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Out of Hospital Oxfordshire

Out of Hospital

About the Service

Our Specialist mental health workers work in a multi-disciplinary team of psychiatrists, social workers and housing officers to support people with complex mental health who are homeless, or at risk of homelessness, whilst they are in hospital and when they are discharged from hospital.

Our Embedded Housing Workers (EMHW) support the person to return to living in temporary or permanent accommodation in the community, after a stay in hospital.

As part of their role, the Housing Worker also supports colleagues and professionals to increase their knowledge base and skill set of professionals within the housing system and to increase their knowledge and skills in working with people experiencing mental health and embedding a person-centred approach.

What can we help with?

  • Maintaining accommodation/tenancy and avoiding homelessness
  • Accessing the relevant pathways to housing if needed
  • Avoiding admission and re-admission to mental health or general hospital
  • Supporting engagement with medication and treatment (including for substance misuse)
  • Forging/maintaining connections with family and friends and engaging in activities of your choice (therapy, group support, employment or volunteering)
  • Reducing/managing debt
  • Increasing confidence, developing routines and planning for your future
  • Connection with community-based support and services

Who is this service for?

  • People in acute general or mental health wards who are either homeless or at risk of homelessness
  • People needing continuity of care as they transfer from hospital to stabilise in the community and avoid re-admission
  • People who are having to repeatedly access acute health services
  • People who discharge themselves from hospital and risk ending up rough sleeping without the right care in place
  • People who are at risk of homelessness because they have lost their previous accommodation whilst in hospital
  • Rough sleepers

What can I expect from the Service?

If you are being discharged from hospital, the EMHW will offer you a period of re-settlement support. Providing someone you know and trust to support you through setting up or handing over any mental or physical health, care, support and living arrangements.

How do we work?

The Embedded Housing Worker uses a range of techniques, including coaching, training, advice and role-modelling, issues.

The EMHW works closely with GPs and refers to other specialist services as needed, supporting and encouraging you to engage at all stages of your journey from hospital to home.

Working in Partnership

The Out of Hospital project operates across the whole of Oxfordshire and is a partnership between:

  • Local authorities: Oxford City Council (lead local authority), Oxfordshire County Council, Cherwell District Council, South Oxfordshire District Council and Vale of White Horse District Council; and West Oxfordshire District Council
  • VCSE: Connection Support and St Mungo’s; and Response
  • Housing providers: Response, South Oxfordshire Housing Association, Cottsway Housing Association and Sovereign Housing
  • Health: Buckinghamshire, Oxfordshire and Berkshire West Integrated Care System, Oxfordshire Clinical Commissioning Group; Luther Street Medical Practice

Oxford University Hospitals NHS Foundation Trust:

  • The John Radcliffe hospital, Horton General, Churchill Hospital and Nuffield Orthopaedic Centre;

Oxford Health NHS Foundation Trust:

  • The Warneford Hospital, Littlemore hospital, Community hospitals.



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