Discharge Planner's Toolkit

The purpose of this project is to develop, implement, and pilot an adaptable, dynamic, real-time discharge planner’s toolkit. The toolkit is intended to facilitate coordination between discharge planners in Behavioral Health crisis stabilization organizations (pilot underway and substance use treatment facilities (pilot in very early planning stage) and the networks of housing and service providers operating in Washington to assist people experiencing or at risk of homelessness. It is also intended to help discharge planners and individuals across the state understand and identify possible options in the private housing market when possible and appropriate.

Checklist

Items or resources individuals may need in place for a successful discharge or to help facilitate warm handoff.

  1. Does the person you are working with have an ID or Social Security card?

  2. What kind of resources does the person have/had in place?

    An individual’s resources may be suspended or terminated while in an institutional setting. This information is intended to assist the D/C planner but not intended as an eligibility determination tool.

  3. Does the person you are working with have Medicaid?

Housing choices

Choice in housing is fundamental to recovery. The following questions may help match the person to the environment the need for success. There are many types of housing. This is meant to help the discharge planner have a conversation with the individual to identify the type of housing they may desire.

Scatter-site housing - housing throughout a community rather than being concentrated in a single neighborhood which allows for community integration.

Oxford housing - Oxford Houses of Washington State is a group of self-run, self-supported recovery houses that provide an opportunity for every recovering individual to learn a clean and sober way of life.

Project site housing - publicly built and operated housing development, usually intended for low - or moderate-income tenants, senior citizens, or other set aside populations.

Single-site housing - housing projects owned by service providers where services are provided on site.

Transitional housing - a housing project that is designed to provide housing and appropriate supportive services to homeless persons to facilitate movement to independent living.

Sober living houses - housing can provide a nonprofessional, clean and sober living space for someone who is not ready to live on their own, or back at home yet.

Tiny home villages - tiny houses can provide an affordable tool for combating homelessness by getting people off the streets and into their own space.

Hotel - a hotel is an establishment that provides paid lodging on a short-term basis.

Motel - an establishment which provides lodging and parking and in which the rooms are usually accessible from an outdoor parking area.

Shared living - situation in which two or more unrelated persons live together as a “family of choice” where each has some private space (usually a bedroom) while sharing common areas such as kitchen, living and dining rooms and outside yard areas.

Master leasing - it is a lease that allows an existing lessee to lease additional assets under similar terms and conditions without negotiating a new contract to the current lease.

Shelter - homeless service agency which provide temporary residence for homeless individuals and families

For more information about types of housing and addressing the housing shortage please go to ezview.wa.gov/site/alias__1976/37311/default.aspx.

Linking individuals to housing resources and supports

Please complete the following questions and follow the prompts for each answer.

  1. Is the individual currently in an inpatient setting such as a community psychiatric hospital, evaluation and treatment facility, substance use treatment facility and in need of housing resources upon discharge?

  2. Prior to admission, where has the individual lived the most in the previous 12 months?

    The location may impact services/resources the person is eligible for.

  3. Where does the individual plan to stay after leaving the current setting?

  4. Does the individual feel safe in returning to previous location?

  5. If the previous living situation was healthy/safe but they owe back-rent, could the individual return to previous housing if arrears were paid?

  6. Is living with family members/friends a safe/healthy option that supports recovery?

  7. Did they serve in the military?

  8. Does the person want to live on their own?

  9. Does the person need support to accomplish activities of adult daily living (bathing, cooking, showering etc.) to live independently?

Resource region and supplemental pamphlet

Selected regions Leave blank to show results for all regions. To select multiple regions, you can hold down the Control key and click on multiple regions. If you need to un-select a region, you can hold down the Control key and then click the region you would like to un-select.

Discharge planner: Please print out the Integrated behavioral resources pamphlet for the client also.

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