Implementation and qualitative evaluation of an innovative social work-led intervention for patients experiencing homelessness

People experiencing homelessness (PEH) access health services at higher rates than their housed counterparts, with higher rates of hospitalization and emergency department (ED) visits, excess hospital readmissions, and longer lengths of stay resulting in higher costs to the medical system. 

Implement a tiered social work-led housing transitions team (HTT) at an academic medical institution to (1) direct medical and community-based resources appropriately toward those with the most intensive needs, and (2) Improve the patient and provider experience.

The program consisted of three full-time social workers and one social work leader. Duties included liaising with community partners, building a repository of community resources for use by other social workers within the institution, providing individualized support for social work colleagues on specific patient-related housing issues, and following a subset of referred patients directly as the primary social work contact. Examples of community resources to address patients' immediate needs included emergency shelters, crisis mental health centers, substance use treatment facilities, and transitional housing.