Social worker facilitates referrals to shelters
Social worker facilitates referrals to shelters
LOS drops from 27 days to 9 days
Having a dedicated social worker who works with local homeless shelters to place patients has significantly reduced the length of stay for homeless patients at New York Presbyterian Hospital/Columbia.
In 2000, before the program was started, the average length of stay for homeless patients was 27 days. In 2005, the figure had dropped to nine days, according to Paula Roberts, LCSW, director of social work at the New York City hospital.
The hospital developed the homeless patient referral program in 2001, assigning one social worker as the liaison between the hospital, the shelter system, and the New York Department of Health's department of homeless services.
Before the new system was instituted, individual social workers would fill out the forms for shelter referral and send them to the department of homeless services, a city agency that assesses patients' eligibility for shelter placement.
"They were taking a long time in responding and they were dealing with new social workers at our hospital each time," Roberts says.
If the patient is eligible for a shelter placement in New York City, the hospital must send a patient's medical history, including laboratory results, to the medical review team at the Department of Homeless Services. The information is reviewed and provided to the program referral unit, which determines which shelter will meet the patient's needs.
The system was developed to streamline the complicated system necessary to place patients from the hospital into shelters in New York City.
"Having one social worker track the patients being referred to the Department of Homeless Services has made a tremendous difference. It smoothes the transition of patients from the hospital to the shelter," Roberts says. "The Department of Homeless Services now has one person to call. This has led to a good working relationship between the agency and the hospital," she says.
The agency has agreed to let the hospital know within 72 hours if the patient can be placed in a shelter. The social worker tracks the time and date the application is filed and the length of time it takes to get a response. "We have a dedicated person who has established a great relationship with the department of homeless services, who is relentless about calling them and making sure the paperwork goes through on a timely basis," says Roberts.
When patients who have been in a shelter are readmitted to the hospital, the social worker knows their history and which shelter they have been in. The social worker contacts the Department of Homeless Services and lets them know that the patient has been readmitted.
The hospital provides homeless patients with a two-week supply of medications when they are discharged.
"We pick up the medications for them and hand it to them because we want to make sure they have it in hand," she says. The hospital keeps a supply of clothing for homeless patients and often arranges transportation to the shelter.
Medical needs determine patients' eligibility for placement. "If patients do not want to go to the shelter, it's their right to decline by self-determination," Roberts says.
If a patient is not eligible for shelter or refuses shelter placement, then it is the responsibility of the interdisciplinary team in collaboration with the patient to develop a safe and appropriate discharge plan.
"We've had people who stayed in our hospital for a long time. With this patient population, you have to be creative. We try to find some family or other support system to take care of them," Roberts says.
When patients at Presbyterian Hospital say they are homeless, they are assessed by a social worker who visits them in their room and further assessed by the interdisciplinary treatment team.
"When the social workers do the assessment, they may find that some of the patients are not really homeless. They may have a place to stay but choose not to return for various reasons. In those cases, the social worker works with the patient to either return home or to identify a safe discharge alternative," Roberts says.
In addition to shelter referral, the social workers also may refer patients to a mental health clinic or other community agencies for continuing care needs.
(For more information, contact Paula Roberts, LCSW, by e-mail: [email protected].)
Having a dedicated social worker who works with local homeless shelters to place patients has significantly reduced the length of stay for homeless patients at New York Presbyterian Hospital/Columbia.Subscribe Now for Access
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