Care Transitions
Mental Health Matters: A Social Worker's Perspective on Care Transitions
May 20252 min read
SilverStay works with thousands of patients including some that are experiencing experienced homelessness and housing instability.
Vijay VarmaSeptember 20232 min read
SilverStay works with thousands of patients being discharged from the health system each year to identify appropriate care and housing options. Many of these patients do not have assets, funds, or even the support of family members to lean on during such a significant transition. Additionally, some of these patients have also experienced homelessness and housing instability.
In hospitals, the work to identify discharge solutions for these patients often falls on social workers who are overburdened and may not have resources and time to identify appropriate community housing and care options.
SilverStay has partnered with hospitals in Baltimore City to develop an innovative model that connects homeless patients at the hospital with assisted living facilities (ALFs). This model quickly discharges homeless patients with significant short- and long-term care needs to ALFs that can provide a high quality of care at a cost well below the daily cost of a hospital stay. SilverStay has successfully transitioned hundreds of patients with housing instability, producing significant hospital cost savings, reduced Emergency Department utilization and 30-day readmissions, and reduced hospital length of stay (LOS).
Almost every urban hospital across the US is facing the challenge of how to manage the cost of care and service delivery for an aging homeless population. SilverStay is excited to be at the forefront of innovating in this area.
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