Several months ago, the Network’s Individual Services Committee began planning for systematic outreach to area institutions to address the shared challenge of discharging homeless individuals.  The Committee agreed to focus its first round of outreach on medical and psychiatric institutions, as well as nursing homes and rest homes.  On October 28, our first meeting took place and was hailed as a great success by all,  with over 30 representatives from both shelters and area institutions attending, including representatives from each of our four counties.  The minutes of this meeting are below.  Congratulations to the coordinated efforts of our Individual Services Committee members for making this initiative happen!

Discharge Planning Meeting – October 28, 2010

In attendance:  Pam Bennett, Berkshire Community Action Council, Heather Biernacki, Berkshire Medical Center, Dave Christopolis, Berkshire Community Action Council/Berkshire CoC, Danielle DeBerry, Grove Street/Interfaith Cot Shelter, Doreen Fadus, Mercy Hospital/Health Care for the Homeless, Susan Fortin, Department of Mental Health, Dave Havens, Mental Health Association, JP Hennessey, Community Support Options, Peg Keller, City of Northampton, Marla Killough, Baystate Franklin Medical Center, Rose Knapik, Cooley Dickinson Hospital, Jenifer Lucca, Samaratin Inn, Nicole Marceau, Noble Hospital, Dave Modzelewski, Department of Mental Health, Maureen Normand, Smith College intern, Joan O’Meara, Cooley Dickinson Hospital, Claudia Phillips, Mercy Medical/Health Care for the Homeless, Martin Pope, Bay State Medical Center, Jerry Ray, Mental Health Association, Sherri Ryan Mann, Berkshire Medical Center, Paul Santolini, Bay State Medical Center, Joe Schroeter, Samaratin Inn, Pamela Schwartz, Network coordinator, Nina Slovik, Noble Hospital, Amy Swisher, Baystate Franklin Medical Center, Mark Warren, Brien Center, Kevin Weir, Mass. Behavioral Health Partnership, Nancy Wyman, Berkshire Medical Center

Pamela summarized what and who the Network is and how we got to this point of hosting a meeting to develop better collaboration around the challenges  of discharging homeless individuals.

We shared what brought us here today, including:

  • Seeing people discharged to the streets with complicated medical issues who are clearly not best taken care of in a shelter;
  • Need to know  possibilities as cold weather approaches.  People are ready to be discharged, nowhere to go – heart strings say can’t put out in cold, bottom line and need for bed space says we need to let them go
  • Desire  to fine tune the steps that could be taken prior to discharge to avoid shelter; create a workable process for everyone involved
  • Build a better understanding of resources that are out there so best match-up of individual needs and services can be made
  • Challenge is to start working on support services right away in institution so support can happen upon release to shelter
  • Looking for better communication, better collaboration; need to get housing planning going
  • Mandate is narrow lens through psychiatric issues.  Frequently, homeless patients don’t have psych issues.  CSP doesn’t always show up.  Can’t keep them longer b/c disposition is an issue – other people knocking on doors.
  • Need to get involved with housing issue on day one – even before, with crisis team.
  • Network is about systems change.  Network could offer a way to come up with new solutions.  Is there a resource in our community to create a liaison to facilitate discharge planning in a consistent
  • Need to also take stock of interpreter services.  It’s a big gap.

Kevin Weir, Mass. Behavioral Health Partnership (manages primary care plan for MassHealth) announced new initiative:  psych and detox inpatient units will be required to have community support provider (CSP) come to each adult patient to offer community support services to facilitate aftercare for transition to community.  This is an exciting development!  The burden is now on CSP providers to hire fast enough – money is not the issue but staff resources are.  Kevin will provide list of CSP programs in western Mass. and we agreed we would invite CSP workers to next meeting.

Discharge Guidelines Review:

Click here for the draft guidelines under discussion.

Add to #3 (information to exchange between institution and shelter regarding at-risk individual);

Follow-up appointments?
Do they have a CSP worker?
Medical treatments that have to be done?  E.g, dressing changes
Do they have insurance?  What kind?  If not MBHP, can change easily to MBHP so can receive CSP services.
What providers have they worked with before?

Change 5 days notice prior to discharge to “as soon as possible”

Vulnerability Index

Jay Levy proposed using the vulnerability index – produced by Health Care for the Homeless – a tool for measuring risk to unsheltered homeless individuals.  Click here to review it.  Variables such as age, tri-morbidity, recent history of attendance in emergency rooms, history of frostbite.  Jay will send to Pamela and Pamela will relay out.  Can also find it at

Network Resource Directory

Pamela distributed an updated resource directory that now includes emergency shelters in the region. Please review and edit or add as needed – this is a constant work in progress!  Click here to obtain a copy.

Join the Network Blog!

To stay updated on Network developments, including access to a continually updated resource directory, Pamela encouraged all attendees to subscribe to the Network’s blog.  Go to to subscribe.

Next steps:

  • Invite CSP workers to next meeting:  Kevin Weir, JP Hennessey and Joan Meara will lead the charge on this.  Kevin will contact CEOs of CSP providers.
  • Create a quick list of relevant agencies for referral use:   Kevin Weir, Jay Levy, Dave Havens, Dave Modzelewski and Maureen Normand will comprise the sub-group responsible for bringing back this list for larger group review at the next meeting.  Everyone will send recommendations of who they feel should be on there  to Kevin at [email protected].  Jay and Dave M. will coordinate the follow-up.
  • We will also reach out to senior services – please send to me names and email addresses of those who should be added.
  • Janice Humason will revise the discharge planning guideline to reflect the discussion and Pamela will recirculate the revised version prior to the next meeting.

Next meeting:

Thursday, December 9
10 am – 12 noon
Northampton Senior Center
67 Conz Street, Northampton

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