Advancing the Care Continuum for the Homeless: A Shelter-based Care Coordination Project Focused on Mental Health

Advances in the care continuum are crucial for those with serious mental illness, especially those homeless individuals in the community. Schizophrenia is a leading cause of re-hospitalization and disability, accounting for billions of dollars spent in the United States. A prominent city shelter reports the prevalence of schizophrenia among its guests, and the community recognizes homeless shelters as the greatest source of 911 calls with countless surrounding emergency department visits. This project’s purpose is to implement a shelter-based, internal process to identify these high-risk guests and increase their subsequent care coordination services. Outcomes reflect individual benefits with increased shelter-based contacts and a facility-wide significant decrease in overall 911 calls. Further descriptive results indicate the value of post-hospitalization guest follow-ups in regard to diminishing healthcare disparities. The future implications of this project include prevention of excessive healthcare usage, community cost savings, and better mental health outcomes.