Piloting a housing support navigator program at a safety net hospital

OBJECTIVES: Homelessness is associated with poor health outcomes and increased healthcare utilization. The existing roles of social workers and case managers often are inadequate in addressing the complexity of patients' housing-specific needs. Our intervention aimed to pilot a novel housing support navigator (HSN) role within the existing electronic medical record workflow at one large safety-net hospital. 

METHODS: This innovation encompassed 877 adult patients with defined housing needs at Grady Health System (GHS), a large academic safety-net hospital in Atlanta, Georgia. All social workers and community health workers at GHS were surveyed to quantify the demand for housing resources, prioritize housing needs, and elucidate current barriers to housing placement. These results informed the creation of a new HSN role that could use the regional Homeless Management Information System to evaluate the housing needs of referred patients and connect them to community resources. All referrals to the HSN were tracked over the period 2021- 2022. A point-in-time count was subsequently conducted at GHS to capture patient needs and characterize the extent of sheltered and unsheltered patients experiencing homelessness. Program evaluation included descriptive data from each HSN referral documenting demographic data and discharge location. 

RESULTS: Nearly half of the patients referred to the HSN were connected with a housing resource such as a nonprofit organization, shelter, or rooming house. Key challenges in piloting the HSN program included management of timely referrals during brief inpatient stays and securing buy-in from stakeholders. 

CONCLUSIONS: This early innovation report hopes to inform other institutions aiming to incorporate a housing navigator role into their care for unhoused patients. Future studies will assess for the impact of HSN utilization on long-term patient outcomes and healthcare utilization.