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.
Please contact us on behalf of your client rather than instructing them to call or come to The INN Between directly.
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 (PHI) form.
Program Overview
The INN Between provides a safe, sober-living residence for unhoused adults with medical conditions that cannot be appropriately managed on the streets.
Priority is given to those facing end-of-life and in need of palliative or hospice care.
Residents receive:
- 24/7 support with meals, transportation, and case management
- Medical care coordination with external providers
- Life skills mentoring, emotional, and social support
We are not a medical provider, so each resident must have an active Primary Care or Hospice/Palliative Care provider responsible for ongoing medical treatment as well as a home health order.
Housing Options
- Medical Respite (Independent Living): For clients who can manage their own Activities of Daily Living (ADLs), including medications.
- Assisted Living Facility Type II: For clients who require medical respite and help with one or more ADLs, including medication management.
Clients requiring skilled nursing or total assist should be referred to a Skilled Nursing Facility. We are not a detox, mental health, or memory care facility.
The INN Between offers stable housing for terminally ill clients, whether or not they are on hospice.
Typically, clients have a prognosis of six months or less, though this is flexible. Hospice care is provided by licensed outside agencies.
When a resident enters the active dying phase, No One Dies Alone (NODA) volunteers help our staff provide 24-hour companionship. After passing, we hold a memorial service, post an obituary, and add their name to our Memorial Garden.
Medical Respite (MR) serves individuals too ill to be on the streets but not sick enough to remain in the hospital. Learn more about MR standards at nhchc.org/medical-respite-care.
Typical MR situations include clients who:
- Are being discharged from the hospital and need recovery time before returning to shelter or encampment
- Require stable housing to begin or continue treatment (e.g., chemotherapy, wound care, post-surgery recovery)
- Need short-term support before or after surgery
At The INN Between, MR is not intended for clients with chronic, non-acute conditions.
Client Eligibility
We review each client’s circumstances on a case by case basis. In general, we accept adults (18+) who:
- Are homeless or at risk of imminent homelessness
- Are low-income
- Have a qualifying medical condition (terminal illness or short-term need for medical respite), verified by a current History & Physical (H&P) and Admission and Home Health Orders faxed by their medical provider
- Can manage within our scope of care (no dementia, severe mental instability, or need for skilled nursing)
- Agree to house rules (no alcohol/drugs, smoking only in designated areas, 10 PM curfew, etc.)
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.
Step Two
If the client seems appropriate after an internal review of the submitted referral form, our next step is to review the client’s History & Physical (H&P). 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 it to:
- The client’s medical provider requesting H&P.
- The INN Between Medical Fax Line: 385-474-4066
- Notify us once the request has been sent.
Step Three
If the client is a good fit, we’ll request Admission Orders from the provider, specifying whether the client qualifies for:
- Assisted Living (requires help with ADLs/meds) or
- Independent Living (manages own meds/ADLs).
Orders must include:
- Medication list (fixed doses only for Assisted Living; no ranges)
- Home Health Order
- Treatment and diet orders
- POLST or Advanced Directive (required by licensing)
- Provider contact info and signature
Preferred Pharmacy: Guardian Pharmacy Phone: 385-324-2508 | Fax: 833-734-1433 | guardianpharmacy.com
Client review process takes approximately two days. Please plan accordingly and know that same day admits are not normal.