Montefiore Medical Center's Housing At Risk Program

Montefiore Medical Center: Housing at Risk Program

Overview The Housing at Risk program is designed to provide coordinated health and housing support to a vulnerable population in the Bronx.  As part of a larger Montefiore initiative to support people with complex needs, we have been able to test a variety of interventions as well as improve multi-professional teamwork both within and outside the institution.  Through this work, Montefiore is better able to position itself as an ACO Accountable Care Organization and Health Home and vulnerable patients get more intensive and effective interventions.  Often, interventions and processes that are tested through this program are spread to other Montefiore programs that work with people with complex needs. 

The purpose of the Housing At-Risk Patients Program includes:

• Provide appropriate care in the appropriate setting
• Link patients to PCPs/medical homes
• Avoid social, clinically unnecessary ED visits, admissions and decrease LOS
• Link to community services for f/u and case management, often via case conferences

The key interventions and activities include:

• Identifying people who are unstably housed (street homeless, shelter homeless, staying with others, losing their housing, inappropriately housed, etc) at the point of ED registration
• Alerting the ED Social Workers, patient navigators and others with information about the patient in real time.  They, in turn, discuss cases with ED physicians as needed.
• Alerting HAR teams of ED visits, admissions and discharges to facilitate follow up
• Supporting the ED Social Worker to discuss the patient’s needs and refer as appropriate
• Improving multi-disciplinary teamwork in the ED for this patient
• Improving hand offs to inpatient social work when admitted
• Improving hand offs to shelters, the Living Room, PCPs and others when needed
• Multi disciplinary case conferencing to create care plans and information flows to support their use
• Identifying and supporting effective interventions
• Monitoring changes to ED utilization, admissions, AMA rates, housing status, etc

Key challenges include:

• Working across disciplines and services within the hospital and across organizations to support patients
• Working with patients who are wary of interventions and uncooperative
• Finding services for people in need
• Avoiding the term “homeless” as patients often react negatively to this label

Key benefits include:

• Appropriate decrease in admission rates over time
• Improved relations with BronxWorks that lead to smooth community referrals
• The satisfaction of providing temporary and permanent housing for formerly homeless patients
• Multi-disciplinary working and learning to expand available ideas and resources