Background: Our institution serves counties where more than 10,000 people are currently unhoused. This is reflected in our patient population, where 6% of patients admitted to the hospital medicine service at any time are unhoused. These patients face challenges such as higher readmission rates, longer lengths of stay, limited access to critical medications, and difficulties accessing care after discharge. Such patients require comprehensive support to transition safely from the hospital to a stable environment conducive to recovery and continued care. Recently passed state legislation requires hospitals to provide appropriate discharge planning and assistance for unhoused patients to transition to the community. Assessments reflecting the progress towards these goals are not readily available. As such, we aim to obtain data relevant to the outcomes of unhoused patients. This analysis will guide interventions aimed at improving their care and reducing readmissions.
Methods: Per standard of care, unhoused patients were identified by the registration process during inpatient admission. Manual chart analysis for patients was conducted. Key metrics assessed include risk classification for housing needs, rates of consults to Social Work, rates of medications to bedside, rates of primary care appointment scheduling, distribution of discharge locations, and 30-day readmissions to our institution. Protected Health Information was stored in a secure online database, and data analysis was conducted using Excel.
Results: From January to June 2024, we tracked 140 unhoused patients across 169 unique encounters on the hospital medicine service. Only 49% of patients were initially identified as high risk for housing needs. 99% of patients subsequently received consult to Social Work services. 36% of these patients received medications to bedside prior to discharge and 9% of unhoused patients were discharged with a primary care appointment scheduled. 29% of patients returned to the street, 27% to shelters, 23% to skilled nursing facilities, 13% reported going “home” (reflecting non-traditional discharge locations such as family/friend residences, motels, church parking lots, etc.), 5% to sober living, 2% to a mental health facility, and 1% to medical respite. Ultimately, 24% of inpatient stays for unhoused patients resulted in readmission to our institution within 30 days.
Conclusions: Preliminary data highlight gaps in the care transitions of unhoused patients. Specifically, only 49% of unhoused patients were accurately flagged as high risk for housing needs, underscoring the limitations of current screening workflows. Despite high needs, just 9% of unhoused patients were discharged with a scheduled primary care appointment, and only 36% received medications at bedside, indicating persistent gaps in the discharge planning process. Additionally, a significant number of patients (29%) returned to the street, with another 13% returning to unstable environments. Ultimately, the rate of 30-day readmissions (24%) signals the need to strengthen care transitions. Future work will aim to improve care for unhoused patients and reduce readmissions using a three-pronged approach: integrate EHR-tools to improve identification and tracking of unhoused patients; create staff training and education on best practices; and collaborate with interdisciplinary teams to ensure proper deployment of available resources.
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