When Services Exist but Integration Fails

SCENARIO

A mid-sized European city has:

• A public hospital

• Primary care clinics

• A Housing First programme

• Social benefit offices

• NGOs providing outreach

• A small ACT team

• Emergency shelters

Despite this, people experiencing homelessness continue to:

• Be discharged from hospital to shelters

• Cycle repeatedly through emergency departments

• Lose housing after short placements

• Drop out of addiction treatment

• Miss specialist follow-up

The services exist. Integration is weak.

ANNA

Health perspective

“We treat acute conditions effectively. But once patients leave the hospital, we lose visibility. We discharge them with referrals — but we don't know if follow-up happens.”

She continues:

“We don't have structured discharge protocols for people experiencing homelessness. There's no formal housing linkage before discharge.”

PAUSE AND REFLECT

Is referral the same as integration?

Who owns continuity after discharge?

MAREK

Social care perspective

“We have Housing First. We have case managers. But health information doesn't flow to us consistently. Hospitals do not systematically notify us about discharges.”

He adds:

“Our ACT team is small. Many people who need high-intensity psychiatric support are managed with standard case management.”

PAUSE AND REFLECT

Is support intensity matched to need?

Is case management structured or reactive?

Are we using ICM where ACT is needed?

EVA

Lived experience perspective

“When I left hospital, I had a discharge letter and three appointments. I didn't understand which was most important. No one called me after I missed one.”

She continues:

“It feels like I am the coordinator of my own care — but I don't have the capacity to manage that.”

PAUSE AND REFLECT

Does the system assume executive functioning capacity?

Are we shifting coordination burden to the person?

Is that equitable?

Integration Maturity Gap

This city demonstrates:

Multiple services

Weak coordination

Limited shared protocols

Insufficient data integration

Under-resourced ACT

No medical respite

It operates at partial integration maturity.

Comparing with International Models

ANNA reflects:

“In Boston, medical respite prevents unsafe discharge. We don't have that.”

MAREK adds:

“In Toronto, ACT teams are scaled for high-need individuals. Ours is minimal.”

EVA says:

“In the UK Pathway model, someone in hospital would already be planning my housing. That didn't happen.”

Reflection: Which integration mechanism is missing?

Discharge coordination?

High-intensity psychiatric integration?

Formal hospital–housing protocols?

Data monitoring?

Structural Questions

Is case management embedded into hospital systems?

Are discharge pathways formalised?

Is support intensity proportionate to complexity?

Are data used to track outcomes?

Do we have continuity mechanisms beyond referral?

Ethical Layer

ANNA asks:

“Is it enough to provide excellent hospital care if we know discharge leads to destabilisation?”

MAREK asks:

“Is Housing First enough without health integration?”

EVA says:

“Stability isn't just a flat. It's knowing someone is still there when things get complicated.”

STRATEGIC TURNING POINT

The question is no longer: “Do we have services?” The question is: “Are these services functioning as a coordinated system?”

Integration maturity requires:

Shared accountability

Formal agreements

Data transparency

Proportional support intensity

Cross-sector planning

Link to Next Steps

You are now asked to move from analysis to design. If you were responsible for this city:

What integration component would you introduce first?

Hospital discharge team?

Medical respite?

Expanded ACT?

Shared data system?

Integrated case conferencing?

This leads directly to the Applied Assessment Task.