Online Program

Montefiore Medical Center's Housing At Risk Program

Monday, November 2, 2015

Deirdre Sekulic, LCSW, Department of Social Services, Montefiore Medical Center, Bronx, NY
Bernice Asamoah, MPH, Department of Social Services, Montefiore Medical Center, Bronx, NY
Margaret Williams, LMSW, Department of Social Services, Montefiore Medical Center, Bronx, NY
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

Learning Areas:

Other professions or practice related to public health
Social and behavioral sciences

Learning Objectives:
Describe the Housing at Risk Alert system for identifying patients who are unstably housed. Explain the impact of homelessness on a patients health and access to care such as transplants List the number of unstably housed patients found in the hospital system Demonstrate how the program works and tracks patients from the emergency room to inpatient and through discharge. Assess how the program has impacted patients access to care and overall health Discuss the techniques that hospital based staff are having to employ to try to house patients. Identify gaps in available housing to medically ill patients Forumlate a plan for future Supportive Housing Needs

Keyword(s): Homelessness

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am the assistant director of social work at Montefiore Medical Center and run the Housing At RIsk Program. I create and collaborate with community partners within the Bronx to find and link patients to appropriate Supportive Housing. I work closely with the New York City Department of Homeless Services.I also educate all new hospital staff on how to identify unstably housed patients.I oversee a staff that directly places patients into Supportive Housing.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.