North West London (NWL) has the largest homeless population in London, with Westminster experiencing an 18% increase in rough sleepers since 2020. People experiencing homelessness face significant health inequalities, with much lower average life expectancy and higher rates of co-morbidities, trauma, and social exclusion. These factors contribute to high intensity use of urgent and emergency care (UEC) services, frequent hospital admissions, and challenges in accessing mainstream health and social care.

This role is central to improving health outcomes and reducing inequalities for homeless individuals, many of whom are High Intensity Users (HIUs) of UEC services. The post holder will provide specialist housing advice, advocacy, support, and high quality discharge interventions, focusing on accommodation options and holistic support. The aim is to ensure safe, appropriate, and sustainable hospital discharges, reduce unscheduled admissions, and support patients to access housing, benefits, healthcare, and follow-up after discharge.

Provide front-line, immediate, hands-on support to people experiencing homelessness who may be high intensity users in the Emergency Department (ED) to facilitate discharge from ED, including referrals to appropriate agencies and signposting to other services.
Provide longer-term support to those individuals with more complex needs, in particular those who are High Intensity Users of ED, including:

Undertaking and collating timely, detailed assessments of housing, health, and social care needs.
Preparing Urgent Care Plans (with clinical support) and uploading those to the Pan-London Urgent Care Platform
Ensuring that, where needed, cases are presented and discussed at suitable MDT meetings.
Liaising with the SMH ED HIU Case Worker and the patient’s relevant local Borough HIU Care Coordinator to agree responsibilities for longer term support.

Support the department in fulfilling its Duty to Refer, safeguarding and related responsibilities with relation to this cohort of patients.
Advocate on behalf of patients with local authorities, housing providers, and other services.
Work closely with clinical teams, local authorities, and voluntary sector partners to improve pathways out of homelessness and reduce health inequalities.
Deliver training and awareness sessions to hospital staff on homelessness and HIU care, including signposting information.
Ensure patient involvement and empowerment throughout care planning and discharge.

Our Trust is one of England's top-performing and safest trusts. We operate two main acute hospital sites—Chelsea and Westminster Hospital and West Middlesex University Hospital—along with award-winning clinics across North West London.

Our nearly 7,500 staff care for a diverse population of 1.5m, providing full clinical services including maternity, A&E and children’s services, plus specialist HIV and sexual health care. The CQC rates us Good in safety, effectiveness, care and responsiveness, and Outstanding in leadership and resource use.

We continually invest in our facilities, including a £30m expansion of critical care at Chelsea and an £80m Ambulatory Diagnostic Centre at West Mid.

We are delivering sustainable healthcare through our Green Plan. In line with Greener NHS ambitions, we aim for net zero carbon emissions by 2045. Achieving this requires collective effort. We encourage staff to reduce their impact on carbon, waste and pollution wherever possible. Every action counts to create a healthier, more sustainable future.

We are committed to equal opportunities and believe diversity drives innovation and excellence. We welcome applications from the global majority, veterans and underrepresented communities, valuing the perspectives they bring.

If you haven’t heard from us within 3 weeks of the closing date, your application was likely unsuccessful. Employment is subject to a six-month probation. Some roles may require weekend shifts at multiple sites.

Work with ED colleagues, the hospital Homeless Health Team, local HIU ED Case Worker and Borough HIU Care Coordinators to implement referral and feedback mechanisms for homeless people and HIUs.
Build comprehensive knowledge of support services for people with high needs (e.g., housing, welfare, social isolation) and develop and maintain a directory of services in suitable formats to ensure up-to-date information sharing with internal and external colleagues.
Agree robust patient flow processes from referral to outcome delivery.
Develop and implement communication strategies to inform stakeholders about the service.
Identify and escalate risks and implement actions as directed by the line manager.
Keep accurate records relating to the care of homeless patients.
Attend the fortnightly pan-NWL HIU Network and other relevant meetings.

Service Delivery and Casework

Act as the central point of contact for referrals of people experiencing homelessness from ED and other hospital departments.

Provide immediate support:
Provide direct support with housing, financial, and wellbeing needs, including access to primary and specialist health services on discharge.
Coordinate and support reconnection of patients to areas of local connection, arranging travel, accommodation, and care packages as needed.

Support the production of Universal Care Plans for homeless people who are also HIUs.

Support the development of longer-term packages of care:
Carry out time critical, detailed housing and support assessments for homeless patients.
Contribute to individualised, patient-led care plans addressing health, housing, and wellbeing needs, including risk management.
In collaboration with Borough HIU Care Coordinators, manage a caseload of patients, including ensuring that suitable community outreach and escorting to appointments is available when needed.

Advocate for patients within clinical and external settings, ensuring their rights and needs are communicated and met.
Advise, signpost, and refer patients to a range of external services relevant to their needs.
Ensure all casework is properly recorded and outcomes are entered onto appropriate databases (e.g., Cerner, HIU Case Tracker, local systems).
Uphold confidentiality and comply with data protection and safeguarding requirements.

Partnership and Team Working

Build and maintain effective relationships with ED staff, HIU teams, GPs, ambulance services, police, mental health professionals, social services, community teams, and third sector partners.
Work proactively within the hospital and with external agencies to ensure holistic care and safe, timely discharges from ED. This will necessarily include close relationship to out of hospital care team and specialist GP services.
Attend and contribute to MDT meetings, ward rounds, and governance meetings.
Represent the team in training, conferences, and committees as an expert in homelessness interventions in an Emergency Department setting.
Promote the vision of the Homeless Health Team and act as a role model for staff.

Safeguarding and Risk Management

Proactively identify and act on safeguarding issues for vulnerable adults and children.
Identify and manage risks for staff, patients, and visitors, ensuring that appropriate actions are in place to reduce these risks.
Diffuse difficult or dangerous situations in line with Trust policies.
Ensure compliance with safeguarding legislation and hospital protocols.

Education, Training, and Service Improvement

Provide housing and homelessness advice to ED staff and contribute to teaching and awareness sessions.

Develop patient leaflets and educational materials, ensuring accessibility

Chelsea and Westminster Hospital NHS Foundation Trust jobs

ED, Homeless Health HIU Housing Worker