Homeless Consult Service

The Homeless Consult Service aims to reduce subsequent ED visits, repeat admissions, and length of stay in the hospital and increase lower cost health utilization, such as outpatient visits. In addition, the program serves to provide hands-on experience with Social Determinants of Health for UVA medical students and helps the inpatient team understand how homelessness affects an individual's care and treatment plan.

The Homeless Consult Service was started by Jacqueline Carson, UVA MD/MPH Candidate 2022, as a pilot program with the Medicine and Family Medicine Teams on the 3rd floor of UVA Medical Center. The service has since been expanded hospital-wide. The goal of the Homeless Consult Service is to establish relationships with patients who are experiencing homelessness and to arrange for a smooth transition of care upon discharge by:

  • Finding an appropriate placement for discharge
  • Providing continuity of care
  • Connecting the patient to homeless health services in the area such as The Haven and Premier Clinics
  • Identifying barriers to care and attempting to mitigate them by offering assistance in obtaining housing, Medicaid, the Supplemental Nutrition Assistance Program (SNAP), financial assistance, transportation, durable medical equipment, cell phones, IDs, clothing, etc.
  • Increasing trust and health care satisfaction

Referrals and Follow-up Process

Currently admitted patients can be referred to the program when the primary team or unit social worker identifies a patient who is experiencing homelessness. Once the Homeless Consult Service team is notified, one of the trained student-advocates from the Homelessness Consult Service team will visit the patient and complete a thorough assessment of social determinants of health including the patient’s barriers to follow-up care. The student-advocate then coordinates with social work and Population Health’s Interactive Home Monitoring (IHM) team to address follow-up needs and connect the patient with resources.

The Homeless Consult Service is currently coordinating with hospitalists, General Medicine and Family Medicine teams, Social Workers and Case Managers, and the Population Health IHM team to improve care coordination for patients experiencing homelessness in Charlottesville.


    Charlotte Badenhop, AS, CMA

    Lead Population Health Case Manager

    Darcy Baker, BA, COTA/L

    Population Health Case Manager