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Guidance and Information For Discharge Planners

Determining a new patient’s housing situation – are they housed? homeless? unstably housed? – early in their admission is the first step to ensuring the safest, healthiest discharge possible for them.

Table of Contents

Identifying Patient’s Housing Status and Needs

Discharge planning should begin at intake with a discussion about the patient’s current housing situation. For individuals with a history of homelessness or housing instability this intake should include a discussion or current living arrangements; with this early planning some housing situations can be reserved while the individual is hospitalized.

  • For patients that were housed prior to admission, it may be possible to retain the housing by speaking with the landlord or housing agency and working out a plan for paying the rent (or accessing housing assistance programs if the patient has no available resources).
  • For patients who were homeless prior to admission and have short hospitalization stays, discharge planning should include a discussion with the local emergency shelter about whether the patient could return after the hospitalization. Note that patients that need assistance with Activities of Daily Living or have behavioral health issues that would be dangerous in shelter should never be discharged to a shelter.
  • For patients who were homeless/housing unstable prior to admission and have long hospitalization stays, discharge planning should include discussions with family, friends, and any person with a relationship with the patient that may have resources and/or willingness to help provide a housing option. This would include contacting any involved case managers and helping the patient apply for available resources for which they may be eligible.
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