Denver Health tells council its hospital-based HOPE team is connecting patients to housing, easing stays and readmissions

Denver Health officials told the Denver City Council Health & Safety Committee on Aug. 20 that a hospital-based outreach team is using episodes of hospital care to connect people experiencing homelessness to housing and community services, reducing average inpatient length of stay and repeat admissions.

The HOPE (Housing, Outreach, Partnerships, and Engagement) presenters — Dr. Sarah Stella, an internal medicine physician and hospitalist at Denver Health; Mara Prandy Abrams, operations manager of patient flow and co-director of the HOPE program; and Tom Gray, a project coordinator in Denver Health’s Office of Research — described a model that uses electronic health record data to identify patients who may benefit from housing referrals, performs in-hospital outreach and consent, and attempts a “warm handoff” to housing partners such as the Denver Housing Authority and the Colorado Coalition for the Homeless.

The presentation emphasized both patient welfare and system impact. Dr. Stella described a patient she treated, identified in the presentation as “Mr. D,” who had poorly controlled diabetes, recurrent limb-threatening infections and mobility loss; she said he told her, “Doc, I just keep falling through the cracks,” and the HOPE team’s work seeks to prevent those gaps. Tom Gray described the workflow: identify high-utilizers through electronic records, outreach and consent in the hospital, then connect patients to bridge or permanent supportive…