Medical Respite Program Policies and Tools

This section includes a carefully selected sampling of respite-specific policies and procedures, and programmatic forms which you are welcome to use and adapt to your own needs. These are organized into the following broad categories: policies and procedures; referral/screening forms; intake/admission; forms used during stay; and miscellaneous. All of the documents are either in Adobe or Microsoft Word formats. If you have any questions or suggestions about these tools, or if you are willing to share some from your own respite program, please contact Sabrina Edgington at sedgington@nhchc.org.

Policies and Procedures

Policies and Procedures Manual | McInnis House (Boston, MA)
Program Guidelines | JWCH Institute, Inc. Recuperative Care Program (Los Angeles, CA)
Sample Infection Control Policies | McInnis House (Boston, MA)

Referral/Screening Forms

Initial Screening Form | Homeless Health Care Los Angeles
Referral Form | COTS Mary Isaak Center (Petaluma, CA)
Referral Form | Health Care for the Homeless Network (Seattle, WA)
Referral Form | McInnis House (Boston, MA)
Referral Form | JWCH Institute, Inc. Recuperative Care Program (Los Angeles, CA)

Intake/Admission

Admission Agreement | Homeless Health Care Los Angeles
Client Information Form | Health Care for the Homeless Network (Seattle, WA)
Referral/Intake Form | Health Care for the Homeless Network (Seattle, WA)
Admission/Discharge Form | Samaritan House (Denver, CO)
Intake Form | Homeless Health Care Los Angeles
Admission Check List | McInnis House (Boston, MA)
Intake and Assessment Form | McInnis House (Boston, MA)
Routine Admission Orders | McInnis House (Boston, MA)
Employment and Support Assessment | Homeless Health Care Los Angeles
Family and Social Relationship Assessment | Homeless Health Care Los Angeles
Psychiatric Status Assessment | Homeless Health Care Los Angeles
Addiction Severity Index | Homeless Health Care Los Angeles
Psychiatric Evaluation | Harmony House (Houston, TX)
Medical Diagnosis | Harmony House (Houston, TX)
Patient Admission Agreement| Health Care for the Homeless Network (Seattle, WA)

Forms Used During Stay

Episode Form | San Francisco Medical Respite Program
Discharge Summary | Health Care for the Homeless (Baltimore, MD)
SELPH Living Will | Song, J., Ratner, E.R., Wall, M.M., Bartels, D.M., Ulvestad, N., Petroskas, D., West, M., Weber-Main, A.M., Grengs, L., & Gelberg, L. (2010). Effect of an End-of-Life Planning Intervention on the completion of advance directives in homeless persons: a randomized trial. Annals of Internal Medicine, 20(2): 76-84.
Self Management Support Tool/ Healthy Changes Plan

Job Descriptions

Nurse Manager | San Francisco Medical Respite Program
Medical Director | San Francisco Medical Respite Program
Medical Evaluations Assistant | San Francisco Medical Respite Program
Health Worker | San Francisco Medical Respite Program
Convalescent Care Manager | Health Care for the Homeless (Baltimore, MD)
Convalescent Care Clinical Case Manager | Health Care for the Homeless (Baltimore, MD)
Licensed Practical Nurse | Health Care for the Homeless (Baltimore, MD)
Behavioral Health Consultant | Health Care for the Homeless (Baltimore, MD)
Social Worker | San Francisco Medical Respite Program

Additional Policies and Clinical Tools

Additional policies and clinical tools including those more general to homeless health care provision, are in the Clinical Tools and Support section of our website.

 

DISCLAIMERS

Copyright status: Unless stated otherwise, these documents and files are in the public domain, and can be freely downloaded and reproduced.

Liability: Neither the National Health Care for the Homeless Council nor any of its employees assumes any legal liability or responsibility for accuracy, completeness, or usefulness of any information, apparatus, product, or process disclosed, or represents that its use would not infringe privately owned rights.