Project Goals

Partnership to improve discharge coordination for patients experiencing homelessness.  Patients experiencing homelessness and require a higher level of care will discharge from the hospital to a medical respite program to improve health and healing.

Project Description

Embedded Public Health Nurse that bridges hospital, county, and shelters to improve the discharge plan and success for hospital patients that are experiencing homelessness requiring additional care following discharge through a medical respite program.  During stay at medical respite, patients engage with Hennepin County Social Services designees to evaluate gaps in service needs and connect to county and state programs (SNAP, Cash – General Assistance, Health Insurance, Social Security).  Healthcare for the Homeless will complete a Housing Assessment with a Coordinated Entry Assessor for the VI-SPDAT (Vulnerability Index – Service Prioritization Decision Assistance Tool).

Entities Involved

Hennepin Healthcare System, Hennepin County Public Health /Healthcare for the Homeless, Homeless Shelters that are supported by Healthcare for the Homeless clinical staff for medical respite, Hennepin Health, and Hennepin County Human Services.

How Health Plans Support the Project

Co-funding the Public Health Nurse position and ongoing consultation and referrals.