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. 2022 Dec 14;12(12):e065688. doi: 10.1136/bmjopen-2022-065688

Table 1.

Examples of main activities of Homeless Outreach Counsellors

Category Examples
1. Connection to community-based providers
  • Referral to case managers, housing workers, harm reduction services, and shelters.

2. Patient advocacy during hospital stay and discharge process
  • Link to addiction and harm reduction services within hospital and surrounding area.

  • Help patients apply for housing, social benefits, and identification.

  • Connect to social activities and provide other materials for in-hospital entertainment.

  • Participate in creation of discharge plan and support patient/team in the actual discharge process.

3. Health-related support after discharge
  • Remind patients about their medication regimes.

  • Arrange medication storage at postdischarge setting.

  • Help patients fill prescriptions (direct patients or accompany them to local pharmacies).

  • Help patients with accessing opioid agonist therapy and safer supply.

  • Help patients procure medical aides and devices.

  • Remind patients about upcoming medical appointments.

  • Attend medical appointments with patients.

  • Help patients find and connect with primary care providers.

  • Help patients arrange for home care, wound care, eye care and dental care.

  • Connect patients to disease-specific programmes.

  • Purchase medical-related items to help follow through with postdischarge plans.

4. Social-related support after discharge
  • Help patients apply for housing, social benefits and identification.

  • Arrange transportation to postdischarge setting.

  • Help patients find alternative shelter based on unique needs.

5. Information transfer
  • Follow-up with shelters and case managers to ensure that they have the patient discharge plan and are supporting it.

  • Ensure that outpatient services are also aware of patient discharge plan and following through with it.

  • Ensure that this hospital and other hospitals are aware of the hospitalisation and discharge plan.