Discharge Planning Skills and Resources

Section 5 of the training series on discharge planning with patients experiencing homelessness or housing instability.

Housing Tool for Hospital Discharge Staff

MassHealth, in partnership with the Executive Office of Housing and Livable Communities (EOHLC), created the Housing Tool for Hospital Discharge Staff to provide hospital staff with the tools to better assist those individuals admitted to acute care hospitals and behavioral health facilities who do not have appropriate housing upon discharge. This tool is part of a larger initiative to prevent individuals from becoming homeless upon discharge from a hospital.

Take some time to familiarize with the housing tool by starting with this video.

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For individuals experiencing homelessness that are not able to care for themselves independently after discharge and therefore cannot be discharged to an emergency shelter, discharge planning staff should identify long-term care options. Resources for this population of patients can be found on the Helping Patients with Skilled Nursing Needs webpage.

Housing Problem Solving with Patients Experiencing Housing Instability or Homelessness

The Housing Tool for Hospital Discharge Staff refers to Housing Problem Solving as key practice to helping patients avoid homelessness. Housing Problem Solving, also known as diversion, is an emerging best practice that supports people at risk of homelessness problem-solve their housing crisis to avoid entering homelessness by identifying safe alternatives such as staying with family or friends or resolving issues with their current housing situation.

Housing Problem Solving typically happens through conversation with the individual at risk of homelessness. Oftentimes, people on the verge of homelessness are experiencing stress overload which impacts the cognitive functioning in the brain that we usually use to problem-solve. Because of this, Housing Problem Solving can be used to combat stress overload and discover potential alternatives by using questioning to better understand the housing crisis, explore housing options, and brainstorm solutions. 

While Housing Problem Solving will not always result in an individual finding a safe alternative and avoiding homelessness, it is essential these conversations take place prior to entering homelessness in case alternatives are available. Housing Problem Solving typically happens before entrance to shelter by shelter staff or staff who specialize in Housing Problem Solving. However, hospital discharge planning staff can build Housing Problem Solving into their discharge procedures to help patients avoid going to shelter and identifying safe alternatives earlier in the discharge process, ultimately facilitating a more seamless discharge.

Watch the following video to see an example of housing problem solving between a discharge planner and a patient.

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One resource developed to support the initiative to eliminate hospital discharges to shelter, is the Find Alternatives to Shelter: A Discussion Guide for Hospital Discharge Staff. This guide provides targeted questions that can be utilized for Housing Problem Solving conversations.

Review the discussion guide before continuing this training course: Find Alternative to Shelter: A Discussion Guide for Hospital Discharge Staff

Collaborating with Emergency Shelters in Massachusetts

Another key practice to supporting patients experiencing housing instability or homelessness is collaborating with emergency shelters. Watch the following video to understand how collaboration between shelters and hospitals can reduce discharges to homelessness.

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Key Resources to Support Patients Experiencing Housing Instability

Through conversation with the patient, you may find that patients may be able to avoid homelessness by accessing resources available to people at risk of homelessness. Discharge planning staff who are assisting  patients experiencing housing instability or homelessness should be familiar with the following resources:

Housing Consumer Education Centers 

Housing Consumer Education Centers across Massachusetts are available to support individuals with housing issues and may be able to help patients with

• Rental assistance to help cover past rent owed and future rent,
• Legal services and support to resolve legal issues preventing them from returning to their housing situation or obtaining new housing, and
• Case management.

The Housing and Consumer Education Centers webpage displays Regional Agency contact information and various resources. As an initial step, discharge staff can contact the Regional Agency closest to the patient’s community.  

Common Housing Application for Massachusetts Programs (CHAMP)

Massachusetts has a common application for state-aided public housing and the Alternative Housing Voucher Program (AHVP) called CHAMP. Patients who have not yet completed an application in CHAMP and are interested in subsidized housing should complete the application. If the patient has already completed the CHAMP, hospital staff can  help the patient login, update their account if needed,  and monitor their application and waiting list status.

Section 8 Housing Choice Voucher Program Application

The Section 8 Housing Choice Voucher Program is federally-funded resource to support households in obtaining affordable housing. Patients who have not yet completed a Section 8 Housing application should complete the application if interested. If a patient has already completed an application, the application status on the waitlist should be determined by contacting the Housing Authority where they submitted the application or creating or checking their account on the centralized waiting list.

Tips for Supporting the Housing Process

For patients with facility stays longer than two weeks, discharge planning staff should support patients in identifying long-term housing options using these resources. Oftentimes, patients will have already applied to subsidized housing programs and may be approaching opportunities.

Here are tips for helping patients be prepared as housing opportunities arise:

• Contact agencies where patients have already submitted housing applications to determine their waitlist status. Although subsidized housing will most likely not be immediately available, completing or updating these applications will support the patient in accessing housing more quickly, even post-discharge. Specifically, make sure that the applications are updated with regards to mailing address and current housing situation. Also, where possible, make sure that a secondary contact is listed in the application (e.g., family member, friend or other person who usually knows where the patient is). If patients miss correspondence from a Housing Authority or other entity, they could miss an opportunity for long-term housing.
• Support the patient in gathering documents that are often required as part of a housing application process, including government identification and birth certificates. Take some time to review more tips on obtaining an ID.

To better familiarize with the resources available, watch the following video to see how a hospital discharge planner can utilize these resources with a patient experiencing housing instability.

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Addressing Basic Needs Prior to Discharge

While your efforts to problem solve a housing crisis with a patient and pursue housing opportunities may result in a patient finding a safe alternative to shelter and resolving their housing crisis, there will be times when a patient is not able to identify a safe alternative. In situations where a patient is discharging to an emergency shelter it is important to facilitate a smooth discharge that supports the patient’s dignity and ensures they are not vulnerable to any additional issues. 

At this point, discharge planning staff should have already notified the shelter to when the patient will be  discharged in order to coordinate the transition. Utilize the following checklist to ensure the patient has their basic needs met prior to discharging to shelter.

Click here to download this checklist.

Determining Inappropriate Discharges to Shelter

You may have noticed that one of the first questions asked in the Housing Tool is whether or not a patient can care for themselves independently after discharge. The answer to this question helps determine what may be appropriate settings and possible resources that could support the patient. For patients who cannot care for themselves independently after discharge, discharging to shelter should not be considered an option.

The following are examples of patient circumstances that most shelters could not accommodate:

• If the individual cannot independently ambulate, transfer to bed/chair, shower/bathe, or dress themselves independently, they are likely not appropriate for shelter.  
• If the individual cannot manage their daily medications independently and there is no reasonable plan to receive medication management offsite.
• If the individual has a feeding tube they cannot independently maintain or the shelter space cannot support the individual in safe use.
• If the individual has open wounds.

Some shelters may have specific physical demands or protocols such as being outside that the individual must be able to meet. When you are unsure if a patient’s circumstances are appropriate for a shelter, it is best to call the shelter prior to discharge to understand what the shelter can accommodate.

Watch the following video to practice identifying inappropriate discharges to shelter.

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For individuals experiencing homelessness that are not able to care for themselves independently after discharge and therefore cannot be discharged to an emergency shelter, discharge planning staff should identify long-term care options. Resources for this population of patients can be found on the Helping Patients with Skilled Nursing Needs webpage.