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Helping Patients who are Homeless or Housing Unstable

Resources, information and a support line to assist hospital staff in placing individuals who are experiencing homelessness or housing instability

Table of Contents

General Guidance and Information

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 those 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 those 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 those 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.
  • For those patients who were homeless or housing unstable prior to admission and will need skilled or long term care upon discharge, go to Helping Patients with Skilled Nursing or Other Long Term Care Needs.
  • For patients with serious mental illness and/or functional impairment, contact the local Department of Mental Health (DMH) Area Office to determine if the patient is a DMH consumer and to identify potential housing and/or respite resources If the patient is not already a DMH consumer, complete and submit the DMH application for services.
  • Patients who were homeless prior to admission and are COVID-19 positive and can safely isolate at one of the Commonwealth’s Isolation and Recovery Sites. Individuals must no longer require medical supervision.
  • For those patients that are insured, discharge planning should include outreach to the health insurance plan to determine if the plan may be able to provide resources or help identify solutions to assist with housing.
  • For patients in need of MassHealth coverage, information on the application process can be found here. For further assistance with coverage or eligibility issues, please contact the MassHealth Customer Service Center (800) 841-2900

Resources for Discharge Planners to Assist Patients who are Homeless or Housing Unstable

Discharge support is available to assist staff from acute hospitals, behavioral health facilities, and other publicly assisted systems of care, who are working with current to secure appropriate housing post- discharge. The Hotline is limited to providing support to staff for only those situations when the patient will be forced to go to a homeless shelter or the streets upon discharge. For those patients in need of skilled or long term care, please contact the EOHHS Long Term Care Discharge Support Line.

This support line is meant to supplement comprehensive discharge planning efforts as required per applicable EOHHS regulations and contracts. This service is a resource meant for use by provider staff only.

When to contact Homeless Support Line for Discharge Staff

  • Discharge staff should contact the Homeless Support Line only after they have exhausted all efforts.
  • For those patients who are homeless at intake, discharge planning should include a discussion with the emergency shelter about whether the patient could return after the hospitalization. For example, with notice, a shelter may be willing to “hold” a bed when it is a short hospitalization stay (e.g. less than 14 days) and the shelter is able to meet the patient’s needs. For those patients who are homeless and have short hospitalization stays, before contacting the Hotline, discharge staff should contact the shelter to discuss whether the patient will be allowed to return to shelter upon discharge.
  • For MassHealth members enrolled in MassHealth health/managed care plans, please contact the member’s health plan to coordinate discharge planning prior to contacting the support line. Please see the Accountable Care Partnership Plan (ACPP) Contact List for Discharge Planning for contact information.

 

Types of assistance the Homeless Diversion Hotline can provide:

Hotline staff will attempt to identify any agency that is currently assigned to work with the specific patient, such as a managed care organization or state agency, and bring that entity into the conversation about discharge options. Hotline staff will also attempt to identify any untapped resource that may be of assistance, such as resources from MassHealth, the Department of Mental Health, or the VA.

Recognizing that there may still be a handful of situations when a patient has no option but to go to an emergency shelter upon discharge, discharge staff should contact the shelter ahead of time to discuss the situation.

How to connect with the Homeless Support Line for Discharge Staff:

 

Last updated: June 24, 2021
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