Step A. Determine if patient has an active DHS case and is assigned to a DHS facility (shelter, safe haven or stabilization bed):

Contact (212) 361-5590 or DHSHRDS@dhs.nyc.gov and request:

• Name of patient’s assigned shelter/safe haven

• Name, phone and email address of the facility director

• Patient’s DHS CARES database ID number

Step B. Submit referral based on DHS assignment status:

• Patients who have a current DHS assignment: Email Institutional Referral forms to facility contact at assigned shelter or safe haven

• Patients who do not have current DHS assignment: Email Institutional Referral form to the DHS Health Services Office at DHS-HCFReferral@dhs.nyc.gov

• Chronically street or subway homeless patients who decline shelter: Email Institutional Referral form to request safe haven placement: SHSCC@dhs.nyc.gov or (212) 607-6040

Contact DHS-HCFreferral@dhs.nyc.gov for assistance when assigned shelters, safe havens or street outreach teams do not respond to the institutional referral within a business day. Use the email subject heading "Assistance requested: No response to institutional referral to DHS assignment".

All patients:

• Complete Institutional Referral Form
• Signed patient consent to discharge to shelter

• Psychiatric evaluation
• Recent psychiatric progress note
  
• Psychosocial evaluation

Clinical evaluations are required for successful placement in safe havens, supportive housing, or other residential placements.

In-patient medical/surgery admission for more than 60 days, referred from nursing home or short/long term rehab facility and/or ADL functioning may be in question:

• Patient review instrument (PRI), must be current and accurate
• Recent PT/OT note

• Cognitive assessment, e.g. MMSE, MOCA
  

If requesting expedited placement in a specialized shelter:

• Tuberculosis test results 
  
  

All patients upon discharge:

• Discharge summary and medication list
  
  

• Supportive housing-related documents, such as psychosocial evaluation and HRA 2010e application. Providing these documents can help expedite supportive housing placement.

Institutional referrals must meet the following criteria in order for the referral to be deemed complete and a determination of medical appropriateness to be made:

1. Institutional Referral Form must be fully complete. Institutional Referral Forms with missing information will be returned to the sender.

2. All referrals must attach a signed patient consent form.

3. Patients who meet absolute medical exclusion criteria are not eligible for shelter. 

   • The most common absolute medical exclusion criteria is the patient needing assistance with activities of daily living (ADLs). These patients should be discharged to a higher level of care, such as supportive housing or assisted living. See residential placement options.

   • Patients who meet absolute medical exclusion criteria upon assessment at shelter intake will be transported back to the hospital.

4. All applicable non-DHS residential placement must be attempted prior to discharging to DHS.

5. Patients must have at least one follow-up medical appointment listed on their referral. If patient is unlikely to engage in follow-up medical care and treatment independently, refer patient to mobile health programs specialized in serving people with high service needs and/or experiencing homelessness.

6. Patients with chronic street or subway homelessness should be enrolled in a program such as Safe Options Support (SOS), Critical Time Intervention (CTI) or Intensive Mobile Treatment (IMT) prior to the referral. If a patient is chronically danger to self or others and lacks insight into their risk, applications can be submitted even if the client declines services or does not consent. These programs will outreach and attempt to engage over time.

7. Patients with a history of serious mental illness who are not engaged in care and are dangerous to self or others should be enrolled in a program such as Shelter-Partnered ACT, Critical Time Intervention (CTI) or another mobile mental health program prior to discharge. These programs should accompany the client from the health care facility to the shelter to initiate care coordination with the shelter immediately after discharge.

8. All required medical documentation must be provided.

Referrals are processed in the order they are received and must be complete in order to make a determination. If any section of the form is incomplete or requested documentation missing, the form will not be reviewed and will be returned to the sender. Ensuring that the referrals meet all of the above criteria prior to submission will facilitate a more timely determination of medical appropriateness.

DHS is required to ensure safety in shelter. According to New York State regulations, a person should not be placed in shelter if they:

• Have a mental/physical condition that causes danger to self/ others
• Requires medical services beyond what shelter is able to provide

To submit a RA request, send the DHS Reasonable Accommodation Request form (DHS-13) and supporting documentation, if required, to the DHS Disability, Access and Functional Needs (DAFN) Unit at DAFNRARequests@dhs.nyc.gov and copy DHS-HCFReferral@dhs.nyc.gov. If the client is currently assigned to a shelter site, please include the Program Director on the email.

• If a need for an RA is obvious/apparent (e.g., a client that uses a wheelchair needs a wheelchair accessible bathroom), supporting documentation is not required.

• If the need is not obvious/apparent, supporting documentation (e.g., letters from treating physicians/clinicians, medical records) is required. Supporting documentation should speak to why the client needs the requested RA.

• A HIPAA Authorization form is not required but is very helpful. It enables the review team to reach out if they need additional information or to help get documentation for a client if they need help.
• If you are submitting a HIPAA form along with the RA request form, please make sure that the HIPAA is filled out completely otherwise it’s invalid and cannot be used.
• When completing the section on page 2 that requires the provider’s information, be as specific as possible. Do not just include the name of the hospital.
• For more information and copies of forms, please visit: https://www.nyc.gov/site/dhs/about/applicants-and-clients-with-disabilities.page 

Discharge on business days only, 9AM to 3PM. Do not discharge on holidays, during code red or code blue, or during an emergency.

Discharge patients with:

• Two-week supply of medications and a pharmacy available (and delivers) city-wide

  • Consider long-acting medications

  • Simplify regimens so patients can self-manage

  • Enroll patients unlikely to adhere to treatment in medication management services

• All necessary medical and assistive equipment

• Discharge summary, medication list and follow-up care plan instructions using a method the patient is likely to retain (paper, text message, app, web portal, or other)

• Discharge after a full meal, and with weather-appropriate clothing and shoes

• Coordinate accompaniment and transportation from health care facility to shelter for medically complex patients unlikely to be able to follow through on their own

Give the patient Handout for Patients Discharged to Shelter.

Inform patients to arrive to the shelter before the daily curfew of 11pm in order to secure their bed placement on the date of discharge agreed upon with the assigned shelter.

Patients should arrive before 5pm while social services staff are still on-site.