Safe Transitions-Managing Hospital Discharge for County Residents Who are Homeless

About the Program

Category: Health (Best in Category)

Year: 2012

Recent data show that one in five homeless individuals admitted to shelter programs came from either in-patient medical facilities or other institutional settings. Without a stable home environment and family or per support, people who have experienced homelessness and are recovering from a hospital visit are especially vulnerable to the harsh realities of living without shelter or food. Ensuring an individual’s successful transition from an institutional setting into the community requires linkages to appropriate housing and community treatment following discharge. Unfortunately, much of America does not have a system set up to encourage a safe transition for the homeless, leaving individuals with life-threatening conditions to return to the streets. In Montgomery County, officials have started a program that breaks this trend and ensures a safe transition after hospital discharge. The program in the Washington, D.C. suburb established a detailed protocol for discharge planners to follow. The protocol primarily includes an in-depth consideration of whether or not the patient is suitable for discharge, even under homeless conditions. Next, the protocol enforces that the discharge planner contacts appropriate shelter providers to determine that the patient will have a bed and resources to assist with their on-going medical needs. Finally, the protocol ensures that arrangements are made for follow up medical care, which involves transferring medical records to the patient as well as providing them with clothing, medical equipment, discharge instructions, and transportation to/from shelter locations. The program resulted in a very successful change. Prior to the program, five area hospitals were identifying only a few dozen discharged patients as homeless, and arrangements for post-discharge care were largely left to the patient. Following implementation of the program, nearly 200 discharges of homeless patients have been collaboratively managed by hospital discharge staff each year, leading to a significant improvement in housing stability of homeless patients and a reduction in hospital re-entry discharge. Considering a start-up cost of $25,000 to support staff development, along with a $150,000 per year cost to staff community health nurses, this program is affordable and can be easily replicated in any county that has a homeless transition dilemma.