H2Home Pathway: Lessons learned while instituting a care transition management program for hospitalized clients experiencing homelessness

The H2Home Pathway provides multidisciplinary care transitions for hospitalized patients experiencing homelessness from an inpatient setting to a primary care medical home by addressing the unique needs and challenges that those patients present. With both physician and social work support, the H2Home care team is comprised of nurses at Harborview Medical Center's (HMC) Pioneer Square Clinic who blend their daily work in the ambulatory care setting with outreach to patients experiencing homelessness in the acute care setting. This allows time to establish trusting rapports with patients and to work closely with patients and their inpatient team to ensure the best possible discharge goals and plans. The H2Home nurses have a robust knowledge of and access to community-based homeless resources as well as an ability to schedule patients for timely medical home follow-up. The team provides the patients with both system-level support and practical interventions to help them stay informed and engaged. For patients experiencing homelessness who have a previously established relationship with a primary care provider, the H2Home team assists those patients in re-engaging with their primary care providers. For patients experiencing homelessness without a primary care provider, the H2Home team coordinates establishment of care at a medical home within the HMC Downtown Programs. Program implementation includes a year-long, IRB-approved research study on two inpatient units of HMC. We chose our intervention floors after a QI project conducted (with a 68 percent response rate) showed that up to 25 percent of admission to that floor could be considered homeless. Program goals are to educate and engage patients experiencing homelessness to access primary care resources and become active participants in holistic health maintenance; improve quality of health care for patients experiencing homelessness; decrease hospital readmission rates; decrease hospital length of stay; and decrease utilization of Emergency Department services for management of health care needs that can be managed in the medical home. The research portion of our project comes to a close in January 2016, and our presentation will share information about the project as well as 6-month follow up data. While we feel there is a benefit to conducting quantifiable research with this population, it has certainly been a barrier to our ability to provide swift and effective care to our clients. We are hopeful that by sharing lessons learned so far, we can help other organizations interested in starting similar programs.