1. Lighthouse Supporting People Service A Pilot Service for HIV + people A Partnership Between the two Supporting People Administering Authorities of Lambeth & Southwark, the local Primary Care Trusts and the Terrence Higgins Trust / Lighthouse

2. Objectives of the Service – What did we set out to do To engage complex service users with health care, housing and other services To engage complex service users with health care, housing and other services To provide support around attendance at appointments To provide support around attendance at appointments To provide a support package tailored to individual wishes and needs To provide a support package tailored to individual wishes and needs To work within a multi disciplinary team to maximise support networks To work within a multi disciplinary team to maximise support networks

3. Aims of the Service To reduce acute hospital admissions To reduce acute hospital admissions To improve access to primary health care To improve access to primary health care To improve access to housing To improve access to housing To maximise support networks To maximise support networks To balance complex support needs To balance complex support needs To improve quality of life To improve quality of life

4. Service Criteria HIV + HIV + Homeless or at risk of homelessness Homeless or at risk of homelessness Complex support needs Complex support needs No or poor access to health services No or poor access to health services Communication difficulties Communication difficulties No access to other types of support No access to other types of support Entitled to receive public funds Entitled to receive public funds

5. How Did We Attempt to Achieve the Objectives Referral Referral Assessment Assessment Risk Assessment Risk Assessment Support Plan Support Plan Delivery of services Delivery of services Review of Risk Assessment & Support Plan Review of Risk Assessment & Support Plan Float off once support needs are met Float off once support needs are met

6. Referral agencies Caldecot HIV Clinic Caldecot HIV Clinic Harrison Wing HIV Clinic Harrison Wing HIV Clinic Cascaid HIV Mental Health Team Cascaid HIV Mental Health Team Kings College Hospital Kings College Hospital St Mungo's Street Population Outreach Team St Mungo's Street Population Outreach Team Terrence Higgins Trust Terrence Higgins Trust Strutton Housing Association Strutton Housing Association Tyddyn Bach Trust Tyddyn Bach Trust Clinical Nurse Specialists Clinical Nurse Specialists St Giles Trust St Giles Trust Positive Place Positive Place Trust Trust Lambeth Disabilities Team Lambeth Disabilities Team Lambeth HIV Specialist Housing Worker Lambeth HIV Specialist Housing Worker Southwark Resettlement Team Southwark Resettlement Team Self Self Brixton Prison Brixton Prison Drug & Alcohol teams Drug & Alcohol teams And Many More And Many More

7. Service User Primary Support Groups

8. Service Users Secondary Support Groups Single Parents Single Parents Sex Working Sex Working Minimal Life Skills Minimal Life Skills No support networks No support networks Domestic violence Domestic violence Offending Offending Learning Disabilities Learning Disabilities Language Barriers Language Barriers Health Issues Health Issues Hepatitis C or other co-infection Hepatitis C or other co-infection Child Protection Child Protection Physical Disability Physical Disability

9. A Service User Story History History Diagnosed HIV+ in 2004 Diagnosed HIV+ in 2004 Hepatitis C Positive Hepatitis C Positive IV Heroin & crack user IV Heroin & crack user Rough Sleeping Rough Sleeping Never engaged with HIV Clinic Never engaged with HIV Clinic Several acute hospital admissions Several acute hospital admissions No primary care provision No primary care provision CD4 count of 16 CD4 count of 16 Not engaging with any support services Not engaging with any support services Offending behaviour Offending behaviour Poor diet Poor diet

10. Story to date Commenced combination treatment Commenced combination treatment CD4 Count risen to over 100 CD4 Count risen to over 100 Viral Load Undetectable Viral Load Undetectable Permanently housed Permanently housed Maximised benefit entitlement Maximised benefit entitlement Registered with a GP Registered with a GP Commenced methadone treatment Commenced methadone treatment Receives meal deliveries from Food Chain Receives meal deliveries from Food Chain Registered with a Dentist Registered with a Dentist Engages with a HIV Clinic on a regular basis Engages with a HIV Clinic on a regular basis No hospital admissions No hospital admissions Engages with support services on a weekly basis Engages with support services on a weekly basis Completed probation and addressed rehabilitation issues Completed probation and addressed rehabilitation issues Purchased all essential items for his home Purchased all essential items for his home Adheres to HIV treatment as required Adheres to HIV treatment as required Has been to Tyddyn Bach twice to enjoy a respite break Has been to Tyddyn Bach twice to enjoy a respite break

11. Service to date We have provided support to 43 service users We have provided support to 43 service users 8 cases have been closed and the service users support needs fully met 8 cases have been closed and the service users support needs fully met 2 service users deceased (1 unrelated to HIV) 2 service users deceased (1 unrelated to HIV) 9 service users have commenced combination therapy 9 service users have commenced combination therapy 1 service user gave birth to a healthy baby girl who has tested HIV negative 1 service user gave birth to a healthy baby girl who has tested HIV negative 39 service users are now engaging with HIV clinics on a regular basis 39 service users are now engaging with HIV clinics on a regular basis 16 Service Users have been placed in accommodation 16 Service Users have been placed in accommodation 12 Service Users registered with GP’s 12 Service Users registered with GP’s

12. Key Successes Built positive relationships with Service Users and other agencies Built positive relationships with Service Users and other agencies Engaged Service Users with complex support needs Engaged Service Users with complex support needs Seen positive Improvements in health Seen positive Improvements in health Seen a reduction of hospital admissions Seen a reduction of hospital admissions Closer of several cases with Support Needs fully met Closer of several cases with Support Needs fully met Seen improvements to quality of life Seen improvements to quality of life Reduction of homelessness Reduction of homelessness Improved adherence to combination therapy Improved adherence to combination therapy Registration with primary care services Registration with primary care services Excellent Service User Involvement Excellent Service User Involvement

13. Challenges Engaging complex service users on a regular basis Engaging complex service users on a regular basis Time management and planning when working with complex service users Time management and planning when working with complex service users Other agencies not always structured to the needs of complex service users Other agencies not always structured to the needs of complex service users Limited resources, there is more need for the service than we could provide Limited resources, there is more need for the service than we could provide

14. What Transferable Lessons Did We Learn About Joint Working Agencies will actively joint work if they have a good understanding of the work we do Agencies will actively joint work if they have a good understanding of the work we do By introducing our agency to others and meeting with them we were able to agree joint working protocols By introducing our agency to others and meeting with them we were able to agree joint working protocols By agreeing joint support plans work was not duplicated By agreeing joint support plans work was not duplicated Ensuring referral agencies were kept informed of progress, they soon started updating us as relationships were formed Ensuring referral agencies were kept informed of progress, they soon started updating us as relationships were formed Joint Working strengthened support to our agency; as well as service users by increasing knowledge, skills and experience available Joint Working strengthened support to our agency; as well as service users by increasing knowledge, skills and experience available By forming relationships with specialist agencies, it was a great way to ensure Service Users feel safe about referrals outside of our agency By forming relationships with specialist agencies, it was a great way to ensure Service Users feel safe about referrals outside of our agency

15. Most Rewarding Aspects Positive feedback from service users Positive feedback from service users Service users taking control and managing their lives Service users taking control and managing their lives Seeing the improvements to health & quality of life Seeing the improvements to health & quality of life Seeing service users smile and caring about themselves Seeing service users smile and caring about themselves Baby girl testing HIV – Baby girl testing HIV – Positive feedback from agencies Positive feedback from agencies Engaging a group of people that would of ‘slipped through the net’ of support Engaging a group of people that would of ‘slipped through the net’ of support The overall success of our pilot and being part of the challenge The overall success of our pilot and being part of the challenge Working with a group of people THT have never worked with before Working with a group of people THT have never worked with before