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:
- Developed a tool to identify patients experiencing homelessness. The tool overhauled screening processes to include information about housing status and the use of other social assistance programs.
- Improved service coordination by introducing patients experiencing homelessness to outpatient community care management during hospitalization. Patients received care management for 90 days or more following discharge.
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.
“Our Hennepin Health Accountable Care Organization was key in this work,” explains Danielle Robertshaw, MD, Senior Medical Director, Hennepin Healthcare Community Connections Care Ring who was the project’s co-leader. “The close partnership between Hennepin Healthcare and Hennepin Health allowed us to be creative and think differently about how we could connect shared patients to needed, appropriate and high impact services at the right time to improve outcomes.”
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.
About Hennepin Health
Hennepin Health is Minnesota’s only county-owned, state-certified health maintenance organization that provides coverage to Hennepin County residents who qualify for Medical Assistance and MinnesotaCare. Hennepin Health operates an accountable care model for health coverage and health care delivery with Hennepin Healthcare, NorthPoint Health and Wellness Center, Hennepin County Public Health and Hennepin County Human Services.
For more information about Hennepin Health, visit hennepinhealth.org.
About Hennepin Healthcare
Hennepin Healthcare is an integrated system of care that includes HCMC, a nationally recognized Level I Adult Trauma Center and Level I Pediatric Trauma Center and acute care hospital, as well as a clinic system with primary care clinics located in Minneapolis and across Hennepin County. The comprehensive healthcare system includes a 473-bed academic medical center, a large outpatient Clinic & Specialty Center, home care and hospice, research institute, philanthropic foundation, and Hennepin EMS. The system is operated by Hennepin Healthcare System, Inc., a subsidiary corporation of Hennepin County.
For more information about Hennepin Healthcare, visit hennepinhealthcare.org.
Look for more news at hennepin.us/news.