Providing homeless or housing insecure individuals with transitional supportive housing after a hospitalization was a key focus area under DSRIP and began with Project 2.b.vi Transitional Supportive Housing Services. This project focused on increasing access to safe transitional supportive housing and services which would allow for the high need individual to rehabilitate and stabilize in the community instead of being re-admitted to the hospital due to their housing instability. Many of these individuals also have behavioral health disorders that can contribute to patterns of high utilization of emergency and crisis services.
We continued convening a multi-sector housing workgroup after the project was completed to strategize on the development of solutions as there continued to be a high need for post-acute beds for housing insecure individuals. Homeless individuals were discharged to emergency shelters which were not designed to adequately manage complex medical and behavioral health conditions or address the post-acute needs of these individuals.
A Transitional Supportive Housing in Emergency Shelters pilot was launched to improve collaboration and coordination between clinical and non-clinical providers and to better address the post-acute needs of housing insecure individuals. The program operationalized a new care pathway (see below) and resulted in a reduction of hospital utilization, increased use of primary and behavioral health care services, and increased housing stability.