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M Health Fairview’s Coming Home program breaks the cycle of homelessness

Working with a network of community partners, M Health Fairview is helping people experiencing homelessness move out of hospital emergency departments and into permanent housing.
After experiencing a series of personal crises, Katie enrolled in the Coming Home program in 2017. The program helped her find stable housing and reconnect with her daughter. “Without housing, you can’t focus on anything else,” Katie said.

When she was admitted to M Health Fairview St. Joseph’s Hospital in 2017, Katie was in crisis. She was homeless, suffering from mental illness, and had attempted suicide. Homelessness had taken away the most important person in her life: her daughter.

Katie had been in and out of the hospital emergency departments across the Twin Cities. But this time St. Joseph’s Hospital workers connected her with Joan Weatherspoon, a Guild case manager. Weatherspoon told Katie about Coming Home – an intensive program designed to reduce emergency department and hospital visits by helping people who are homeless and in crisis get access to social services and find permanent housing.

More than 70 percent of emergency department visits at St. Joseph’s Hospital could be prevented with proper primary care. Many people like Katie seek emergency department care that might solve a short-term need without addressing the bigger picture.

“We often see the same patients with mental illness and substance use disorders in our emergency department and inpatient units over and over again,” said Jayne Conley Braun, director of clinical services at St. Joseph’s Hospital. “Many times, these patients are unsheltered or experiencing chronic homelessness and don’t have access to the social services needed for them to be successful.”

Coming Home – a partnership between M Health Fairview, Guild, and Hearth Connection – aims to disrupt that cycle. For years, the program has helped people in the East Metro break the cycle of homelessness. The program will continue as St. Joseph’s Hospital transitions from a hospital to a community hub of health and wellness, focusing on social determinants of health like housing and workforce development. In the future, the program may expand to M Health Fairview University of Minnesota Medical Center or other hospitals across our health system.

Addressing the social determinants of health

Here’s how the Coming Home program works: 

It starts when M Health Fairview social workers identify candidates like Katie during a hospital or emergency department visit. Hospital staff refer candidates to a Guild caseworker, who connects with them at the hospital to build relationships. From there, the caseworker connects each person with the resources they need. Catholic Charities Higher Ground Shelter provides temporary shelter for those working toward permanent housing. Hearth Connection, which developed the model for the program, helps fund services and provides the housing subsidies.

The person-centered program goes beyond housing needs, too. Weatherspoon helps her clients find employment, furniture, clothing, food, and any other resources they may need. She goes to appointments with them and helps them access support programs. The program is tailored to meet each client’s needs and services are ongoing – often for years.

At the end of 2019, 13 people were enrolled and active in the Coming Home program. The results are promising—after enrollment participants have had an 87 percent decrease in the number of emergency room visits and 88 percent decrease in inpatient hospital stays.

“Housing is a social determinant of health, meaning it is one of the factors that impact health and wellbeing,” said Weatherspoon. “We know the benefits of stable housing—it helps clients experience fewer symptoms of mental illness, better track medications, reestablish relationships with children and family members, reduce chemical dependency, have a place to cook food where they can make better nutrition choices, and so much more. Our clients often tell me their life is fulfilled in ways that they didn’t realize were possible.”

“In addition to supporting the client, the program really benefits the community,” said Julie Grothe, Guild’s service director, integrated services. “The program reduces costs for law enforcement, shelters, and hospitals, and participants are more likely to be active in their community.”

Katie’s new beginning

Katie was eager to engage. She wanted to be successful in the community and reconnect with her daughter and saw the Coming Home program as a chance to do both.

“Things were chaotic and were not going well in my life,” Katie said. “I struggled with severe depression, anxiety and PTSD for more than 20 years. I really hoped to have a stable place to live – and to live independently.”

Before getting started, Weatherspoon needed to gain Katie’s trust so they could work as a team. Weatherspoon visited Katie and learned what she wanted to achieve. Then Katie’s team helped her develop a plan that included mental health and substance use treatment.

Once stable, Katie worked with Weatherspoon to get a housing subsidy and to find housing that was safe for her and her daughter. After a year of hard work, Katie moved in to her own apartment in 2018. She quickly made the apartment her home, decorating it with plenty of plants and her own unique touches. She established routine visits with her daughter. She re-established relationships with family and friends and completed Peer Support Training, a certification for individuals that have walked the path of recovery. Katie is creative and enjoys making art with many different media. She is driven to find her version of success.

“Without housing, you can’t focus on anything else,” Katie said. “Now I’m able to go to therapy every week, spend time with my daughter, and form friendships and hobbies that help my mental health because I feel somewhat normal. I feel able now to participate in my life.”