Health system-based housing navigation for patients experiencing homelessness: A new care coordination framework

Advancing social risk‐informed care for people experiencing homelessness

“…This process starts with awareness, the first component of the framework defined as “activities that identify the social risks and assets of defined patients and populations.” This routine social risk screening is supported by multiple professional medical societies and is newly included as a quality measure by the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission for a variety of quality reporting and accreditation programs. To operationalize this approach, care teams must develop strategies to identify PEH and persons at risk for homelessness in their patient populations, which is currently done inconsistently in hospital settings 9,10 . Teams can use one of several commonly used, population‐specific tools to screen and document their patients' housing‐related risks—such as current or anticipated housing instability and current problems with housing quality (e.g., pests and mold) 11 .…”

“…Other high‐touch assistance interventions include referring patients to support staff, such as community health workers, who can connect patients to community‐based organizations, government services, or in‐house support services (e.g., clinic‐based food pantry). Care teams can also refer PEH to housing navigators—when available, as done at Vanderbilt University Medical Center—who can, in turn, link patients with community‐based case managers and, if patients qualify and units are available, to supportive housing 10 . Hospitals could also consider creating consult teams specifically for PEH to help coordinate the tailoring of services to these patients.…”

“…To operationalize this approach, care teams must develop strategies to identify PEH and persons at risk for homelessness in their patient populations, which is currently done inconsistently in hospital settings. 9,10 Teams can use one of several commonly used, population-specific tools to screen and document their patients' housing-related risks-such as current or anticipated housing instability and current problems with housing quality (e.g., pests and mold). 11 For example, the Accountable Health Communities Screening Tool was designed to help care teams understand if patients did not have a steady place to live (e.g., temporarily staying with others); it is meant to be used in clinical delivery sites, including hospitals, and was recently introduced by the CMS.…”

“…19 e.g., clinic-based food pantry). Care teams can also refer PEH to housing navigators-when available, as done at Vanderbilt University Medical Center-who can, in turn, link patients with community-based case managers and, if patients qualify and units are available, to supportive housing 10. Hospitals could also consider creating consult teams specifically for PEH to help coordinate the tailoring of services to these patients.…”