Specialized Referrals
What you need to know about making referrals for clients with disabilities and clients who would benefit from convalescent and psychiatric care.
Benefits Referrals for Clients with Disabilities
At Health Care for the Homeless, we help people with disabilities access federal disability benefits such as SSI and SSDI. In order to receive assistance, these individuals must be:
- Over the age of 18
- Experiencing homelessness or at risk of homelessness
- Diagnosed with a mental illness by a psychiatrist or psychologist
- Exhibiting symptoms of severe mental illness or having symptomatic episodes that prevent them from sustaining employment
- Exhibiting functional impairments in at least three (3) of the following areas:
- Activities of daily living
- Social functioning
- Concentration, persistence and pace
- Understand, remember and apply information.
Through our SOAR (SSI/SSDI Outreach, Access and Recovery) program we work directly with individuals experiencing homelessness to help them obtain income and health insurance. And we provide our fellow providers in the community with the training, education and technical assistance they need to expedite federal disability benefit application approvals and the overall federal disability benefits process for vulnerable individuals.
For more information about training opportunities or to refer an eligible individual, call 443-703-1485 or email Tristan Roberts at troberts@hchmd.org.
Sarah
Sarah’s brother took her to the hospital emergency room after she told him she planned to overdose on sleeping medication, so she’d “never wake up.” Her affect was flat: She spoke in monotone and her facial expressions were neutral, betraying nothing. She had shown symptoms of depression for 10 years, and following her mother’s death in 2006, she became afraid to leave her house and had very little contact with people outside of her family. She often hears bells ringing and a harmonica playing when other people do not. Because she was suspicious of medical providers, Sarah never sought mental health care. And though she owned her house outright, she was at risk of foreclosure due to unpaid utilities, insurance and taxes.
Sarah was admitted to the hospital’s psychiatric unit and, once she had stabilized, her social worker referred her to Health Care for the Homeless. A specially-trained social worker helped her complete the application for disability benefits, and documented information about her symptoms and functional deficits to supplement her medical records. Sarah was approved for SSI and SSDI in 60 days.
Albert
Diagnosed with bipolar disorder and panic disorder, Albert consistently exhibited scattered thinking and was often in crisis when he met with his outpatient mental health therapist. He had been fired from jobs multiple times for forgetting instructions mid-task and for yelling at coworkers or supervisors after receiving feedback on his performance. His therapist referred him because his poor concentration and impaired social functioning prevented him from maintaining employment. After an initial meeting at Health Care for the Homeless to assess his eligibility for federal disability benefits, Albert missed his next six appointments for various reasons. Our staff ultimately completed his application and medical summary report with him over the phone and through the mail. Albert was approved for SSI four months after his referral.
Psychiatric Referrals
Our behavioral health therapists assess clients for psychiatric services at Health Care for the Homeless. You can make an appointment with a therapist by calling 410-837-5533.
A client typically meets with a therapist three times before being referred to psychiatry; these visits typically take a month to complete. Please consider this time period if you are discharging a client and need to calculate the number of days of medication they will need until their first visit with a psychiatrist.
Referrals for Convalescent Care
Find an informative guide here.
The Health Care for the Homeless convalescent care program provides people experiencing homelessness a safe place to rest and recuperate from acute illness or surgery. Clients often are released from the hospital before being fully recuperated. They may have difficulties with mobility, they may have open wounds or they may be unable to manage post-acute care instructions independently. They are physically vulnerable and have no place to rest during the day or to store supplies and medications. And they cannot fully recover from their illness on the street.
The convalescent care program is located in the Weinberg Housing Resource Center, Baltimore City’s largest public emergency shelter. Clients are able to rest 24 hours a day, while benefiting from nursing and social work services. Nurses provide health education, care coordination and outpatient nursing services 7 days a week, 7 a.m.-7 p.m. Health Care for the Homeless doctors stop in twice a week, and clients who do not already have a primary care provider are linked to the Health Care for the Homeless medical team for ongoing care. The social work staff assists clients with referrals to housing resources, with applications for identification and benefits and with mental health and addictions treatment.
To be eligible for the program, an individual must:
- Be experiencing homelessness
- Be at least 18 years old
- Have a short-term medical need with an identifiable end point
- Be independently continent, ambulatory, able to manage/administer medications and able to perform activities of daily living (bathing, dressing, eating, etc.)
- Be able to tolerate the lack of privacy which is inherent in the program’s dormitory-style living
- Be medically and psychiatrically stable
- Be willing to comply with medical orders and program rules
- Be coming from a Baltimore City or Baltimore County hospital or agency
We cannot accommodate clients who:
- Require IV lines or oxygen
- Need assistance with activities of daily living
- Are behaviorally disruptive
Considering a Referral?
Call the convalescent care referral line—410-598-6758, 7:30 a.m.-4 p.m., seven days a week—to discuss your client’s condition and whether this program is a fit for his or her medical needs. We will ask that you fax all pertinent patient information to us: 443-703-1117. You can find the referral form here. We will notify you of your client’s acceptance within 24 hours.
Joseph
Joseph was living under a bridge and working outside until prolonged exposure to the winter cold resulted in frostbite on his hands and feet. He was referred by a local hospital to the Health Care for the Homeless convalescent care program, where he was able to stay while getting the care he needed to avoid amputation and heal. Program staff referred Joseph to a transitional housing program. They also connected him to primary medical care at Health Care for the Homeless, so he could address chronic health conditions he had long been neglecting.
Anthony
Anthony was staying at a residential employment program and actively seeking a job when he suffered a stroke that left him permanently disabled in his mid-40s. He lost his spot in the program due to his inability to work, and was referred by a hospital to the Health Care for the Homeless convalescent care program. Here, the nurses helped him manage his new medical conditions (including being on Coumadin, a blood thinner that requires frequent monitoring), and a social worker helped him adjust psychologically to being disabled at such a young age. Staff also helped him secure insurance, which allowed him to start a physical therapy program that had been delayed due to his lack of insurance. Anthony left the convalescent care program for a transitional housing program for individuals with disabilities.
Warren
Most of Warren’s family members are deceased, so when he became acutely ill with liver disease and was no longer able to work, he had no support and nowhere to go. A referral to the Health Care for the Homeless convalescent care program allowed him to recover from his liver disease, while also getting help for cognitive problems that resulted from a related chemical imbalance. Nurses and social workers helped Warren stabilize medically and regain most of his cognitive functioning; they also helped him apply for federal disability benefits. He was discharged to an assisted living program where he will live until he is approved for disability or able to go back to work.