DISCHARGE PLANNING
The TX-601 CoC is working in coordination with hospital districts and shelters to better align expectations for patients who are discharged from healthcare facilities to homeless shelters in Tarrant County. The intended audience for this guidance includes hospital staff, nursing facilities, medical transportation organizations or anyone assisting a patient transitioning from a healthcare facility to a homeless situation.
To assist during the discharge process, the TX-601 CoC Hospital Discharge Committee has developed new tools and guidance all of which are available on this page.
It is recommended to review all documents before discharging a patient experiencing homelessness:
STANDARD OPERATING PROCEDURE
The purpose of this Standard Operating Procedure (SOP) is to provide clear and consistent guidance for hospital to discharge people experiencing homelessness. This SOP is designed to ensure that people experiencing homelessness are discharged safely with access to appropriate resources and to reduce the likelihood of readmission.
Scope:
This SOP is recommended by the TX-601 CoC Hospital Discharge Committee to all hospitals in Tarrant County discharging people experiencing homelessness.
Procedure:
- Identify patients experiencing homelessness through standard hospital screening and assessment.
- Use the Hospital Discharge Tips and Hospital Discharge Form to assess the patient’s needs, including shelter, food, clothing, and transportation.
- Coordinate with partner agencies using the SHELTER AND OUTREACH INFORMATION, Shelter Screening Tool, and Other resources to plan for safe and appropriate discharge.
- Ensure the patient has a follow up appointment scheduled at True Worth Medical Home, unless the patient has another PCP they see regularly.
- If the patient is already in a shelter program, contact their case manager.
- Ensure all assessments, discharge plans, and follow up communication are documented in the patient’s medical record.
SHELTER AND OUTREACH INFORMATION
All shelters require that clients be fully, independently able to safely:
- Mobilize and self-transfer (wheelchair/walker/ambulatory all ok)
- Self-manage stool/urine
- Get themselves to meals 3x a day, stand in line to wait for meals, self-manage carrying tray
- Independently dress, perform hygiene, feed, medicate
The shelters cannot assist clients with these tasks and are unable take on that liability by staff or other guests. Guests that do not meet these requirements are not appropriate for shelter discharge.
You must be specific if requesting a medically required bunk. Shelters can try but cannot guarantee a bottom bunk to all guests who request one.
Not all clients can or want to go to shelter. These clients can still access housing and other resources through our outreach teams.
Anytime you are referring to a shelter or program, you should contact the agency to ensure no changes have been made to eligibility, requirements, or hours of operation and to ensure availability of beds or services.
True Worth Place
1513 E. Presidio
Fort Worth, TX 76102
817-289-7474
Day Shelter Only
Provides day shelter and supportive services
Restrooms, showers, laundry, mail, computer access, public telephones, classes, temporary storage, life skills, case management, co-located with JPS True Worth Medical Home, Scan cards
Monday – Sunday
7:00am-3:00pm
**Only guests enrolled in case management can enter after 10am
***Guests must be over the age of 18 to receive services
SHELTER
SINGLE MEN
SINGLE WOMEN
FAMILIES
Union Gospel Mission
1321 E Lancaster
Fort Worth, 76102
817-332-3019 (Men’s Shelter)
817-338-8475 (Women’s Shelter)
Emergency Shelter: Check-in at 2:00pm-3:00pm & 6:00pm-8:00pm
Requirements: State ID, No Sex offenders, no violent crimes, must be 18 or older
Program: Must attend orientation @ 8:30am & 1:00pm Mon-Fri (at Club 1401)
Program fee: $182 per month
Call for intake appointment
(817) 338-8475
After hours: 817-733-4125
Program Director: Aretha McJimson, 817-338-8481
Emergency Shelter: Check-in at 1:30pm
Requirements: State ID, No Sex offenders, no violent crimes, must be 18 or older
Program: Must attend orientation @
8:30am & 1:00pm Mon-Fri (at Club 1401)
Program fee: $182 per month
Call for intake appointment
(817) 338-8475
After hours: 817-733-4125
Program Director: Aretha McJimson, 817-338-8481
Emergency Shelter: Check-in 3:00pm
Program: Must attend Orientation @ 10:00am Mon-Fri
Requirements: State ID. Married couples must have proof of marriage. Family size – 6
Program Fees: Based on income
Call for intake appointment
(817) 338-8475
After hours: 817-733-4125
Program Director: Aretha McJimson, 817-338-8481
Presbyterian Night Shelter
Men’s Shelter
2400 Cypress
Fort Worth, 76102
817-632-7401
Women’s Shelter
2401 Cypress
Fort Worth, 76102
Women and Children’s Shelter
2320 Poplar
Fort Worth, 76102
817-632-7429
*Dogs are allowed with proof of vaccinations
Emergency Shelter check-in: 2:00-6:00pm
*1:00pm on days over 100°
Fee: No charge to stay
No length of stay restrictions – cases reviewed every 30 days
Must be 18 and over
Must be able to care for self
Program Intakes: Monday 2pm, Wed & Fri 10:00am
Program requirements – Guest with income over $300 per month will pay a program fee of $125 at enrollment. This is to be in the form of a money order.
Guest without an income will be placed in our vocational program with the expectation of completing 12 hours of vocational duties per week.
All guest will participate in case management on a weekly or bi weekly basis.
Presbyterian Night Shelter is a low barrier shelter so all backgrounds are accepted.
(817)-632-7401
Program Manager: 817-632-7423
After hours: 817-372-2450
Emergency Shelter check-in: 2:00-6:00pm
*1:00pm on days over 100°
Fee: No charge to stay
No length of stay restrictions
Must be 18 and over
Program Intakes Tues & Thurs at 10:00am
Program requirements – same as single men
(817)-632-7401
Program Manager:
Miranda Parker 817-632-7407
After hours: 817-372-2450
No overnight emergency shelter
Program: Have to get name on waiting list. Usually Referred through Salvation Army Mabee Center
Serves families including single moms or dads
Documentation will be required to enroll children
Parents must be 18 and over
Salvation Army
1855 E Lancaster
Fort Worth, 76102
Front Desk: 817-344-1801
Family Navigators:
817-344-1806
817-344-1841
Shelter Case Management:
817-344-1822
Service & emotional support animals allowed
No overnight emergency shelter for single men
Programs: Must call to get program information for single men
(817) 344-1801
Emergency Shelter: Check-in after families (if there is room)
Fee: No fee. 3 nights per month
Requirements: Scan card (will take Picture ID up to 3 days), No Sex offenders, must be able to pass a breathalyzer.
Program: See Case Manager
(817) 344-1801
*(Only if there is availability)
Overnight: Check in all day until full
Must be referred by TCHC Helpline for emergency shelter (not guarantee)
Fee: No fee
30 days (must see case manager after 4thnight)
Requirements: Scan card (will take Picture ID up to 3 days), No Sex offenders, must be able to pass a breathalyzer.
Program: See Case Manager
(817) 344-1801
Salvation Army Arlington
712 W Abram St
Arlington, 76011
817-860-1836
Do not serve single men
Do not serve single women
No overnight emergency shelter
Check-in process: Complete an application in person to get onto waiting list
Fees- none
Required documentation- none
Family size- Up to 8 family members
Arlington Life Shelter
325 W Division St
Arlington, 76011
817-548-9885
*Service and emotional support animals allowed
Emergency shelter: 3-night stay (once every 3 months)
Emergency Shelter check-in: 2pm-4pm
Fee: No fee
Requirements: Background check, 2 forms of ID (1 photo ID), SS card (or #), No crimes against another person in the last 2 years, No sex offenders.
Basic Needs Program: 2 weeks stay. Help get BC, SS card, JPS assistance. Must attend assigned classes, have worked in the last 6 months & currently looking for full time work or currently employed
Employment Program: Max stay is 90days. (can repeat program up to 3x)
Guest have 30 days to get a job.
Emergency shelter: 3-night stay (once every 3 months)
Emergency Shelter check-in: 2pm-4pm
Fee: No fee
Requirements: Background check, 2 forms of ID (1 photo ID), SS card (or #), No crimes against another person in the last 2 years, No sex offenders.
Basic Needs Program: 2 weeks stay. Help get BC, SS card, JPS assistance. Must attend assigned classes, have worked in the last 6 months & currently looking for full time work or currently employed
Employment Program: Max stay is 90days. (can repeat program up to 3x)
Guest have 30 days to get a job.
Emergency shelter: 3-night stay (once every 3 months)
Emergency Shelter check-in: 2pm-4pm
Fee: No fee
Requirements: Background check, 2 forms of ID (1 photo ID), SS card (or #), No crimes against another person in the last 2 years, No sex offenders.
Basic Needs Program: 2 weeks stay. Help get BC, SS card, JPS assistance. Must attend assigned classes, have worked in the last 6 months & currently looking for full time work or currently employed
Employment Program: Max stay is 90days. (can repeat program up to 3x)
Guest have 30 days to get a job.
Center for Transforming Lives
512 W 4th St
Fort Worth, 76102
817-332-6191
Do not serve single men
Do not serve single women
Has shelter for women with children.
Intake hours between 8:00am-5:00pm
Up to 2 children ages 3 and under
Application Process
Submit application online or stop by in- person
(817) 332-6191
JPS/ Acclaim Street Medicine
817-702-1582
[email protected]
JPS Acclaim Street Medicine provides primary care services to people experiencing homelessness directly to clients where they stay on the streets and in campsites.
First Street Mission
801 W 1st St
817-335-6060
[email protected]
First Street Mission provides food assistance for families and individuals, both those with a residence and those experiencing homelessness.
Grocery Services
Wed & Thur 10:00-12:30pm
Sack Lunches & Clothing
Tues 10:00-1:00pm
Wed 2:00-4:00pm
DRC Solutions
817-810-9797
[email protected]
DRC Street Outreach provides services to ensure unsheltered people experiencing homelessness have access to housing opportunities by completing assessments for housing, helps them gather documentation and connects with appropriate housing interventions in Tarrant County.
Community Crossroads (1516 Hemphill)
Mon 9:00-11:00am
Penn Square Clinic (300 Pennsylvania Ave)
2nd & 4th Wed 2:00-3:00pm
Flag Building (1100 E Lancaster)
Fri 9:00-11:00am
Hands of Hope
817-298-2779
[email protected]
Hands of Hope is a street outreach team for unsheltered people in Arlington who complete coordinated housing assessments for entry into the system for housing assistance.
Love and Light Ministries
Love and Light Ministries provides outreach, food, camping supplies, clothing and other resources to people experiencing homelessness in Fort Worth.
Glenwood Park (900 S. Riverside)
Tues 7:30 – 9:00pm
Cypress & Lancaster
Tues 9:30 – 10:00pm
Windham & Lancaster
Tues 10:30 – 11:30pm
MHMR IOS
817-569-5760
MHMR IOS provides street outreach specifically focused on individuals experiencing mental health challenges and living on the street.
VA
972-898-0159
[email protected]
The VA provides street outreach to homeless veterans and works to get Veterans registered for VA health and mental health services and accessing veteran housing.
Hearts Full of Love
817-677-1312
[email protected]
Hearts Full of Love provides support for homeless individuals and families in Weatherford, TX and surrounding areas of Parker County.
Grand Prairie Homeless Outreach
214-212-7958
[email protected]
Grand Prairie Homeless Outreach provides support for homeless individuals living Grand Prairie, TX.
Fort Worth Fire Department HOPE Team
682-715-3288
[email protected]
HOPE offers EMS care, conducts vital checks, and serves as a hub to connect people experiencing homelessness with those who provide other services. HOPE reaches out to clients where they reside in the streets and or campsites.
SHELTER
POPULATION SERVED
TCHC Homeless Helpline
817-996-8800
(Call or Text)
All referrals for families with minor children must be referred to shelter through the TCHC Helpline. Clients can call or text the Helpline to receive a referral. Currently all shelters are over capacity and a bed cannot be guaranteed. For assistance, discharge planners can contact the Helpline Coordinator Lisa A.
ACH Child and Family Services
3712 Wichita Street
Fort Worth, 76119
817-335-4673
Offers homeless and runaway youth, ages 10-17, emergency shelter.
Available to do intakes 24 hours a day, 7 days a week.
The Underground
1100 Hemphill Street
Fort Worth, 76119
817-885-7735
Inside One Safe Place
Drop-in center for youth that provides a place to rest, lite meals, shower facilities, safety, trauma, counseling, and referral for services for youth up through age 22.
Open 24/7
SafeHaven
Crisis Line: 877-701-7233
Serves Fort Worth and Arlington
Emergency shelter for women and their children, and men fleeing current intimate partner violence
Men do not stay in the shelters but are placed in hotels.
Length of stay: on a case by case basis
Has 2 outreach teams if needed (one in FTW, one in Arlington)
Freedom House
817-569-8922
Operates as emergency shelter for domestic violence victims serving Parker County
Must call crisis line for screening 817-596-8922
OTHER RESOURCES
The Pocket Pal is a pocket-sized resource guide that includes information about homeless services in the area. To obtain copies of the Pocket Pal for your patients contact Audrey Klein or view the printable PDF version.
The Contact Directory is a list of contacts from the hospital, shelter, outreach, and others from the Hospital Discharge Planning Committee.
It is recommended that service providers who work with people experiencing homelessness in Tarrant County attend Boot Camp. Boot Camp is incredibly valuable for anyone who wants to learn more about homeless services in our community. Attendees learn about what the Continuum of Care is, how it functions, important systems we work with, best practices in case management, and other useful resources available to those experiencing homelessness.
Other valuable trainings are also available through Tarrant County Homeless Coalition.
