Institutions’ Discharge Planning of Homeless Individuals

The following guideline is created by shelter providers across western Massachusetts to assist you with discharge planning for homeless individuals from your institution, organization or agency, and to determine whether shelter is a feasible option.  

Discharge planning for homeless individuals is a process rather than an action. Early identification of an individual’s homelessness is important to begin working on the most appropriate and feasible referral. Shelter referrals may not be feasible for various reasons such as the individual’s discharge needs, shelter capacity or other circumstances.  Shelters are the decision makers on determining whether the shelter is able to accept the referral to shelter at that time.

If you have any questions about the discharge planning guidelines, please give us a call. Our contact information is attached to the guidelines:

1. Reach out to the individual’s home community first.
   1. Use resources such as housing referral lists for sober houses, rooming houses, and shelters.
   2. Discharge to shelter as the last resort.
   3. Contact the shelter nearest the individual’s home community first.
      1. Provide a list of other resources that have been contacted prior to contacting shelter.
   4. If other shelters are contacted, please provide information on which shelters have been contacted and when the contact was made.
2. Speak with the appropriate authorized staff person at the shelter about the referral.
   1. Contact authorized shelter staff prior to the anticipated discharge date as soon as possible.
      1. A list of shelter providers in the region with contact information is attached.
   2. A conversation with the authorized staff person is required prior to accepting the referral. Voicemail messages are not sufficient.
      1. All referral information is collected and documented by the shelter.
   3. Provide shelters with the following information about the homeless individual:
      1. What is the individual’s home community (last known address or dwelling)?
      2. What other connections have been attempted for this discharge?
      3. What other service providers are working with this individual?
      4. Does the individual have a CSP worker?
         1. Does the individual have MBHP insurance?
      5. Why is the individual currently hospitalized?
      6. What is the individual’s discharge needs?
         1. Are there medical treatments beyond medication (such as dressing changes) that are necessary?
         2. Has the individual been given follow up appointments? If so, please provide.

• Is the individual on medication?
  1. If so, what medication is the individual taking/prescribed?
  2. Who prescribed the medication?

1. Does the individual have income?
   1. If so, what is the individual’s monthly income and income source?
2. What are the individual’s housing plans post-discharge?

4. Once the referral has been approved:
   1. The homeless individual will then need to speak with the staff person to complete a phone interview.
   2. Logistical arrangements for shelter intake can be discussed.