Hospital to Home is a specialized effort operating within our larger street outreach and housing initiative, Street to Home, that combines coordinated health care, social supports, and housing to aid medically fragile clients.
Working in partnership with health care providers at three New York City hospitals (Bellevue, Woodhull, Elmhurst), Hospital to Home stops the cycle of repeat emergency room visits and hospitalization among chronically ill homeless individuals by providing stable housing and health-focused case management.
Homeless patients with frequent hospital admissions comprise a small percentage of all patients, but they account for a disproportionate share of service use and costs. Among non-elderly disabled Medicaid patients in New York State, the most costly 20% account for nearly 75% of expenditures. By addressing the complex needs of patients in this small but high impact group, Hospital to Home enables clients to stabilize their health, and consequently has the potential to greatly reduce Medicaid expenditures.
The efforts of Street to Home and Hospital to Home are mutually reinforcing. Hospital to Home expands the traditional scope of Street to Home (which exclusively targets the chronically homeless, defined as a person who has lived without shelter for nine months or longer) by also reaching medically frail individuals who have lived on the streets for less than nine months, or who reside in the shelter system. Similarly, clients known to Street to Home but not yet fully engaged have accessed housing because Common Ground was notified of their hospitalization through the Hospital to Home program.