SHM Converge Scientific Abstract ePoster Gallery-What's Missing? Improving Transitional Care for Our Unhoused Patients

Pdf Summary

This quality improvement project examined hospitalizations for unhoused patients at a Stanford-affiliated institution to identify gaps in discharge planning and post-hospital care. The authors reviewed 140 patients across 169 hospital medicine encounters from January to June 2024. Homelessness affected a large population in the surrounding counties, and unhoused patients made up 6% of all admissions.<br /><br />The study found several major care gaps. Only 49% of encounters were correctly flagged as high risk for housing needs at registration, limiting early support. Social work was consulted in only 36% of cases. Just 36% of patients received medications at bedside before discharge, and only 9% left with a scheduled primary care appointment. Discharge destinations were often unstable: 29% went directly to the street, while many others were discharged to shelters or non-traditional “home” settings such as motels or temporary stays with friends or family. Thirty-day readmission to the institution was high at 24%.<br /><br />These findings suggest that current processes are insufficient to support safe transitions of care for unhoused patients, despite California Senate Bill 1152 requiring hospitals to provide structured discharge planning and transition assistance. The authors conclude that better data tracking and proactive interventions are needed.<br /><br />Planned improvements include an EHR-integrated banner to standardize discharge interventions, physician education on best practices for caring for unhoused patients, and stronger interdisciplinary collaboration to assess needs and connect patients to services.

Asset Subtitle

Lisa Shieh

Meta Tag

Author List Christine Santiago, De'mond Glynn, Devon Lee, Jason X. Shen, Lisa Shieh, Nancy F. Liu, Natasha Steele

Category Research

Concept Homelessness

Concept Health Disparities

Concept Transitional Care

Concept Medication Access

Concept Discharge Planning

Distinguished Non-Finalist

Presenter Organization Stanford University School of Medicine

Presenting Author Lisa Shieh

Track Quality Improvement

Keywords

unhoused patients

hospital discharge planning

post-hospital care

housing insecurity

social work consultation

readmission rate

Stanford-affiliated institution

EHR-integrated banner

California Senate Bill 1152

care transitions

Homelessness

Health Disparities

Transitional Care

Medication Access

Discharge Planning