Nate was living on the streets, using heroin and pills and suffering from anxiety and recurrent chest pains. He was also a frequent visitor to the emergency room at Bellevue Hospital, where he was repeatedly hospitalized for detoxification. But with the help of an HHC Hospital 2 Home (H2H) care manager who practiced some detective skills, Nate was tracked down and linked to the care he needed. Nate now lives in transitional housing, has a full-time job and is better managing his chronic medical conditions.

	Ruth Ross, Community Based Care Manager, counsels Samuel Parker, a patient in the Hospital 2 Home program at Woodhull Hospital.

"Our care manager went to a nearby homeless shelter and methadone clinic looking for him with no luck. She followed clues and information received to get his whereabouts. When she finally found him, she arranged for rehab and escorted him there. After rehab, the care manager gave him a cellular phone with pre-paid minutes so he could stay in touch and hooked him up with a doctor," said HHC Hospital 2 Home Program Manager Rachel Davis.

Developed to address a growing challenge facing hospitals across the country, the Hospital 2 Home program at Bellevue, Woodhull and Elmhurst Hospital Centers is designed to improve the health and social care for patients affected by multiple chronic diseases, including mental illness and substance use, who account for a disproportionate share of costs to Medicaid.

The program is based on a successful pilot program at Bellevue Hospital several years ago where inpatient admissions for patients enrolled in the program decreased by 37.5%, Emergency Department visits decreased by 10%, outpatient visits increased, and Medicaid spending decreased by $16,383 per patient.

"I'm a diabetic, have asthma, orthopedic problems but now I'm not in the emergency room all the time. They send a van to pick me up at the shelter or wherever I'm at and take me to my doctor's appointments. I've been through a hard life but they care about me. I feel like they've given me a second chance," said Jacqueline Posado, an H2H patient at Bellevue.

According to CMS, 20% of patients discharged from the hospital are re-admitted within 30 days. Readmission rates are directly related to a breakdown in care after discharge, including patients not seeing a doctor and lack of an adequate support network.

HHC's Hospital 2 Home program is funded by a $5 million NYS Department of Health grant to target a list of high use patients who live in the neighborhoods surrounding the three participating hospitals. So far, 270 patients have been enrolled and the HHC team is aiming to have up to 500 in the program. Care managers are assigned to aggressively track down patients wherever they are and ensure patients understand how to take care of themselves after being discharged, can get their medications and are taking them, and are going to follow-up visits. Patients receive individualized, intensive care management both in the community and in the hospital.

"These folks are persistent. They called my old apartment and talked to my ex-girlfriend. She gave them my brother's address and they showed up there and left me a letter. I was on alcohol and cocaine when they found me. I went to detox, got housing and they helped me get a job. H2H changed my life," said John, 45, an Elmhurst H2H patient.

The 20 members of the care management teams at HHC include social workers, community-based care managers, a housing coordinator and physicians. Interventions are conducted in partnership with community providers of homeless, mental health, substance use, and other key services.

"With a little detective work, and a lot of compassion and resourcefulness, we are succeeding here and helping patients who often fall through the cracks by bridging the gap between the hospital and the community," said HHC Hospital 2 Home Project Director Maria Raven, M.D.