduced when housing and other social determinants are taken into account.

Purpose: Homelessness is a colossal issue, precipitated by a wide array of social determinants, and mirrored in substantial health disparities and a revolving hospital door. Connecting people to safe and secure housing needs to be part of the health system response. The paper aims to discuss these issues.Design/methodology/approach: This mixed-methods paper presents emerging findings from the collaboration between an inner city hospital, a specialist homeless medicine GP service and Western Australia’s inaugural Housing First collective impact project (50 Lives 50 Homes) in Perth. This paper draws on data from hospitals, homelessness community services and general practice.Findings: This collaboration has facilitated hospital identification and referral of vulnerable rough sleepers to the Housing First project, and connected those housed to a GP and after hours nursing support. For a cohort (n=44) housed now for at least 12 months, significant reductions in hospital use and associated costs were observed.Research limitations/implications: While the observed reductions in hospital use in the year following housing are based on a small cohort, this data and the case studies presented demonstrate the power of care coordinated across hospital and community in this complex cohort.Practical implications: This model of collaboration between a hospital and a Housing First project can not only improve discharge outcomes and re-admission in the shorter term, but can also contribute to ending homelessness which is itself, a social determinant of poor health.Originality/value: Coordinated care between hospitals and programmes to house people who are homeless can significantly reduce hospital use and healthcare costs, and provides hospitals with the opportunity to contribute to more systemic solutions to ending homelessness.

The ED is often the first and sometimes the only place where people experiencing homelessness seek medical assistance. While access to primary healthcare is a preferable and more cost-effective alternative to ED, for many reasons, people experiencing homelessness are much less likely to have a regular General Practitioner compared to those living in stable accommodation. Drawing on a growing body of emergency care and homelessness literature and practice, we have synthesised four potential interventions to optimise access to care when people experiencing homelessness present to an ED. Although EDs are in no way responsible for resolving the complex health and social issues of their local homeless population, they are a common contact point and therefore present an opportunity to improve access to healthcare.