Hospital to Home: Positive Outcomes Continue

LL sewing cropped
One of Lisa’s favorite spots in her apartment is at her sewing machine. Click on the photo for a link to the H2H One-Year Outcomes Summary, including her full story.

Following surgery for a degenerative back condition, Lisa found herself unemployed. Plagued by chronic pain due to vascular disease, she turned to prescription pain killers.

By the time she met Susan, a Guild case manager, Lisa had been living in her truck for three years. She was in treatment for substance use and dealing with multiple health conditions including anxiety, vascular disease, schizoaffective disorder, post-traumatic stress disorder (PTSD), and asthma.

Susan helped Lisa enroll in Hospital to Home partnership between Guild Incorporated, Hearth Connection, Regions Hospital Department of Emergency Medicine and Behavioral Health, the Office of Healthcare Research and Quality, and the Minnesota Department of Human Services. Originating as a pilot program with 7 individuals in 2009, the initiative later expanded and aims to reduce costs and better serve patients that tend to seek care in the emergency department. Guild provides a mobile community health services team, which ensures access to permanent, supportive housing and allows health services to follow participants – wherever they are – keeping them engaged, and providing continuity and coordination in their care.


Wilder Research’s latest reports on Hospital to Home continue to indicate – as in past reports – positive outcomes for participants:

  • The total number of emergency department visits by all participants decreased by 68%.


  • Despite long histories of homelessness, all participants moved into stable housing within four months of enrollment.


  • Participants tended to have higher ratings of self-sufficiency in most domains after H2H enrollment

“These findings for the expansion mirror what we found in the pilot, but the pilot was with only seven individuals,” says Wilder Research author Kristin Dillon, Ph.D. “The larger group is replicating the changes we saw with the smaller group, which provides further evidence that this initiative is meeting the needs of individuals served.”

Hospital to Home staff helped Lisa meet her needs by: helping her to find an apartment, assisting her to manage her medications, and helping her get to healthcare appointments. In fact, after six months in H2H, Lisa reduced her emergency department use to just two visits – down from seven visits in the previous six months. She’s also maintained stable housing for over one year and re-established connections with her family.

“Overall,” says Dillon of the report’s findings, “the picture is that these individuals are the highest need group the initiative can access, and while they are going to have ongoing healthcare needs and continue to receive care, it’s very positive to see what we’re seeing: the program is important – participants appear to be getting the right care in the right place.”

Lisa seems to agree. “I’m just happy going at the speed I’m going,” she says. “I’ve come so far.”

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