Discharge Planning

Patching the Safety Net: Review of a Rapid Post-Hospitalization Shelter Pilot Program

This presentation discusses a pilot post-hospitalization shelter program combined with a medical respite program that provides a rapid-admission option for people awaiting respite bed availability and offers a short-term recovery option for discharges not acute enough to require respite. The pilot has demonstrated that a same-day safety net shelter for hospital discharges provides an important […]

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Supporting Safe Discharge from Health Care Facility to Shelter

Health care facilities discharge thousands of patients to shelter annually. For clients transitioning from street into shelter and those with serious mental illness, careful discharge planning is needed for shelter integration and safety. In 2023, the NYC Department of Homeless Services formalized its “Assisted Discharge Planning” intervention to support healthcare facilities in developing realistic follow-up

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Healing Hands: Care Coordination

Over the past decades, care coordination models have emerged as important tools for health care providers working to better serve the needs of people experiencing homelessness. Historically, health care services have been segmented, meaning that a person seeking health care would have to go to one location for their primary care and different sites for

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Healing Hands: Tools to Help Clinicians Achieve Effective Discharge Planning

Too many people without financial resources and social supports cycle among hospitals, mental health facilities, foster care or group homes, correctional institutions, shelters, and the streets. These insidious “revolving doors” exacerbate homelessness and call for clinicians and communities to find coordinated solutions that are humane and cost effective. First steps often involve creative adaptation of

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