Hospital to Home
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Hospital to Home |
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The Institute |
The Hospital to Home (H2H) Team
The H2H Team is comprised of 8 communities improving the health of people experiencing homelessness and decreasing unnecessary health care costs. Health care providers are working alongside homeless outreach and housing providers to link individuals with an integrated medical home and a “bricks and mortar” home.
The H2H Team gains faculty support and access to an international learning community by participating in the Institute for Healthcare Improvement’s Triple Aim initiative.
Early Outcomes September 2009 - January 2010
- 135 people housed
- 631 people connected to primary care
Teams also track:
- Self‐reported health status
- Hospital and outpatient utilization
- Individuals’ experience of care systems
Current Member Communities
New York, NY: Common Ground Community and Bellevue, Woodhull and Elmhurst Hospitals
Bronx, NY: BronxWorks and Montefiore Medical Center
Camden, NJ: Camden Coalition of Healthcare Partners
Philadelphia, PA: Jefferson Medical Center, Pathways to Housing and Project HOME
St Petersburg, FL: St. Anthony’s Health Care
Santa Monica, CA: Venice Family Clinic, St. John’s Health Center, Ocean Park Community Center, City of Santa Monica Department of Homeless Services
Los Angeles, CA: United Homeless Healthcare Partners, Access to Housing for Health, St. Joseph Center
Portland, OR: Central City Concern and CareOregon
Hospitals and outpatient care providers work to:
- Develop Care Management Teams
- Pay for respite beds
- Link individuals to primary care & homeless outreach
- Provide patient navigation
Housing Providerswork to:
- Partner with hospital staff to inform discharge plans
- Secure housing
- Link individuals to primary care and social services
- Provide patient navigation
Sample Interventions:
- Connect individuals with primary and mental health care
- Help individuals back into permanent housing
- Coordinate outreach efforts to improve in‐reach to people who frequently use emergency and inpatient care
- Leverage resources across various community‐based health and social service providers and local government
- Coordinate care plans with individuals to address individuals’ stated health and concrete needs
- Host collaborative workgroups and ongoing case presentation meetings to bridge complex systems of care
The map below shows cities across the country participating in Hospital to Home.
To inquire or to join the Hospital to Home Team, please contact:
Catherine Craig, LMSW MPA Health Integrator Common Ground
T: 212.471.0846 E: ccraig@commonground.org
