Your guide to referring clients to the INN Between
This guide is meant to help homeless service providers and community partners identify clients who may be appropriate for The INN Between, with the goal of initiating an agency to agency warm hand-off referral.
Therefore, please contact us on behalf of your client rather than instructing your client to call The INN Between.
With rare exceptions, the admissions process typically takes a minimum of two days. In the interim, clients should be referred to emergency shelter.
Please fill out the Personal Health Information Release form at the bottom of the page.
If you prefer, you can download the guide here.
The INN Between is a residence dedicated to providing a safe, sober-living environment for homeless persons with medical problems that cannot be managed appropriately on the streets.
Priority is given to those who are facing end-of-life and needing palliative or hospice care. Residents are provided with basic needs 24/7 including three meals a day, transportation to medical appointments, life skills mentoring activities, medical case management, and comprehensive social and emotional support.
We are not a direct provider of medical care, so each resident must have a Primary Care or Hospice/Palliative Care provider who will continue direct and provide medical care.
Most rooms are double unites and have two beds separated by a wall and privacy curtain; two rooms share a bathroom. We have medical respite beds for people who can perform their own Activities of Daily Living (ADLs) and 30 Assisted Living Facility Type II beds for clients who need help with one or more ADLs including medication management.
Clients who need skilled nursing or are a total assist should be connected with a Skilled Nursing Facility. We are not a detox facility. We are not a mental health or memory care facility.
The INN Between is a stable housing solution for terminally ill clients, whether or not they are on active hospice care. Clients generally need a diagnosis of less than six month to live; however, this is difficult to ascertain and is therefore a loose guideline. Clients are connected with professional hospice care from a State-licensed Hospice agency. When a resident enters the active dying phase, a team of NODA (No One Dies Alone) trained volunteers sit vigil with residents. At The INN Between, no one dies alone. We then will hold a memorial service, post an obituary online, and etch their names in the memorial garden.
Medical Respite (MR) is for individuals who are not sick enough to be in the hospital but are too ill to safely be on the streets (learn more about MR and the standards of care we follow on https://nhchc.org/medical-respite-care). MR helps clients recuperate from an acute medical condition, after which time we strive to initiate a warm hand-off back to shelter in order to minimize the trauma on the client. MR is not a solution for clients who have chronic conditions; however, New Choices Waiver Medicaid members may be eligible for long term care at The INN Between.
Typical MR circumstances include, but are not limited to, clients who:
- are being discharged from the hospital but need time to recuperate before they can safely return to shelters, motels, or encampments.
- need home health care, require stable housing in order to begin or continue cancer or other intensive treatments.
- require stabilization prior to surgery or after surgery.
Client Eligibility
We review each client’s circumstances on a case by case basis. In general, we accept adults 18 and over who:
- Are homeless or at risk of imminent homelessness.
- Are low-income.
- Are terminally ill or require Medical Respite, as verified by a current History and Physical (H&P) and Admissions Orders faxed to us by their medical provider.
- Do not have Alzheimer’s/dementia or a medical condition that requires a higher level of care than we can provide.
- Agree to our House Rules which include smoking in the outside designated area only, no drugs or alcohol on the premises, and a 10:00 pm curfew, to name a few.
How to make a referral
Step One
Use our online referral form to initiate a referral. If you have questions before starting, please call our Referral Line at 801-456-4566 if you think a client may be appropriate for The INN Between. We staff this line Monday through Friday, between 8:30 am and 4:30 pm. If you get voicemail, please expect a callback the same day (next business day if after hours). 
Please DO NOT instruct your client to call the referral line or send your client to our location, as we cannot accept walk up traffic.
Initial Phone Call
Questions we will ask you:
- IPC Client’s first and last name and date of birth.
- Client’s medical condition (what is the medical crisis?).
- Current living situation (shelter, encampment, friend’s, getting evicted, etc.).
- Name of Primary Care Physician or Clinic.
Step Two
If the client seems appropriate, our next step is to review the client’s History & Physical (H&P). Clients typically face a roadblock when asked to obtain their H&P; therefore, please help your client get their H&P by following these easy steps:
- Help the client complete and sign the attached Release of PHI form.
- Fax the completed form to:
- Client’s medical provider and to (You can get the medical provider’s fax number via a web search).
- The INN Between Medical Fax Line: 385-474-4066
- Give us a call to let us know you have requested the H&P.
Step Three
After review of the client's H&P and it is determined that they would be a good fit and do well at The INN Between, we will request a Doctor's Admissions Order. This step cannot be done in advance. It will be completed after the client has been accepted to the program.
Client review process can take up to two days. Please plan accordingly and know that same day admits are not normal.
COVID Testing/ Vaccine Updates
- We require a negative COVID test prior to admission.
- We will ask for their COVID Vaccine status and information.
Please note, referrals are accepted Monday through Friday 8:30 am - 4:30 pm via phone, 801-410-8314 option 2.
Our referral team will be in touch with you as soon as possible. With rare exceptions, the referral process typically takes a minimum of two days. In the interim, clients should be referred to emergency shelter. Same day admits are not normal.