“ It does change the narrative for health and social care ” views of clinical and homeless service staff about the use of intellectual disability screening tools within homeless support pathways in the north of England

Homelessness is a worldwide health inequality. People with intellectual disability represent a relatively high proportion of homeless people, and for many their intellectual disability is not recognised. The study intended to obtain stakeholder views about how intellectual disability screening can be integrated into the support pathway for people who are homeless. A qualitative approach was taken using Thematic Analysis. Nine staff, who work with homeless people or are involved in the intellectual disability assessment pathway, were interviewed. Analysis produced three themes, each containing two subthemes. ‘ Current routes to support ’ investigates experiences of the existing pathway; ‘ Labels ’ , explores views about making intellectual disability visible; ‘ Creating a pathway, ’ outlines ideas about developing and implementing a screening pathway between services. The results help inform how current practices of identifying people with intellectual disability might be improved and the role of screening in this. These results, when combined with other research around screening tools, provide insight into how intellectual disability screening can be integrated within services.


INTRODUCTION
Homelessness is a pressing worldwide health concern.Exact statistics for homelessness are difficult to ascertain given differences in measurement and definition in each country/state.In England an estimated 282 000 people are homeless (Watts et al., 2022), in France 330 000 people (Fondation Abbé Pierre, 2023, p. 299), and in the USA 582500 people per night experience homelessness (Sousa et al., 2022).The path towards homelessness is complex, but influencing factors include poverty and having a lower socioeconomic status (Giano et al., 2020).
People with an intellectual disability are particularly affected by social inequality and homelessness.In the Abbreviations: LDSQ, Learning Disability Screening Questionnaire; NICE, National Institute for Health and Care Excellence; UK, United Kingdom; USA, United States of America United Kingdom (UK), the 20% most disadvantaged families are four times more likely to have a person with an intellectual disability in the household (Emerson et al., 2006) and across Europe severe intellectual disability is associated with increased deprivation (Delobel-Ayoub et al., 2015).Increased interaction with the criminal justice system (Giano et al., 2020) and poorer educational attainment (Maness & Khan, 2014) are also associated with an increased chance of becoming homeless; people with intellectual disability are likely to experience both (Marshall-Tate et al., 2020).
Research indicates, that between 12% and 39% of people who are homeless are likely to have an intellectual disability (Durbin et al., 2018).Risk factors for people with an intellectual disability becoming homeless are not well understood and there is unlikely to be a single cause (Brown & McCann, 2021).A number of commonly associated issues have, however, been identified including unsafe housing and housing disputes (Hebblethwaite et al., 2007); a breakdown in social support, often due to the death of a parent; economic factors, such as having lower socioeconomic status, difficulty accessing employment, and living in poverty; and health factors, such as experiencing mental health problems, substance misuse, and displaying behaviours that challenge (Brown & McCann, 2021).It has also been suggested that people who only just meet the intellectual disability criteria are most at risk, as their intellectual disability is more likely to be missed, meaning they are left unsupported (Trueland, 2009).
In the UK, the National Institute for Health and Care Excellence (NICE) highlights some of the issues faced by people experiencing homelessness, including those with an intellectual disability NICE (2022).Their guidance notes the need for integrated health and social care for this group of people, and that more targeted services may be required to help people access, engage with, and receive high-quality services.
The first step to ensuring people with an intellectual disability receive appropriate support is to identify that they have an intellectual disability.A comprehensive assessment of intellectual disability involves an appropriately qualified professional conducting an intellectual and adaptive functioning assessment, and developmental history (American Psychiatric Association, 2013).Not everyone who should receive an assessment do so and therefore not everyone's intellectual disability is recognised (Emerson & Glover, 2012).This has important implications for service provision for people with an intellectual disability who experience homelessness.
In the United Kingdom, where the current research was conducted, under the Homelessness Act 2002 (UK Government, 2002), homelessness strategies are based at the local level with general principles that must be adhered to, including the provision of sufficient and adequate accommodation for those who become homeless.Some groups, including those who are vulnerable due to disabilities, are prioritised for housing.Under the Homelessness Reduction Act 2017 (UK Government, 2017) services also have a duty to refer, whereby consenting individuals must be referred to other relevant support agencies.If an adult is thought to have an undiagnosed intellectual disability, the approach would usually be to speak to a general practitioner.The GP may then refer the person to specialist services for more comprehensive assessment and support, as appropriate.The overall aim would be to address the health inequalities faced by people with an intellectual disability (see Bollard et al., 2018), which are exacerbated through homelessness (McKenzie et al., 2019a).Such support may include annual health checks (Robertson et al., 2011) and reasonable adjustments (Moloney et al., 2021).
Screening tools can facilitate the identification of intellectual disability, and subsequent assessment and support.The Hayes Ability Screening Index (Hayes, 2000) and the Learning Disability Screening Questionnaire (LDSQ; McKenzie & Paxton, 2006) have been used in homeless services (McKenzie et al., 2019b;Van Straaten et al., 2014), however, limited research has explored the views of stakeholders about the use of screening tools in homeless services.One study by McKenzie et al. (2019a) obtained the views of staff and people using homeless services in Scotland about screening, identification, and support of people with an intellectual disability who were homeless.
The present qualitative study expands on previous research, by obtaining the views of a wider group of stakeholders who are involved in the intellectual disability screening and assessment pathway for homeless individuals in the North of England.This formed one aspect of a wider project that was exploring the performance and impact of the LDSQ when used in homeless services.The research question posed here was 'how can we integrate intellectual disability screening for people who are/have been homeless within the wider assessment and support pathway?' The study aimed to understand the current landscape, what steps could be taken to support people who are homeless and may require an intellectual disability assessment, and what challenges might be faced in implementing a more cohesive screening pathway.

METHOD Participants
In total, nine people were interviewed, all of whom worked in homeless or healthcare services that supported people with intellectual disability (see Table 1).Participants were recruited via contacts of the research team and wider project steering group.The latter were provided with information to pass on to potential participants who met the inclusion criteria of being aged 18 years or older, providing informed consent, and supporting people with an intellectual disability in some capacity.Due to the time and resource limitations of the project, the target sample size was between 8 and 12 participants.Recruitment ended when it appeared that data saturation had been achieved at nine participants.It became clear during the interviews that some participants had experienced homelessness themselves.

Interview schedule
The interview covered three areas: background about the person and their role in relation to intellectual disability and homelessness; views about existing identification and support processes; and views on introducing a screening tool to existing pathways.The full schedule is included in the supplementary materials.
The LDSQ (McKenzie & Paxton, 2006) The LDSQ is a short questionnaire, with seven core items which are completed by the person being screened or someone who knows them well (see https:// learningdisabilitymatters.co.uk/tools/).It takes approximately 5 min to complete.Scores can be used to indicate whether a person is likely or unlikely to have an intellectual disability.The LDSQ was viewable via the participant's web browser.

Procedure
Ethical approval for the study was provided by the first author's university (ref 26698) and interviews with participants were carried out between March and June 2022.
Potential participants were emailed information about the study, which included a link to provide consent online and leave their contact details for the research team.All consenting participants were subsequently interviewed and the initial questions about their background were used to ensure they met the criteria of supporting people with an intellectual disability in some capacity.The interviews were conducted via Microsoft Teams or telephone, and on average lasted 59 min (between 40 and 100 min).Interviews were recorded and later transcribed verbatim; recordings were deidentified during transcription; transcription was handled by the first author.

Researcher characteristics
All of the research team had experience working with people with an intellectual disability.Two researchers had experience of this in both clinical and research contexts, one had experience in a research context, and one had experience within homeless services.Three members of the research team had extensive experience of the development and use of developmental screening tools.Within the research team, there was an understanding of the general process of the assessment and identification of intellectual disability, as well as the support offered to people who experience homelessness.No member of the research team had experience of being homeless themselves.

Data analysis
An inductive approach at the semantic level was used to analyse the interview data and to prioritise the real-world experience and expertise of the participants.Within this, a predominantly critical realist approach was utilised (see Fletcher, 2017) that recognised the unique experiences of the participants, whilst accounting for how services work and interact, which allowed for discussions around the development and improvement of such services.The analysis, using thematic analysis (Braun & Clarke, 2019), was conducted by the first author.Thematic analysis was chosen because it offers a way of gaining the perspectives of a number of different stakeholders (Nowell et al., 2017) and is a flexible approach that can be used by researchers with different theoretical stances (Braun & Clarke, 2020).
To minimise the influence of factors other than the participants' perspectives, relevant existing literature was not read until after the analysis process was complete.Data familiarisation took place by reading the transcripts whilst listening to the interviews.During this phase, notes were made about initial ideas that arose from the interviews and potential links between the issues that participants were discussing.Paper copies of data were highlighted and annotated with notes/codes.Highlighted sections were inductively brought together in broad proto-themes that related to the research question.After reflection, an iterative process was used to refine the codes and proto-themes at this stage, which led to the moving of some quotes between themes to have thematically more consistent ideas within the newly formed themes and subthemes.
The first author then discussed the emerging themes and associated subthemes with the second author, to further refine them, for example, by combining subthemes where there was significant overlap in the concepts.An iterative process of refinement followed through discussion with the whole research team, aimed to create final themes that were internally consistent and provided an integrated narrative.This discussion with other members of the research team was used to check whether the emerging themes and subthemes identified by the first author were perceived by others as being present in the data and supported by participants' quotes.
The themes and subthemes were then named, and links were made with the existing literature.A summary of the results was provided to participants as part of a member-checking procedure.This was followed up by email or phone contact to discuss any potential changes.This resulted in greater emphasis on specific points within some sub-themes and the renaming of one theme.

FINDINGS
Three themes were developed, each containing two subthemes.
Theme 1: Current routes to support All participants had some experience of existing screening, assessment, and diagnostic pathways, but some relied on informal methods to identify intellectual disability: 'It's kind of intuition I guess' (P1) due to the barriers to formal assessment, 'Very few people reach that threshold' (P7).These issues are outlined in the subthemes below.
Subtheme 1: The informal screening processes Existing processes for identifying and assessing people who may meet the criteria for intellectual disability were perceived as informal.For some, this was not problematic: '… happy with the informal nature of it really cos if it was for-mal…it would affect our relationship' (P3).This lack of clarity was an issue at times, as it was unclear who was responsible for conducting screening.Some only saw themselves as a conduit for referrals but not involved in the screening process themselves 'I don't do the referring…I would pass it on to someone who does do the referring' (P3).
The procedure can be stressful and having support throughout from someone who can advocate on the person's behalf to medical professionals is helpful 'I'll ring up and say…I want to see doctor such and such…they'll know why I'm coming…and they'll listen to me' (P9).Having such support may be particularly relevant for people who are homeless.
Most participants did not think screening tools were used within their services, and when they were, there was uncertainty about what they were or the quality of them: 'It's an old one that I recognized…I can't remember the blumin' American author' (P4).

Subtheme 2: The challenges negotiating current assessment pathways
A key challenge was the transition, and friction, between third-sector support organisations and health services; where some support staff felt dismissed by healthcare staff: 'They do need extra support and they're trying to make changes but it's bloody hard for them…they go to the doctors and the doctor looks at them like "you're just another junkie"' (P9).Similarly, when trying to access specialist services, health professionals felt the intellectual disability team would resist requests 'The only route to getting a diagnosis is through the community [intellectual] disability team and the only means of… their threshold at the moment, is at being at risk of death to get a diagnostic assessment' (P7).
Screening tools were seen as able to support transition between services 'having something that we know is evidence based, that…the [intellectual] disability team will accept and consider…that's the benefit' (P7).
This theme provides a useful context when considering the introduction of evidence-based screening to existing support pathways.The findings suggest a formalised pathway may allow for a smoother transition between third-sector support and further care.
Theme 2: The impact of 'labels' Screening pathways were perceived to bring people, who were previously hidden, to the forefront: 'You're only responding to what is visible and what is visible is likely to be a problem' (P1).This process was described as 'labelling.'While this term often has negative connotations, there were discussions of the benefits that being identified may bring.
Subtheme 1: 'Labelling' can be beneficial The main benefit of identification was seen to be the support it could procure: 'It can be quite revealing and helpful in opening access to services' (P4) and how it can match support to someone's needs 'It's that sort of matching between [services and support], these are the resources we've got to help you.Do you need any of them?' (P5).One source of support is a health check which is offered in the UK 'You've got a concrete offer to go on the register and have an annual health-check' (P1).
Labels also improve understanding 'Diagnosis…it does change the narrative for health and social care… there is, I would argue, a hostile environment for a lot of our patients who are receiving benefits…the diagnosis of [intellectual] disability…could mean a huge weight lifted' (P7).It could also ensure the person's needs are recognised in accordance with appropriate legislation: 'to actually trigger the Equality Act…you just have to explain your need' (P1).One potential positive change may include increased self-understanding 'This isn't a ticket to getting more help in some circumstances…where people consent and are happy to answer those types of questions they can be better understood' (P1).It was believed identification in the absence of positive change, would be a negative: 'I would personally consider it to be a failing if we go through the process…and then nothing changes for that individual' (P2).
Understanding people was seen as important to making services more accessible 'If you thought there was [a low] percent of people you work with had an [intellectual disability] diagnosis then you find out, ooh gosh twenty five percent, we might have to look at the way that we run our services' (P3).It was suggested that staff approaches used to make services more accessible for people with a known intellectual disability would help those whose needs were not yet formally recognised: 'If they've got a couple people [with intellectual disability] and they've got someone where they think I'm not sure what's going on with this chap…they can adapt what they're doing' (P4).

Subtheme 2: People may feel resistance towards labels
On the other hand, some people might not want to be labelled 'I know lots of people with [an intellectual] disability, autism who don't want the label particularly' (P1) and attempt to mask their intellectual disability 'Some people…[have] been socialised to present really, really well so people can at a superficial level wing it through lots of systems' (P1), particularly around reading and writing 'I do see [masking] actually in the services I work into, particularly around literacy' (P5).It was, therefore, seen as important that people had an active role within the process: 'It's making sure that it is the collaborative process' (P4), otherwise it could lead to the person resisting screening and identification.
Theme two highlights that the screening and assessment process must be collaboratively carried out with the person's understanding and consent and that there is the potential for the person to experience positive changes resulting from the screening.Screening should also provide information to prompt services to respond to the needs of people with an intellectual disability.

Theme 3: Creating a pathway
Participants had strong views about the ways a screening pathway should be developed and operated in practice.Foremost, this pathway needed to be versatile and allow for different frontline professionals to be involved and support people along the path to being identified.Staff must, however, feel comfortable and empowered in this role.

Subtheme 1: Implementing and sustaining organisational change
Participants identified important factors for initiating and sustaining changes in practice for identifying people with an intellectual disability.There was a recognition that a screening pathway should centre around points at which homeless people and professionals might interact 'Anybody who's working with somebody where they think they're struggling' (P4).Participants mentioned an array of services including GP surgeries, charities, job centres, and the police.
As for who should conduct the screening, there were various suggestions in terms of job role, but the relationship between the person conducting the screening and the person undergoing screening was seen as the key factor: 'Definitely the person with the best relationship with the service user…a stranger coming in and having these conversations with you is not as helpful…it's more intimidating' (P6).
Regardless of setting, properly supported staff were seen as important in facilitating the screening process 'Staff obviously have to be trained in how to do things but equally they need to feel they've got support and permission and they've got somebody to go to when they need guidance with it' (P6).It was noted that successful service innovations require strong advocates who can emphasise the potential benefits for people being identified 'You need a strong lead…you need to establish staff buy in by being very clear about why it's important, what difference it might make to individuals' (P6).
A frequent concern was that screening would add workload: '…I understand that it's another form to fill in which…may not be desirable at a front line service point of view' (P2).But many recognised that this could help reduce the workload overall: 'It's always time, but I think you will save time in the long run by considering these things and accessing appropriate support' (P7).

Subtheme 2: Staff confidence and competence
There was a recognition that whoever conducted screening should feel confident in what they were doing and why they were doing it 'People have got to understand its purposes, haven't they?So, there is a degree of education for people who are using it needed…understanding its purpose' (P4).When discussing training, importance was placed upon understanding intellectual disability and the context of screening, more than learning how to use such a tool 'I think one of the major issues that we face is the understanding of what the term [intellectual] disability means…it's…massively misunderstood.' (P6).For staff to be confident, when using screening tools, it was important that tools have a strong evidence base '…describe the evidence base around a particular tool, so sensitivity, specificity, how far can it go and then it would also need, under current circumstances' (P1).
The final theme highlights important issues when considering implementing screening tools within the wider context of homeless services.Participants suggested screening should be conducted with an evidence-based tool used by someone who was competent and confident in its use.Screening may be useful when people who are homeless interact with a range of formal services.To be implemented successfully, there was a need for organisational support and leadership, and the screening itself should save time and resources, rather than create additional staff burden.

DISCUSSION
The study explored the views of stakeholders about screening for intellectual disability in services for people experiencing homelessness.The results have important implications for policy and practice.In the United Kingdom, there are statutory obligations placed on health and local authority services in relation to vulnerable people, including those with an intellectual disability.These include the provision of support by local authorities that promote the day-to-day functioning of the person, the assessment of whether they have a priority need for accommodation, the implementation of safeguarding policies to reduce the risk of harm, abuse and neglect, the obligation to protect those who lack capacity to make decisions in relation to aspects of their life and the requirement to make 'reasonable adjustments' in health care provision, such as the provision of annual health-checks (see Tickle et al., 2022).Similar obligations exist in other countries, for example, in The Netherlands, once intellectual disability has been recognised, a specialist support plan should be put in place and reasonable adjustments to healthcare must be made (Herps et al., 2013).Research suggests undergoing health-checks can have benefits, including identifying conditions at an earlier stage (Robertson et al., 2011) and reducing the likelihood of emergency admissions to hospital (Cuccu et al., 2021).
If, however, a person is not identified as having an intellectual disability, such statutory requirements cannot be enacted and the person may lose out on crucial support (McKenzie et al., 2019a;Van Straaten et al., 2017).The first theme detailed some barriers to identifying intellectual disability in people who were experiencing homelessness.This included the informal nature of existing methods of identifying intellectual disability, that screening and assessment pathways are not wellestablished, and the lack of clarity around the tools and processes used.This is concerning, as most adults with intellectual disability remain 'hidden' within adult services (Emerson & Glover, 2012) and homelessness will exacerbate the challenges people face (see Brown & McCann, 2021;McKenzie et al., 2019a).This also presents a barrier to reducing homelessness in people with an intellectual disability (Paudyal & Saunders, 2018) thereby undermining a key aim of the Homelessness Reduction Act (UK Government, 2017).This suggests the need to develop more formal screening pathways and to support the consistent use of evidence-based screening tools as a first step in identifying those people with an intellectual disability who are legally entitled to support and protection.
The second theme outlined the recognition that being identified as having an intellectual disability can result in support for the person.Identification may also improve self-understanding which is an important factor for those with other developmental conditions.For example, research with autistic people has found that receiving a diagnosis can come as a relief and validate previous experiences, giving people an explanation for their behaviour and interactions with the world (Stagg & Belcher, 2019).
Research into what people with an intellectual disability think about having the condition is more limited, but there are indications that being identified can bring greater clarity for the person (Wolkorte et al., 2019).
There was also concern that some people may hide their intellectual disability.This was consistent with previous work which reported the concerns of staff and users of homeless services, that if a person was known to have an intellectual disability their additional vulnerabilities might be exploited by others (McKenzie et al., 2019a).Tickle et al. (2022) outlined several ways in which the person can be supported through the screening and assessment process, including having emotional and practical support from a trusted other and helping the person to understand why screening and assessment might be needed.This idea is reinforced within clinical guidelines, which suggests an advocate can support a person experiencing homelessness to access services and understand relevant information (NICE, 2022).
Similar suggestions were made by the participants in the present study when addressing the ways in which a screening pathway could operate in practice, as outlined in the final theme.The context of the conversations about identification of intellectual disability was seen as important.Participants felt such conversations must happen within a trusted setting, with someone that the person being screened was already familiar with.As people who are homeless often have experienced breakdowns in their wider support systems (Brown & McCann, 2021), the trusted person is also likely to be important in supporting the person through any subsequent assessment and diagnostic process (Tickle et al., 2022).
For screening to be successful, it was felt that there must be 'buy-in' from both front-line staff and the wider organisation.This view is consistent with research highlighting the importance of leadership, mentoring, and organisational support to implement and sustain changes in practice (e.g.Rutherford et al., 2018).One factor that can also influence the adoption of new practices is that those who are carrying out the changes have enough training in their use.Other key factors are that proposed changes are evidence-based, seen as relevant to practice, beneficial, acceptable, credible, and do not place increased burdens on those implementing them, such as being time-consuming (McKenzie et al., 2016;Rutherford et al., 2018).
In the current study, the participants emphasised that users of screening tools must be competent and confident.While some screening tools, such as the LDSQ, are specifically designed to be accessible to a range of people without the need for additional training, the participants recognised the need for broader training with a particular focus on understanding intellectual disability and the purpose of identification.It was suggested that this would allow staff to better handle potentially difficult conversations with the people they are supporting.Evidence shows that, despite attempts to address the gaps in understanding about intellectual disability (Reina et al., 2021), knowledge about intellectual disability has been found to be limited internationally and in those in a range of professional roles (McKenzie, Murray, Martin, & Metcalfe, 2023;O'Shea et al., 2012).The inclusion of information about screening tools in awareness training and campaigns, which are being implemented in several countries (Foster, 2022) could help promote their use and associated benefits.
In respect of changes being seen as relevant, beneficial and acceptable, screening tools have already been shown to result in positive outcomes for individuals and organisations (Esch et al., 2020); such as improved healthcare, increased identification and support and lending weight to the views of non-specialists when making the case to external agencies for additional assessment and/or help for the individual.As good screening tools should only take a few minutes to complete, they should not have the disadvantage of being perceived as time-consuming to use, which can act as a barrier to their adoption in practice (Rutherford et al., 2018).
In terms of credibility, the participants emphasised the need for any screening tool to have good psychometric properties and a strong evidence base.This is crucial as research suggests that the subjective views of staff in homeless services about the abilities of those who have reduced cognitive functioning tends to be inaccurate (Van Patten et al., 2020).While checklists and toolkits exist to help people recognise indicators of intellectual disability (e.g.Tickle et al., 2022), few have reported psychometric properties, meaning that their accuracy and reliability is unknown.By contrast, the LDSQ has a strong evidence-base, is used internationally, and has been recommended for use by a range of national and international organisations (McKenzie et al., 2020).Importantly, its acceptability to users and those being screened and its performance in homeless services has been assessed (McKenzie et al., 2019a(McKenzie et al., , 2019b;;McKenzie, Murray, Metcalfe, et al., 2023).This suggests the LDSQ may be a suitable screening tool for use in homeless services, as part of a wider screening, assessment, and support pathway.Indeed, the LDSQ has recently been signposted in a toolkit developed for organisations that support homeless people with an intellectual disability (Tickle et al., 2022).

Limitations
The participants were a relatively small, self-selecting group, all of whom worked in services across the North of England, where they had some ongoing contact with people with an intellectual disability, enabling them to develop relationships over time.Their views may differ to those working in settings where contact with homeless people who have an intellectual disability is more limited, such as drop-in services.Additionally, recruiting via the steering group and research team may have resulted in a sample who had a particular interest in screening and the identification of intellectual disability.
While the results have general implications for practice, the specifics may be different in other regions of the United Kingdom, or other countries.For example, some areas may have more formalised screening structures in place.Similarly, screening tools that were developed and validated in one country may not be appropriate in another.
A further consideration is that, while screening tools may be used as part of the process to help identify people with intellectual disabilities, this is just a first step in the process.There may be challenges to accessing specialist services only for diagnostic assessment, because of the eligibility criteria used by particular services.These can vary across different areas, but many services require that the person being referred has additional needs such as the presence of behaviours that challenge, complex comorbid needs, or that their health needs are unable to be met by mainstream services (e.g., Leeds and York Partnership NHS Foundation Trust, 2017).
Formal assessment of intellectual disability in people experiencing homelessness can be challenging (Tickle et al., 2022).Cognitive performance is known to be affected by a variety of factors pertinent to people experiencing homelessness including malnutrition (Na et al., 2020), depression (McDermott & Ebmeier, 2009), brain injury (Wilson et al., 2020) and drug use (Verdejo-Garcia et al., 2019).There can also be potential issues with the accuracy of measures of cognitive and adaptive measurement functioning in this population (Stone et al., 2019), which presents a further barrier to clinicians working in this area.

Future research
Future research could help address some of these limitations by conducting a larger scale feasibility study into the use of screening tools in homeless services.This could include following up people who have been screened as they navigate the pathway to specialist services, which would provide a clearer picture of the actual facilitators and barriers to accessing further assessment and support.In addition, while some information is available about the short-term benefits of screening in homeless services (McKenzie et al., 2024), future research could address the longer-term impact and whether it helped to reduce health inequalities.

CONCLUSION
Overall, this research highlights the need for more formalised screening pathways for those using homeless services.As there is likely to be considerable overlap between people who access frontline homeless services and specialist intellectual disability services, it suggests greater multi-agency collaboration is required.The use of robust, evidence-based screening tools, in the context of a trusting relationship, offers one way of linking these services.This is on the proviso that tools and information can be understood, as well as used, by specialists and non-specialists alike; this could act as a first step in the process of identifying and supporting people with an intellectual disability.
Participant details.
T A B L E 1