Hospital to Home: Early Success Serving High-Needs Patients

​A relatively small group of people use a disproportionate amount of hospital emergency department and inpatient resources. So how do we best serve these highest need patients, while also reducing costs?

This issue has been receiving a lot of attention in the health care field, including in the Affordable Care Act, which aims to decrease hospital readmissions and associated emergency department use by addressing gaps in insurance coverage and primary health care needs for these individuals. However, these patients face complex issues that extend beyond the health care system. That’s why innovative initiatives like Hospital to Home are essential, because they provide holistic, tailored, person-centered support. And early evaluations by Wilder Research show that it’s working.

Holistic, Tailored, Person-Centered Support

Guild Incorporated’s Hospital to Home initiative serves very high need participants who have at least one chronic health condition, have experienced chronic and often long-term homelessness, have been diagnosed with a serious mental illness and/or a substance abuse disorder, and frequently use emergency departments.

Julie Grothe, Director of Guild Incorporated’s Delancey Services, described the initiative by saying, “Our goal is to assist individuals with complex situations and who have the highest need across a wide spectrum of health and human services. They also often have high barriers to services, including housing, due to past legal issues.” 

Hospital to Home provides individually tailored care based on participant needs and preferences. A multidisciplinary team from Guild Incorporated serves as the hub and ensures that participants have access to all of the services they need, including physical and behavioral health, housing, social supports, and employment services. This wide array of support involves a unique partnership with Regions Hospital, which refers participants, provides hospital-based services, and collaborates in providing continuity of care. Housing subsidies are provided by Hearth Connection and the U.S. Department of Housing and Urban Development. These agencies and the Minnesota Department of Human Services (DHS) contribute data to the evaluation.

Early Success

The Hospital to Home initiative began as a pilot in 2009 with seven participants. During our first evaluation of the program, we saw some very promising outcomes, which led to a 2012 expansion to a second cohort of 18 individuals.

In February 2015, we published the results of the first year of outcomes from this larger group, and we were excited to see that the promising outcomes from the pilot were mirrored in the expansion results. The results revealed that:

• Participants decreased their total number of emergency department visits by 68% after enrollment.
• In the first six months after enrollment, primary care clinic use remained steady while emergency department use decreased, indicating that participants were more likely to turn to clinics for their care.
• Despite long histories of homelessness, all participants moved into stable housing within four months of enrollment in Hospital to Home.
• Participants tended to have higher ratings of self-sufficiency after Hospital to Home enrollment.

Small Group, Big Impact

These results are positive not only for the individuals receiving services, but also for our overall community. Estimates from DHS and the Minnesota HealthScores Cost of Care website indicate that a clinic visit costs, on average, about one-quarter of the cost of an emergency department visit. Because these participants do not have access to private insurance, the costs associated with these medical services are public costs.

Patients receiving the right care in the right place, including primary care clinics, will free up resources within emergency departments, allowing them to better serve the patients in need of emergency care.

What’s Next

As Grace Tangjerd Schmitt, President of Guild Incorporated shared, “We’ve learned much about the impact of social determinants on overall health. Through this initiative we simultaneously address mental and physical health, including substance use, to improve outcomes for the individual and reduce avoidable expense. Now, we work to scale it beyond a pilot project.”