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Massachusetts Resources for People without Homes
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Referral Process and Protocols

  1. DMH Referral. The provider should endeavor to complete and forward a DMH eligibility packet for persons who are not already enrolled for DMH services within two business days of admission. In the Metro Boston Area, once a patient is determined to be eligible to receive DMH services, the provider should immediately initiate a HOT Team referral as noted below.
    • DMH HOT Team Referral (available to members in the Metro Boston Area). People who are homeless in the cities of Boston, Cambridge, and Somerville may be eligible to receive services through the DMH Homeless Outreach Team (HOT Team). The HOT Team assists homeless persons to find temporary and transitional housing. Additional services include case management and outreach to hospitalized individuals when appropriate. In order to receive services through the HOT team, the individual must be DMH eligible (as determined by DMH). Inpatient providers should therefore verify DMH eligibility for all patients who are homeless immediately upon admission. If the patient is DMH eligible, the provider should contact the HOT Team within 2 business days of admission
  2. ICM Referral. Review of empirical literature on homelessness reveals that case management approaches which provide frequent service contact are a critical ingredient leading to positive housing and treatment retention outcomes. In recognition of these findings, the Partnership issues the following Policy & Protocol Directives:
    • Automatic ICM Eligibility: Members who are homeless and mentally ill and/or struggle with chemical dependency are automatically eligible for Intensive Clinical Management (ICM) services through The Partnership.
    • Wrap Around Community Support Services: The ICM program offers one point of contact at the Partnership and "wrap around" Community Support Program (CSP) services.
    • Acute Care Bridge Visits: The Partnership and Community Support Program provide acute and routine bridge visits a) to facilitate timely access to community support services, b) to establish rapport with members identified for potential referral, and c) establish a point of initial contact for members who have accepted ICM/CSP services. The CSP worker helps the member to identify those behavioral health services which will be most helpful. Mobile Outreach Services: The Partnership has expanded its Community Support Program to provide targeted community support for members who are homeless. Mobile outreach services, including Mobile Psychopharmacology Services, are available to members who are homeless through the Partnership's ICM program.

    ICM services vary based on the need of the member and available regional resources, but they always include a comprehensive service plan with care management provided on site at the Partnership (see page 8 for details on the role of the CSP).

  3. Health Care for the Homeless Pilot Project Referral. In a study of mortality and homelessness conducted in Boston last year by Health Care for the Homeless (HCH), common characteristics of homeless individuals who died on the streets of Boston were identified. The study highlights risk factors that should be considered prior to the discharge of any homeless individual. The risk factors, identified in the study, are: Tri-morbidity: medical problems, substance abuse and severe and persistent mental illness Three or more emergency room visits or hospital admissions in the previous three months Age over 60 years HIV/AIDS Cirrhosis, end stage liver disease, or renal failure History of frostbite, hypothermia, or immersion foot
The Partnership joins Healthcare for the Homeless in recognizing the importance of communicating these risk factors to providers throughout the Commonwealth. Additionally, The Partnership strongly encourages acute care psychiatric and detox providers to notify HCH when encountering high-risk patients who are homeless in the Boston Region. Patients who are homeless and who present with one or more risk factors (without regard to health care insurance) may be appropriate for a pilot program offered through HCH. Call HCH at (781) 221-6565, and inquire about case management services available through the pilot program for these patients.

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