Hospital and Shelter Collaboration Video Transcript
Hospital and shelter collaboration
New MassHealth tools and guidance developed to help patients who are homeless or at risk of homelessness, directs acute care and psychiatric inpatient hospitals to work with emergency shelters as part of strategies to decrease discharges to homelessness.
It is hoped that connections between hospitals and emergency shelters will, first and foremost, reduce surprise discharge to shelters and eliminate discharges of individuals who are clinically inappropriate. This new guidance hopes that increasing communication between hospitals and shelters and working collaboratively to leverage all community resources will achieve these goals. Shelters are vital partners in reducing discharges into homelessness and for ensuring that vulnerable individuals without alternatives have a safe place to sleep at night - regardless of where they once called home or the challenges they may face. Early and frequent communication between hospital and shelter staff has proven effective in reducing inappropriate discharges to shelter and better ensuring those who are discharged are prepared for a safe and successful stay.
In addition to the hospital and shelter staff, the patient’s discharge planning team may also include state and/or local service agencies, the health insurer, family members and friends.
At admission
For any member who was experiencing homelessness prior to admission, the acute care or psychiatric inpatient hospital must contact the shelter within two days after admission. DHCD guidance encourages shelters to be prepared to receive and be receptive to inquiries from provider hospitals who may have an individual who previously resided in shelter by sharing information about the individual’s housing history and any other support systems they may have (family, friends, case managers, housing leads, etc.).
If the hospital does not anticipate finding an alternative to shelter and the patient will stay in the hospital for less than 14 days, the hospital may discuss an appropriate discharge plan with the shelter. For patients staying in the hospital more than 14 days, the hospital should work with the shelter to brainstorm housing solutions and resources.
The goal of these conversations is to share information – as consented to by the patient – in order to determine whether homelessness or return to homelessness is avoidable. Identifying even a short term stay with friends or family is preferable to a shelter stay.
As part of this conversation, the hospital discharge staff should review the member’s needs and the anticipated discharge date. With this information the shelter should be able to determine if they are able to meet the member’s needs and when a bed may be available. If the discharge date is more than 2 days from the conversation, the hospital discharge staff will need to contact the shelter again to determine the availability of a bed, if necessary.
Modeling the conversation
Hospital: Hello. I’m a Discharge Planner with the MassBay Hospital. My name is Susan and I was hoping to speak with a staff person at the shelter about one of our patients.
Shelter: Right now I’m probably the best person to speak with. I’m Sam. Who are you calling about? Did the patient give you permission to call the shelter?
Hospital: Yes, the patient is Robin Heer. They gave me permission to talk with you and said they were staying with you last week. They were just admitted to the hospital from the ER. We don’t think they will be staying with us more than 2 or 3 nights so we wanted to see what we could arrange with you for them to either return, or if you had any suggestions for alternative places they could stay?
Shelter: I know Robin. They’ve been staying at the shelter on and off for the last year or so. They had a relationship for a while and stayed with that person, whose name is Charlie. I guess that didn’t work out and they came back here.
Hospital: I plan to talk with Robin once they are settled in. I’ll see if they have any thoughts on alternatives, like Charlie. If not, do you think Robin will be able to return to the shelter?
Shelter: I’m not sure. We don’t usually save beds for people. Let me talk to the Shelter Director. Can you call me back tomorrow?
Hospital: Sure thing. I should know more then.
At discharge
Sometimes discharge to an emergency shelter or the streets may be unavoidable despite the shelter-hospital collaboration.
When a patient will be discharged to shelter, MassHealth has outlined protocols that hospitals are expected to follow:
- Hospital discharge staff provides the shelter with at least 24 hours advance notice prior to discharge.
- The patient is discharged during daytime hours.
- The patient is provided with access to paid transportation to the emergency shelter.
- The patient is provided with a meal prior to discharge.
- Ensure that the patient is wearing weather appropriate clothing and footwear.
- The patient is provided with a copy of their health insurance information.
- The patient is provided with a written copy of all prescriptions and at least one week’s worth of filled prescription medications.
Modeling the conversation.
Hospital: Hi. I’m looking for Sam.
Shelter: Hi. This is Sam.
Hospital. Hi, this is Susan from MassBay Hospital. We spoke a few days ago about Robin Heer.
Shelter: I remember. How are they doing?
Hospital: They’re ready to be discharged and I was hoping you would have space for them.
Shelter: Did you talk with them about any alternatives? You know this isn’t the greatest environment for someone who is sick and just coming out of the hospital.
Hospital: I agree but I have been unable to get them to identify any alternative place. We talked about staying with Charlie but it wasn’t going to be a safe situation. We’ve reached out to family members and they haven’t been responsive. I know the shelter is not ideal but Robin is healthy enough to be there. They are medically cleared and have all their prescriptions filled. There is no indication that they have COVID.
Shelter: This is unfortunate but I get it. When will they get here?
Hospital: I can arrange transportation for this afternoon if that works.
Shelter: I am not sure if we will have a bed at this point. If they can come tomorrow we should have a bed.
Hospital: Okay. We will keep them one more night and send them with an uber tomorrow morning. What time is OK for them to arrive?
Shelter: The doors will open at 4pm, if you can have them arrive then.
Hospital: Great. I’ll make sure they have something to eat as well. Appreciate your help.
Shelter: No problem.
In the event that a shelter bed is unavailable on the planned discharge date, but a bed will be available soon, the hospital is expected to delay discharge until a bed is available. Hospitals should also call the health insurance payer to inform them of the situation.
In the following scenario, a hospital staff person is not able to discharge the patient to a shelter for another couple of days as the shelter does not have any new beds available over the weekend. Listen to the conversation to understand how hospital staff can utilize the health insurer to authorize additional inpatient days. The hospital and health insurer have already communicated about this situation and the health insurer has collected the necessary information.
Health Insurer: You said you called to discuss Rachel’s discharge. Tell me about the situation.
Hospital Staff: Rachel was previously staying at a local homeless shelter upon admission to our facility. We were not able to find her an alternative place to go and she plans to return to the shelter where she was staying, but the shelter does not have a bed available until Monday.
Health Insurer: Is there another shelter Rachel can go to?
Hospital Staff: There is another shelter in the area but in order to follow protocol, we would need to coordinate with the other shelter at least 24 hours prior to discharge and we still need time to have her prescriptions filled. Rachel also prefers to go to the shelter where she previously stayed and has a case manager. Given the situation and the protocol in the contract, we would like to delay discharge and bill at the administrative day rate for the extra days.
Health Insurer: That makes sense and I can approve this on my end. Thank you for explaining the situation and letting us know!
Hospital Staff: Thank you. Could I have your name and contact information to share with our billing department so they can follow up with you.
During discharge planning with patients and using housing problem solving practices, you may find that there is a safe alternative available to a patient but there is an obstacle for the patient in securing that safe place to stay. For example, a patient may have a family member in the next state over that you have talked to and is willing to let the patient live with them instead of discharging to a local shelter, but does not have the financial means to pay for a bus ticket, nor does the facility have the ability to pay for this transportation. Discharge planners should collaborate with local shelters who may have the resources to support the patient in avoiding shelter. In your conversation with shelter to problem-solve, share that this is a barrier to securing a safe alternative to shelter for this patient and ask if the shelter has a way of overcoming this barrier. If they do, work together to coordinate the transportation, payment, and communication with the patient.
Modeling the conversation.
Hospital: Hello. I’m a Discharge Planner with the Main Street Hospital. I was hoping to speak with a staff person at the shelter about one of our patients.
Shelter: Right now I’m probably the best person to speak with. I’m Jackie. Who are you calling about? Did the patient give you permission to call the shelter?
Hospital: Great. My name is Miranda and the patient’s name is Cory Johnson. He gave me permission to talk with you and said he was staying with you last week. He was just admitted to the hospital from the ER. After speaking with Cory, I learned that he has an uncle in Ohio that he recently re-connected with and used to live with. We decided to give the uncle a call together and his uncle will let Cory live with him after leaving the hospital in the next few days. The only issue is that his uncle is a bit stretched financially and can’t pay for the bus or plane ticket for Cory to Ohio. Our facility and Cory’s health plan do not have the ability to pay for transportation like this and we were wondering if you know of any resources to support Cory in getting there and avoiding a return to shelter?
Shelter: Great to hear that Cory reconnected with his uncle and has a place to go now. I will look into what funds we may have available for transportation. Would we be able to schedule a call for tomorrow morning for you, Cory, and I to talk through some options?
Hospital: Yes we can make that work, that would be great. How about 10am?
Shelter: 10am works. Thanks for reaching out.
Hospital: Great. I’ll email you now with the call details. Thank you for your help!
Developing the hospital-shelter relationship can be challenging. Staff responsible for discharge or intake may rotate or change regularly, for example. We are all very busy! Nonetheless, taking the time to reach out to your local shelters before an emergency need develops, taking the time to tour the shelter, meet staff in person and see the space to which patients will be discharged will all assist in improving communication and likely outcomes.