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Massachusetts Resources for People without Homes
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Discharge Planning Process and Protocols

Appropriate discharge planning for individuals who are homeless requires aggressive and exhaustive efforts on the part of all treatment team members and discharge planners in particular. At a minimum, the following steps should be completed as a routine part of the discharge planning process for each member who is homeless (and documented in the member's medical record):
  • Attempts to identify and contact family members and other support systems in the member's community
  • Immediate notification of the DMH Homeless Outreach Team (HOT Team) for all individuals who are DMH clients
  • A DMH referral of any patient who is likely to meet the criteria for DMH services
  • Referral to the Partnership's Intensive Clinical Management program
  • Initiate contact with The Road Home
  • When an acute care treatment team has determined that a brief extended acute care or detox stay is necessary for the safe transition of a homeless patient to an appropriate discharge placement, the facility should formulate and present the request, with time parameters, to the Partnership for review and approval.
  • Except in cases of documented competent refusal of alternative options by a patient, or exhaustion of all reasonable means to arrange for a non-shelter placement, a discharge to a homeless shelter or "the street" is considered a clinically inappropriate outcome of the discharge planning process. Under such circumstances, the discharging facility must ensure the availability of optimal post discharge support and clinical care. The facility must document in the medical record all efforts made to identify and offer alternative options and shall keep a record of all such discharges.

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