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Licensed Hospital Homeless Discharges 

Please report daily if there has been a discharge of a person to a shelter (in any state) or the street. This report replaces the monthly reporting of the numbers of discharges to shelters or the street. 

Please choose your hospital name carefully from the drop down menu, then enter the specified information for each individual who was discharged to the street or to a shelter. We will eventually provide a drop down menu for the most frequently entered names of shelters as we gather this data from hospitals.

Thank you for helping us to better understand the details involved so that we can work with hospitals and with others in state agencies to reduce the frequency of such discharge dispositions. Please also see the Homelessness Prevention Discharge Planning Decision Tool [link to website when ready] for resources that hospitals can use to better plan discharges for people who are housing insecure.

Please note this survey is being conducted in a HIPAA compliant environment.

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* 1. Hospital

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* 2. Unit Type

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* 3. Date of Admission

Date

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* 4. Date of discharge

Date

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* 5. Name of person discharged to shelter/street (Last, First)

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* 6. Date of birth

Date

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* 7. Gender

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* 8. Race

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* 9. Is the person enrolled in MassHealth?

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* 10. Name of shelter or Street discharged TO (If shelter is not listed please email bobbi.spofford@mass.gov for guidance.)

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* 11. Living situation on admission

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* 12. If in Shelter prior to admission select shelter from list. (If shelter is not listed please email bobbi.spofford@mass.gov for guidance.)

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* 13. Are there any agencies providing case management or support services to this person? Select all that apply.

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* 14. Which agencies were contacted as part of the discharge planning? Select all that apply.

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* 15. If the person is enrolled in a MassHealth Managed Care Plan did you contact the plan's designated Point of Contact for discharges of homeless individuals?

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* 16. If the individual is enrolled in a MassHealth managed care plan did you request that the plan provide additional administrative day rate payments to allow the person to stay at your hospital longer and find a place to be discharged that was not the shelter or street?.

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* 17. Other outcomes related to discharge planning with other agencies.

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* 18. Did the person submit a three-day notice or was found not committable?

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* 19. Did you call the shelter and confirm there was a bed prior to discharge?

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* 20. Was the shelter given 24hours notice of discharge?

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* 21. Was transportation provided to shelter?

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* 22. Was the discharge during daytime hours?

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* 23. Did you provide the person a meal prior to discharge?

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* 24. Did you ensure the person is wearing weather appropriate clothing and footwear?

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* 25. Did you provide the person with a written copy of all prescriptions and at least one week’s worth of filled prescription medications?

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* 26. Notes

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* 27. Email address of person completing form:

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