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NYC Shelter Health

Institutional Referral Guide for DHS Facilities

Best practices for receiving patient discharges from the health care facility

Reviewing referrals:
Shelters must review the referral and respond to the hospital within one day with questions or clearance to discharge. If shelter does not respond in one day, hospital can discharge to assigned shelter.
 
Shelters should review for:
  • Activities of daily living (ADL)
  • Absolute medical exclusion criteria
  • Services in place to mitigate (reduce) risk for chronic conditions
Medical staff at the shelter or in the organization should be assigned to review hospital referrals, if available. If no medical staff is available, the shelter Director or Social Service Director should review the referral.
 
Discharge planning:
If patient is medically appropriate for shelter:
  • Ensure client has necessary services in place to support stability in shelter:
  • Follow-up outpatient health care scheduled
  • Mobile mental health program if needed:
    • Shelter Partnered ACT
    • Safe Options Support (SOS)
    • Care Coordination, or other
  • Coordinate with hospital to reserve bed one day before confirmed discharge date
  • If no bed is available, inform the hospital to hold the patient until a bed opens up, or client may be reassigned to a vacant bed
Learn more in the Hospital Discharge Coordination training slides.

Best practices for receiving patient discharges from the health care facility

If you have a high-need client who is hospitalized, start advocating for the necessary care on the day they go to the hospital:

  • Call the hospital (emergency room) to let them know your client is in the hospital 
  • Explain the danger to self or others, or inability to care for themselves in detail
  • Ask them to admit the client
Remain in contact with hospital while in-patient to ensure client gets care and treatment they need to remain stable in shelter:
  • Set up appropriate follow-up care
  • Submit applications for SPACT or AOT if needed
  • Simplify medication regimens if client has trouble managing

If the client needs a higher level of care, begin advocating for discharge to another placement than shelter immediately upon admission.

Learn more in the Hospital Discharge Coordination training slides.