Aligning Expectations to Improve Hospital Discharge Planning for People Experiencing Homelessness

A nurse in scrubs is taking notes while listening to someone on the phone

Prior to joining TAC, I worked at a homeless services organization that operated large, congregate-style shelters in Boston. During my time there, it was not uncommon to see a guest carried away in an ambulance one day, only to see them sitting in shelter again days later. For some, the return was a result of a mental health crisis or a physical ailment, while for others, I imagined it was a desperate attempt to find respite from the chaos. No matter the reason, I knew that returning to a shelter environment would surely only worsen the condition that had led to their hospitalization in the first place.

National studies have demonstrated the association between homelessness and high health care costs. People experiencing homelessness are often “high utilizers” of emergency departments and inpatient hospitalization due to untreated acute or chronic medical conditions; mental illness; and substance use disorders.

Unfortunately, many acute care and psychiatric in-patient hospitals struggle to provide safe discharge for patients who have no place to call home. Inappropriate discharges might include situations in which an individual cannot perform basic activities of daily living without support, or has need for mental health or substance-use-related supports that an emergency shelter is not staffed to provide. While only a small number of those entering shelter are arriving directly from an inappropriate hospital discharge, these situations can be difficult to resolve, traumatic, and frustrating — and may put the individual’s health at further risk.

State-Level Action to Improve Discharge Coordination

In 2020, the State of Massachusetts initiated an effort to better coordinate hospital discharge planning for individuals with complex needs. MassHealth, the state’s Medicaid agency, is working both with the Massachusetts Department of Housing and Community Development and with the state’s Interagency Council on Housing and Homelessness to align expectations for hospitals and emergency shelters and reduce the number of people discharged from psychiatric or acute inpatient units directly to homeless shelters. The initiative is an outgrowth of the Massachusetts Olmstead Plan, which included a specific strategy to support homelessness prevention and improve discharge planning efforts across populations.

To better inform the decisions and interactions that could lead to inappropriate discharges, the state offers an online toolkit, Helping Patients who are Homeless or Housing Unstable, with guidance documents and technical assistance products such as these:

  • A Letter to Individual Emergency Shelter Providers outlining the state’s expectations and requirements with regards to communicating and collaborating with provider hospital discharge staff.
  • New bulletins outlining MassHealth’s expectations and requirements for Acute Inpatient Hospitals, Psychiatric Inpatient Hospitals, and Managed Care Entities with regards to helping homeless and housing-unstable patients, including a requirement to begin discharge planning that starts at admission and includes communicating with local housing agencies and shelters.
  • A reporting form for shelters to complete when an individual may have been inappropriately discharged from a hospital to a shelter. These forms are submitted to the state housing agency, which reviews the forms and tracks patterns.
  • A Homeless Support Line (scroll down to find Support Line info) for hospitals to call when they have exhausted all potential placement options. Support Line staff aid with troubleshooting benefits issues, connecting with resources not known to the facility, and coordinating with state government partners to address the needs of the patient being discharged.

TAC supported this comprehensive effort with the development of an Online Housing Tool for Hospital Discharge Staff. This interactive tool can help guide hospital discharge staff who are working with an unstably housed or homeless individual by providing specific action steps tailored to the individual’s unique situation. More broadly, a resource like the Housing Tool may help address the challenge of staff turnover and lack of discharge and housing training in many hospital environments. TAC also developed a “Finding Alternatives to Shelter” discussion guide for hospital discharge staff which provides examples of specific prompts and questions to help facilitate an in-depth iterative conversation about possible housing options.

TAC is currently developing web-based training modules to help hospital staff build their knowledge of resources and housing problem-solving practices, allowing them to more effectively help patients resolve their housing crises and avoid continued homelessness.

Like many issues TAC works to resolve, inappropriate discharges are a result of systemic issues, including a lack of affordable housing; pressure by health care payers to discharge a person who no longer requires hospital-level care; poor coordination between hospital discharge planners, community-based providers, and the homeless response system; and lack of access to flexible resources than can support a person’s transition. As advocates continue to press for resources to meet the community-based housing and support needs of individuals with complex conditions, the Massachusetts initiative is an example of a strategy that can be taken now to reduce inappropriate discharges to shelter.

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Jenna Espinosa, M.S.W.,

is a TAC Associate II with over five years of experience in the field of housing for people experiencing homelessness, with a focus on program design and rapid rehousing program management.