Intervention to optiMise Palliative caRe for peOple with liVed Experience of homelessness (IMPROVE)

Background: People affected by homelessness experience some of the worst health outcomes in society and often die unsupported in undignified situations. Underlying barriers to health care service access often relate to previous traumatic experiences, poor mental health and/or substance misuse. These barriers are often compounded by a lack of understanding or experience of professionals and lack of flexibility of services.

Addressing the palliative care needs for people who have experienced multiple exclusion homelessness requires a multi-disciplinary response. Person-centred, trauma informed approaches, continuity of care and trusting relationships are key components of good care for this group. We have developed a complex intervention to develop local, multi professional communities of practice around palliative care and homelessness; IMPROVE.

We have piloted IMPROVE and observed variation in outcomes and implementation in different settings but want to understand more about the context, mechanisms and outcomes associated with impact.

Aims, objectives and research questions: This study aims to understand how IMPROVE may work in different locations so we can maximise the potential for widespread implementation, increase multi-professional working and improve care for people experiencing homelessness with palliative care needs. The study asks the following research questions

RQ1 What are the mechanisms by which IMPROVE works to facilitate multiagency approaches to supporting people experiencing homelessness with palliative care needs? RQ2 What are the contexts, which determine whether IMPROVE produces intended or unintended outcomes? RQ3 In what settings is IMPROVE likely to be effective?

Methods: A realist evaluation to (1) develop an initial Program Theory for IMPROVE based on pilot data and a qualitative study, (2) adapt the intervention based on the qualitative study and (3) test and refine the program theory, through realist analysis of IMPROVE in six locations. In phase 3, through direct observations of stakeholder events and IMPROVE sessions, interviews with multiple stakeholders and questionnaires, we will capture different perspectives and explore the contexts, mechanisms and outcome related factors and their interactions to create a case study from each site.

Data from each case will be compiled and analysed, using deductive and inductive approaches. We will use realist analysis, using the programme theory developed in phase 1 as the initial codes, within NVIVO. New nodes will be created to capture new ideas about CMOs that emerge.

Quantitative data gathered through questionnaires and session observations will be collated and described using descriptive statistics with IMB SPSS (Statistical Package for Social Science) version 25. Questionnaires measuring levels of multiagency working, confidence, perceived isolation and burden will be undertaken pre, post and 6 months following the intervention, and scores compared.

Findings from each case will then be synthesised to map context-mechanism-outcome configurations, using retroductive logic.

Anticipated impact and dissemination: Given the variation in services for inclusion health groups across and within the UK, it is imperative that we understand the mechanisms behind complex interventions such as IMPROVE. This study has the potential to develop an intervention to deliver the integrated care that is needed for marginalised groups with palliative care needs.