Addressing Readmissions in County Health Plan Population Experiencing Homelessness

About the Program

Category: Health (Best in Category)

Year: 2020

Hennepin Health and Hennepin Healthcare, the provider system that includes Hennepin County Medical Center (HCMC), worked together to expand access to housing navigation and to reduce the readmission rate for Hennepin Health members experiencing homelessness and inpatient at HCMC. The team found that previous processes were not identifying many inpatients experiencing homelessness. The team gathered data and redesigned screening processes, using databases containing information about housing status and use of other assistance programs. Hennepin Health navigators visit members in the hospital to confirm eligibility and introduce them to outpatient community care management. If members choose to participate, they are added to the navigator’s case load and are often visited again while they remain hospitalized. Team members participate in weekly meetings to review data, delivering real-time information allowing for readjustment. Through the first 37 weeks, 380 members were screened, sixty-nine were visited while inpatient and agreed to participate, and 40 were engaged in care management for at least 30 days following discharge. No engaged member was readmitted within 30 days. In addition, 16% of participants were housed and many connected with other services. This program involved no additional staffing or funding and has now been expanded to members admitted to HCMC for substance use disorder.