Discharge Planning: Preventing Chronic Homelessness
In the early period following deinstitutionalization, several states, including Massachusetts, Rhode Island, and New York, passed discharge-planning laws to address the service needs of the severely mentally ill discharged from hospitals to the community. In general, these laws mandated that comprehensive community care tailored to individual needs, including psychiatric outpatient treatment, an adequate living arrangement, and adequate economic and social support, be arranged before hospital discharge (New York State Mental Hygiene Law, Chapter 804, Section 29.15, subdivision 2f, g, h) (Caton et al., 1984). Despite early studies of discharge planning (Hogarty, 1968; Zolik et al., 1968) that revealed the benefits of a comprehensive discharge planning approach in reducing early rehospitalizations (Caton et al., 1984), homelessness as an outcome has not been assessed, and there is no evidence-based discharge planning intervention (Moran et al., 2005).
Discharge planning is an important element in the national effort to address chronic homelessness (Backer et al., 2007; National Alliance to End Homelessness, 2009). It is well known that homeless people with severe mental illness often experience admissions to institutional settings such as emergency departments, hospitals, correctional facilities, and shelters (Hopper et al., 1997). If they are released from institutional care without adequate housing, follow-up clinical care, income support, or rehabilitation services in the community, vulnerability to homelessness can persist. Discharge planning practices have been specified that underscore its multidisciplinary nature and the need for service coordination among institutional and community-based providers. Needs assessment is typically the responsibility of the institutional provider, who then must partner with housing programs and community service agencies to develop an appropriate service plan and set the stage for its implementation (Backer et al., 2007; Mangano & Hombs, 2002).
While there is considerable consensus on what good discharge planning should consist of, roadblocks to successful discharge planning include inadequate housing opportunities, a fragmented community service system, and lack of staff training. Moreover, discharge planning takes time, a precious commodity among overburdened institutional staff in real-world service settings (Backer et al., 2007; Moran et al., 2005). A major gap in conceptualizations of discharge planning is the lack of a procedure for follow-up after an individual leaves an institutional setting that could help guarantee that a discharge plan is adequately implemented. A brief version of critical time intervention (BCTI), in which a case manager works with an individual for a three-month period following discharge from a psychiatric hospital to ensure an adequate connection to community-based resources, has been shown to reduce early rehospitalizations (Shaffer et al., 2015) and facilitate greater service engagement and improved utilization of outpatient services post-discharge (Dixon et al., 2009). An intervention such as BCTI has the potential to also improve implementation of discharge planning for people with mental illness at high risk of homelessness.