Hennepin Health and Hennepin Healthcare earned first place in the 2020 Innovator Awards Program presented by Healthcare Innovation. The award recognized the team’s 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.
An analysis of 2018 Hennepin Healthcare readmissions data showed higher group readmission rates for Hennepin Health members receiving hospital services at HCMC. It also showed that homelessness was a leading risk factor.
Armed with this knowledge, Hennepin Health and Hennepin Healthcare worked together to build a comprehensive, multilayered initiative to address this leading contributor to high healthcare use. The two organizations:
The results of the program are notable – 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.