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 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.
- For 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 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 who are homeless or housing unstable and are Covid-positive, the hospital may refer them to the state’s Isolation and Recovery program
- For patients with serious mental illness, the hospital should 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, consult with the local DMH Area office to determine if a DMH application for services is appropriate.
- For patients with developmental or intellectual disabilities, the hospital should contact the local Department of Developmental Services (DDS) Area Office to determine if the patient is a DDS consumer and to identify potential housing and/or respite resources. If the patient is not already a DDS consumer, consult with the local DDS Area office about completing and submitting a DDS application for services.
- For patients with traumatic or acquired brain injuries, the hospital should contact the Massachusetts Rehabilitation Commission (MRC) to determine if the patient is a MRC consumer and to identify potential housing and/or respite resources. If the patient is not already a MRC consumer, consult with the MRC office about applying for MRC community-based services.
- For patients with substance use disorders, the hospital should contact the DPH-sponsored Helpline (800-327-5050). Helpline is the statewide, public resource for finding substance use treatment, recovery programs, and assistance with problem gambling. The Helpline’s trained specialists will help the patient understand the treatment system and their options.
- 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
- Online Housing Tool for Hospital Discharge Staff: This decision tree can help guide hospital discharge staff when working with an individual experiencing homelessness or at risk of homelessness by providing specific action steps tailored to the individual’s unique situation. A short companion video provides instructions for using the Housing Tool. Transcript PDF | Doc
- MassHealth Bulletins: These three new Bulletins outline MassHealth’s requirements for Acute Inpatient Hospitals PDF | Doc, Psychiatric Inpatient Hospitals PDF | Doc, and Managed Care Entities PDF | Doc with regards to discharge planning to support individuals experiencing or at risk of homelessness. A list of Acute Inpatient Hospitals PDF | XLSX and Psychiatric Inpatient Hospitals PDF | XLSX to which these Bulletins apply.
- Finding Alternatives to Shelter: A Discussion Guide for Hospital Discharge Staff PDF | Doc: This document provides examples of specific prompts and questions to help facilitate an in-depth iterative conversation between hospital discharge staff and individuals about possible housing options post discharge.
- How to Obtain Identification Documents PDF | Doc: A useful fact-sheet that hospital discharge staff can refer to in assisting individuals in accessing key identification documents
- Shelter Realities PDF | Doc: This DHCD document provides clear information about things for an individual to consider before choosing to discharge to shelter, including space configurations (e.g., beds, privacy, storage), and operations (e.g., rules around daytime hours, time limits).
- List of Shelters and Contact Information: A list of DHCD-funded emergency shelters across the state that serve individuals experiencing homelessness, including contact information for each shelter.
- Discharging to Shelter Question Guide PDF | Doc: This DHCD document provides a list of questions that hospital discharge staff can ask a shelter to learn more about a specific shelter’s operations and resident experience.
- Housing Consumer Education Centers: Housing Consumer Education Centers (HCECs) offer answers to a wide range of questions about all types of housing problems.
- DHCD Resources for People Facing Eviction: Resources available to renters and homeowners.
- ICHH Letter to State Agency Stakeholders: This letter provides the context for the renewed focus on the intersection between facility discharges and homelessness.
- DHCD Letter to Individual Emergency Shelter Providers: This letter outlines DHCD’s expectations and requirements for homeless providers that operate emergency shelters for individuals with regards to communicating and collaborating with hospital discharge staff.
- Reporting Form for Inappropriate Discharge to Adult Individual Shelter: This Reporting Form can be completed by shelter staff for any situations in which an individual may have been inappropriately discharged from a hospital to an emergency shelter. While this form will not be used to troubleshoot specific cases, the information collected will help guide future policy discussions.
Homeless Support Line for Discharge Staff
In addition to the tools and resources above, 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. Support Line staff aid with trouble-shooting benefits issues, connecting with resources not known to the facility, and coordinating with state government partners to address the individual’s needs.
The Support Line 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.
Types of assistance the Homeless Diversion Hotline can provide:
Support Line 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. Support Line 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:
- Please begin with emailing a completed intake form to HomelessSupportLineforDischargestaff@mass.gov to ensure the support team has all the relevant information.
- Discharge Support is available Monday through Friday, 9 a.m. to 5 p.m. You can reach the Support team by emailing HomelessSupportLineforDischargestaff@mass.gov or by calling (617) 660-4810.
|Last updated:||July 30, 2021|