Hennepin Health received a national award in the health category from the National Association of Counties (NACo). The award was for the program, Addressing Readmissions in County Health Plan Population Experiencing Homelessness. The award recognized work to integrate health care and social services by expanding access to housing navigation, and to reduce the readmission rate for Hennepin Health members who use Hennepin Healthcare’s flagship hospital, HCMC, for hospital services.
The two organizations developed a tool to identify patients experiencing homelessness and improved service coordination by introducing patients to outpatient community care management during hospitalization. Patients received care management following discharge. Of the participating patients engaged in care management through the first 37 weeks, no one was readmitted within 30 days. In addition, social workers helped to house 16% of participants and connect many more to other services, such as transportation or food assistance.
The organizations undertook the program without additional staffing or funding. Overall, the program reduces medical costs and improves health outcomes for underserved members. It now includes Hennepin Health members admitted to Hennepin Healthcare for substance use disorder.
The project team included Lori Johnson, Health Rhodes, Danielle Robertshaw, Heather Simon, Dawn Strief, Hillary Hume, Molly Huff, Yang Chan, Christy Barich, Justin Dempsey, Bethany Divakaran and Daniel Hoody, MD, MSc.
Read the award description on the NACo website.