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 care plans matching client needs, expediting community mental health program enrollment using dedicated slots, and coordinating targeted shelter placement based on availability and needs, such as proximity to follow-up care. The agency developed a new data management system to document, monitor, and report on program outcomes.
Speaker: Nirah Johnson, LCSW, NYC Department of Homeless Services
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