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Whole-person care is at the forefront of what nonprofit health plans do. Hennepin Health and Hennepin Healthcare, the provider system that includes Hennepin County Medical Center (HCMC), worked to expand access to housing navigation and to reduce the readmission rate for Hennepin Health members experiencing homelessness and inpatient at HCMC.

The team gathers data about housing status and use of other assistance programs. Hennepin Health navigators then visit members in the hospital to confirm eligibility and introduce them to outpatient community care management. If members participate, they are added to the navigator’s case load and are often visited again while they remain hospitalized.

Through the first 37 weeks, 380 members were screened, 69 were visited while inpatient and agreed to participate, and 40 were engaged in care management for at least 30 days following discharge. No engaged member was readmitted within 30 days. Also, 16% of participants were housed and connected with other services. Hennepin Health received an award from the National Association of Counties (NACo) for this initiative.

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