Pathways Home: Medical-to-Housing Advocacy

Pathways Home is a Central Ohio pilot program designed to support individuals who are medically stable but facing housing instability following hospitalization—so recovery doesn’t lead to displacement.

Refer a Client Program Overview

Serving Central Ohio

Franklin County and surrounding counties

Best-fit referrals

  • Post-hospital discharge housing risk
  • Older adults facing displacement
  • Fixed or disrupted income

Program Overview

Pathways Home bridges healthcare, housing, and community systems to support safer transitions and housing stability after medical crisis. We complement discharge planning and existing housing services by focusing on targeted advocacy, coordination, and stabilization navigation.

Core Services

  • Post-hospital housing advocacy with landlords, housing authorities, and providers
  • Medical-to-housing coordination supporting safe transitions and continuity of care
  • Stabilization navigation (rental assistance, eviction prevention, utilities, county supports)
  • Systems advocacy & escalation when policies/processes create unsafe discharges

Who We Serve

  • Adults age 35+ residing in Central Ohio
  • Older adults on SSI, SSDI, retirement, disability, or disrupted income
  • Individuals recently discharged from Ohio hospitals or receiving ongoing care through Ohio-based health systems
  • Individuals at risk of eviction, homelessness, or unsafe housing

What Happens After a Referral

  1. Intake & screening (1 business day target)
  2. Consent & advocacy plan with the client
  3. Coordination with discharge team and relevant housing/community partners
  4. Documentation & follow-through with measurable outcomes

Outcomes We Track

  • Housing stability at 30 and 90 days post-discharge
  • Evictions prevented or resolved
  • Unsafe discharges delayed or modified (when applicable)
  • Reduced emergency department utilization and readmissions (when data is available)

This pilot aligns with Ohio’s focus on Health-Related Social Needs (HRSN), improved care transitions, and strengthened community-based care coordination.

Quick Contact

Phone: 707-710-1081

Email: kmoorer@wovencareadvocacy.org

Service Area: Franklin County / Central Ohio

Refer a Client

Use this form to initiate a referral. We’ll follow up to complete intake and confirm eligibility. (Tip: Keep details high-level here—full intake happens by phone.)

Referring Organization

Client Basics