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 housing when possible.

Why it matters: Denver Health said it cared for about 16,000 patients in 2024 who together had roughly 80,000 visits across the system and that the hospital encounters for people experiencing homelessness drive measurable increases in resource use. The presenters displayed two utilization slices they track: a small group of emergency-department “super-utilizers” (19+ visits in a year) and a small group of inpatient high-utilizers (7+ admissions). Among their highest ED utilizers, they reported that 66% were experiencing homelessness; among the highest inpatient utilizers the team reported roughly 30% had been unhoused in the past year. Denver Health said patients who are unhoused have an average inpatient stay about 2.5 days longer than housed patients and are substantially more likely to be rehospitalized within 30 days.

Program components and outcomes described in the briefing: Denver Health leases 14 transitional units at 655 Broadway for elderly and disabled patients exiting the hospital; since opening the Recuperative Care Center in February 2023 the system has discharged more than 700 patients to that facility instead of to the street; the 655 Broadway units have housed 34 patients to date, 22 of whom were subsequently connected to longer-term housing (through sources such as permanent supportive housing or Section 8 vouchers, or by family reunification). The presenters said Denver Health has connected patients to the Housing-to-Health program (described in the presentation as a statewide supportive housing expansion or Roads/“Roads to Recovery” program) more than 120 times.

Funding and costs: presenters said Denver Health spends about $864,000 per year on the Recuperative Care Center beds it leases, about $150,000 per year on the 655 Broadway lease, and about $800,000 per year on the HOPE team (grant plus internal investment). They also said that the excess inpatient days attributable to patients experiencing homelessness cost Denver Health about $8,400,000 in 2024 — a figure the presenters used to illustrate how upstream housing connections can reduce hospital costs.

Gaps and limits: the team said many of the hospital’s most medically complex patients who are unhoused cannot be discharged into traditional congregate shelters because of functional or cognitive impairments (Denver Health reported roughly 59% of 2,218 inpatient encounters in a recent review had impairments that would prevent discharge to congregate shelter). The presenters identified limited capacity in short-term medical respite, micro-communities, non-congregate shelters and permanent supportive housing; they said long-term medical respite capacity “does not exist right now.” Presenters also identified data sharing as a key constraint: Denver Health described existing data-use agreements with partners, use of Medicaid attribution data to flag patients connected to the Colorado Coalition for the Homeless, and limited access to the region’s Homeless Management Information System (HMIS) for a small number of inpatient team members.

Council members asked about coordination with city programs, reach into neighborhoods, and length of stays in recuperative beds. Councilmember Kevin Flynn and Councilmember Jamie Torres asked for more detail on the utilization charts and on how Denver Health and the city’s Roads to Recovery program coordinate; presenters said they meet biweekly with Roads to Recovery, that their joint work is still nascent and that data releases and consent workflows are the major operational issues. On neighborhood relations, presenters said Denver Health has been meeting with local merchant groups (Broadway Merchants, Baker neighborhood contacts) and plans a mid-September presentation with its mobile crisis unit and STAR to outline when businesses should summon those response teams versus calling the hospital.

The presenters and councilmembers emphasized partnerships. Dr. Stella framed Denver Health’s role as a place where patients who are disconnected from other homeless services still present for medical care, and she urged continued investment and improved data sharing so hospital-initiated connections can reach appropriate housing resources.

The committee did not take formal action during the briefing; councilmembers asked for follow-up data and additional presentations on metrics and HMIS access in future committee meetings.