Building Healthcare Staff Capacity for Patient-Centered Discharge Planning for Unhoused Patients

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Discharge planning for unhoused patients is impacted by health care personnel and systemic barriers, which often lead to an unsafe discharge. Therefore, a novel training program using communities of practice was implemented to build capacities among post-acute care staff around discharge planning for unhoused patients. A community of practice is based on the social theory of learning that allows knowledge and expertise to deepen due to the community’s ongoing interaction. Hence, the training program coined as the communities for learning and sharing in skilled nursing facilities (CLASS) training program introduced patient-centered discharge planning and trained staff on professional communications. By building the capacities of the post-acute care staff reinforced their knowledge on interdisciplinary discharge planning, improved their attitudes towards the unhoused patients, and increased confidence to participate in discharge planning. Key ingredients in collaborative and effective discharge planning thus ensure equitable delivery of post-acute healthcare services for the unhoused patients.


  • Joel R. Guerrero, Occupational Therapist, Saber Healthcare group