Institutional Referral Guide for Shelters

• Shelters must review the referral and respond to the hospital within one day with questions or clearance to discharge.

  • If shelter does not respond in one day, hospital can discharge to assigned shelter.

• Shelters should review for:

  • Activities of daily living (ADL) 

  • Absolute medical exclusion criteria

  • Services in place to mitigate (reduce) risk for chronic conditions

• Medical staff at the shelter or in the organization should be assigned to review hospital referrals, if available.

  • If no medical staff is available, the shelter Director or Social Service Director should review the referral.

• If patient is medically appropriate for shelter:

  • Ensure client has necessary services in place to support stability in shelter:

    • Follow-up outpatient health care scheduled

    • Mobile mental health program if needed:

      • Shelter Partnered ACT

      • Safe Options Support (SOS)

      • Care Coordination, or other

• Coordinate with hospital to reserve bed one day before confirmed discharge date

  • If no bed is available, inform the hospital to hold the patient until a bed opens up, or client may be reassigned to a vacant bed

Learn more in the Hospital Discharge Coordination training slides.

• If you have a high-need client who is hospitalized, start advocating for the necessary care on the day they go to the hospital:

  • Call the hospital (emergency room) to let them know your client is in the hospital 

  • Explain the danger to self or others, or inability to care for themselves in detail

  • Ask them to admit the client

• Remain in contact with hospital while in-patient to ensure client gets care and treatment they need to remain stable in shelter:

  • Set up appropriate follow-up care

  • Submit applications for SPACT or AOT if needed

  • Simplify medication regimens if client has trouble managing

• If the client needs a higher level of care, begin advocating for discharge to another placement than shelter immediately upon admission.

Learn more in the Hospital Discharge Coordination training slides.