There is progress in the fight against homelessness. According to the latest report from the National Alliance to End Homelessness (NAEH), the overall homelessness rate dropped 3.7% between 2012 and 2013, and the number of individuals who are chronically homeless declined by 7.3%. NAEH credits the effort to move people into permanent supportive housing as a factor in this success.
Housing First is a leader in this initiative, with evidence-based intervention focused on the needs of a very specific group of individuals–chronically homeless individuals with dual diagnoses of mental health and addictive disorders. The goal is to move these individuals directly into permanent housing that offers supportive services. With 30% of chronically homeless individuals having mental health conditions and about 50% with a co-occurring addictive disorder, Housing First is targeting directly a root cause of homelessness.
The underlying concept is that housing stability is the foundation for treating an individual’s mental illness and/or substance abuse. Housing First empower individuals with consumer choice and offers intensive case management and wraparound services.
Housing First programs are funded from various sources including Medicaid, federal, state and local funding, and private foundations. The presence of comorbid behavioral health conditions, homelessness, and the absence of a sobriety or treatment precondition to receive housing means provider organizations must unite a complex network of funding and agency relationships.
Coordinated Care Supports Innovation in Behavioral Healthcare
A Coordinated Care platform can unify all of these complex relationships and enables unique programs such as Housing First to succeed in their missions. Coordinated Care systems optimize interoperability with other systems through an Open Architecture. That enables treatment and discharge plans to be shared with all providers across the continuum of care. With intuitive data exchange across HIEs and other repositories, individual agencies and funding sources can all be properly aligned.
Coordination of care means that the electronic health record, needs assessment, treatment planning and delivery of care can move from one program/provider to another efficiently without duplications of services. It’s how innovation in treating underserved populations, such as the homeless, can succeed and thrive.
Coordinating Care through Effective Discharge Management
Coordination of care can be tangibly put into practice to reduce homelessness by obtaining the right services in the community for individuals as part of their discharge plan from a provider or agency. It ensures that they have access to the right resources, medication management, and support services to get a new job and vocational training. This should all be part of a safe and accountable discharge management process.
To achieve these goals, The National Health Care for the Homeless Council recommends the following Discharge Planning Guidelines for Health Care Institutions:
- Provide physical and mental/cognitive assessment at intake.
- Work with the patient on treatment adherence issues.
- Ensure patient stability prior to discharge.
- Base the decision to discharge on medical, not financial considerations.
- Encourage the patient (or surrogate) to participate in discharge planning.
- Give the patient (or surrogate) written notice of the intent to discharge and allow for an appeal of the discharge determination.
- Involve social work, pastoral care, legal counsel, ombudsman, ethicist, and a multidisciplinary care team in discharge planning.
- Provide information about community resources to clinicians and patients.
- Dedicate a clinical social worker to all homeless discharges.
Through specific, transparent and accountable procedures such as these, combined with unique innovators such as Housing First, real change can be brought to bear in reducing homelessness. But an essential component mush be effective coordination of care to make sure that everyone is working together in unison toward that shared goal.
 “The State of Homelessness in America 2014,” National Alliance to End Homelessness, (May 27, 2014), http://www.endhomelessness.org/library/entry/the-state-of-homelessness-2014
 “Current Statistics On The Prevalence And Characteristics Of People Experiencing Homelessness In The United States,” OpenMinds, using data compiled from the Substance Abuse and Mental Health Services Administration (SAMHSA), (July 2011), http://www.openminds.com/market-intelligence/resources/current-statistics-prevalence-characteristics-people-experiencing-homelessness-united-states.htm
 Rodriguez L. (2008). Discharge Planning Training. Presentation, NHCH Conference and Policy Symposium, Phoenix, AZ, Cited in: “Tools to Help Clinicians Achieve Effective Discharge Planning,” Healing Hands, (October 2008), 12(5)