The Unhoused Consult Service program aims to reduce subsequent ED visits, repeat admissions, and length of stay in the hospital and increase lower-cost health utilization. In addition, the program provides hands-on experience with social drivers of health for UVA medical students and helps the inpatient team understand how being unhoused affects an individual's care and treatment plan.
The Unhoused 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. The goal of the Unhoused Consult Service program is to establish relationships with patients who are experiencing being unhoused.
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, the Supplemental Nutrition Assistance Program (SNAP), 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 Unhoused 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, 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 Unhoused 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.
