The Homeless Consult Services program is designed to support all patients who may benefit from assistance with housing-related challenges. Its goal is to reduce repeat emergency department visits, hospital readmissions, and length of stay by helping patients access appropriate follow-up care and community resources. It also provides UVA medical students with valuable experience in addressing health-related social needs and supports care teams in developing treatment plans that reflect a patient’s living situation and available resources.
The Homeless Consult Service program 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.
This program assists with a smooth transition of care upon discharge by:
- Finding appropriate placement for discharge
- Providing continuity of care
- Connecting the patient to unhoused health services in the area, including The Haven and Premier Clinics
- Identifying challenges to care and working to address them by offering to connect patients with community resources to help with obtaining housing, Medicaid, food/groceries, financial assistance, transportation, durable medical equipment, cell phones, IDs, clothing, and more.
- Increasing trust and healthcare satisfaction
Referrals and Follow-up Process
Currently, admitted patients can be referred to the program when the primary team or unit social worker identifies an unhoused patient. Once the Homeless Consult Service team is notified, one of the trained student volunteers from the team will visit the patient and thoroughly assess for factors impacting health outcomes and care plans, including challenges related to follow-up care. The student volunteer then coordinates with social work and Population Health's post-acute care teams to address follow-up needs and connect the patient with community resources.
The Homeless Consult Service program is currently coordinating with hospitalists, General Medicine and Family Medicine teams, Social Workers and Case Managers, and the Population Health Case Management team to improve care coordination for patients experiencing being unhoused in Charlottesville.
