SHM Converge Scientific Abstract ePoster Gallery-Improving Transitions of Care for Hospitalized Patients Experiencing Homelessness

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This project examined how hospitalized patients experiencing homelessness are identified and connected to support during admission at the University of Colorado Hospital, with the goal of improving transitions of care. The authors note that homelessness is associated with worse health outcomes, higher hospital use, longer stays, higher costs, and increased early mortality. The COVID-19 pandemic has further increased housing insecurity, making this issue more urgent.<br /><br />The team used stakeholder meetings with social work, care management, nursing leadership, discharge coordinators, and community partners, along with process mapping from emergency department arrival through inpatient care. They also queried Epic chart data for the terms “homeless” and “shelter” and conducted manual chart review of selected cases.<br /><br />Findings showed that identifying housing status was inconsistent and spread across 22 different locations in the medical record. In 87 encounters from September 2020, 70% had housing status documented in multiple places, but the most common location was care management evaluation (49%). Although 76% had an address recorded on admission, provider notes documented housing status in only half of a random sample. Social work was not formally consulted in 15 of 87 encounters, though in many of those cases social work still evaluated the patient. Later data from March and June 2021 suggested improvement, with social work consults in 83% and 71% of encounters, respectively.<br /><br />The project concluded that there is no centralized or standardized process for identifying inpatient housing status, but there are opportunities to improve screening and documentation. Importantly, most patients identified as homeless are already being seen by social work. Based on these results, the team secured funding for a Homeless Transitions Team of three social workers to support hospitalized patients longitudinally and coordinate community connections.

Asset Subtitle

Amanda v. Johnson

Meta Tag

Author List Amanda v. Johnson, Erin Bredenberg, Gregory Misky, Jason John, Lauren McBeth, Mangala Iyengar

Category Research

Concept Homelessness

Concept Housing Insecurity

Concept Admission Process

Concept Housing Status

Concept Social Work Consultation

Distinguished Non-Finalist

Presenter Organization University of Colorado

Presenting Author Amanda v. Johnson

Track Quality Improvement

Keywords

homelessness

hospitalized patients

housing insecurity

transitions of care

social work

discharge planning

documentation

care management

University of Colorado Hospital

COVID-19 pandemic

Homelessness

Housing Insecurity

Admission Process

Housing Status

Social Work Consultation