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A new support program at HCMC was supposed to reduce in five years the rate of homeless patients needing to make repeat trips to the Minneapolis hospital.

Turns out, it only needed one year.

HCMC leaders reported this month that the support program dramatically reduced hospital readmissions in a test group of homeless patients who receive Medicaid benefits through the Hennepin Health program. The program started in February 2019 and went 37 weeks without a readmission among these homeless patients who agreed to receive support services during their initial hospital stays.

By year’s end, only 5% of these patients needed second hospital admissions, compared to 15% of other homeless patients. And 16% of the Hennepin Health patients were placed in stable housing.

Preventing avoidable readmissions has been a focal point in health care, particularly since the federal Medicare program started adjusting its payments based on hospitals’ readmission rates.

Preventing them in homeless patients is a greater challenge because they often lack support, said Dr. Danielle Robertshaw, who directs HCMC’s transition services. “They actually end up getting sicker because they end up running all around, carrying everything they own, trying to find shelter.”

While Hennepin Health has social workers and nurses who reached out in the past to homeless patients after their discharges from HCMC, they often struggled to find the patients because they didn’t have reliable addresses or phones. That meant that those patients didn’t get lined up for prescriptions and follow-up doctor appointments, which hastened their medical problems and their readmissions.

Now, the staff is doing more of that work when the patients are still in the hospital, and connecting them with social service, housing, and support agencies before discharge.

The switch didn’t cost more for Hennepin Health or Hennepin Healthcare, the parent health system to HCMC. Robertshaw said it will continue indefinitely. Now the challenge is to broaden it to homeless patients who don’t receive Hennepin Health benefits, and to patients who also suffer high levels of hospital readmissions because of mental illnesses and drug addictions.