Inpatient to Community Care Management and Social

Project Goals

Reduce and avoid readmissions for homeless Hennepin Health members admitted to Hennepin Healthcare (HCMC) and engage members earlier in Care Management.

Project Description

All Hennepin Health members identified as currently experiencing homelessness and admitted to certain inpatient hospital care units are offered (while inpatient) Complex Care Management and Social Service Navigation.  Complex Care Management, Social Service Navigation, and the associated member develop a person-centered strengths-based care plan following discharge to the community.  

Entities Involved

Hennepin Health, Hennepin Healthcare Systems, Hennepin County Human Services and Public Health.

How Health Plans Support the Project

Provide the Care Managers and Social Service Navigators (Hennepin Health Staff).