Partnership provides care and temporary emergency shelter for people who are unhoused
Since 2022, our health system has partnered with Our Saviour’s Community Services in Minneapolis on a unique respite care program for patients who are well enough to be discharged from the hospital but are unsheltered and in need of follow-up medical care.
In 2023, 76 people who were accepted into the program remained out of the hospital and emergency department while recovering. The program has been contracted through 2026 with a possibility of extending further.A fresh start
Carolynn came to Minnesota to get a fresh start. While living in a sober house and receiving treatment for a cocaine addiction, she became ill and was hospitalized at M Health Fairview University of Minnesota Medical Center. When she was ready to be discharged, Carolynn was transferred to the respite program at Our Saviour’s Housing, a program of Our Saviour’s Community Services.
While at the shelter, staff helped Carolynn build her strength, listened to her, helped her with tasks, and provided three meals each day. The onsite nurse helped create a safe space, so she was not at risk for falling, and booked rides for doctor appointments and Narcotics Anonymous meetings.
“And you know everything that I got from [Our Saviour’s] was helpful, even to the fact of me not being able to get around very well,” said Carolynn.
Carolynn was at Our Saviour’s Housing Emergency Shelter for 90 days while continuing her healing and preparing to get a place of her own.
“I came to Minnesota for a fresh start, starting over, and I've been able to do that,” said Carolynn. “The bridge of being at [Our Saviour’s], it gave me something. It gave me hope.”
An unmet need
In 2021, our health system completed a Community Health Needs Assessment – a process of working with community members, local nonprofit organizations, and public health departments to understand health needs and strengths. Through the process, access to affordable housing and homelessness were identified as a community need – one that also affected patients receiving care at M Health Fairview hospitals.
Providers at M Health Fairview University of Minnesota Medical Center noticed that some patients who were known to be unsheltered repeatedly ended up in the emergency department. It was difficult to find after-hospital care for these patients who were recovering, had complex medical needs such as chronic pain, cancer, or an injury, and often had a history of substance use disorder.
“A patient may be well enough to be discharged, but in need of follow-up care,” said Jen Myers, system director of acute care management for M Health Fairview. “Our options were to discharge these patients to the street or keep them in the hospital for an extended period. Neither option was good.”
Around the same time, Our Saviour’s Housing (OSH) also conducted a health-focused survey to better understand the needs of the community they serve. Results overwhelmingly showed that while people said their condition was treated in the hospital, they felt unable to care for their condition upon discharge. This is where the idea for the respite partnership began.
As a specialized shelter located near downtown Minneapolis and the medical center, OSH was open to sheltering patients while they recovered. M Health Fairview rents 10 respite beds at the shelter.
“Our team refers patients who are unsheltered and have ongoing medical needs for a 30-, 60-, or 90-day stay,” said Myers. “It’s a win-win situation, the hospital frees up beds for more critical patients and the patients are able to recover in a more relaxed setting where they get three meals a day and can work with a case manager to find resources to meet their other needs.”
The program is also open to patients from other M Health Fairview locations; both M Health Fairview St. John’s and Southdale Hospitals have referred patients.
Supporting medical needs at the shelter
OSH knew that the clients’ medical needs went beyond a safe place to stay while they recovered. Onsite shelter staff weren’t equipped to help clients understand the after-visit medical summaries they received from our hospitals and clinics. In addition, clients needed assistance managing their medical conditions and support to prepare for when they left the shelter. To help provide that support, M Health Fairview’s Community Advancement team deployed one of their community nurses.
In January 2024, a part-time nurse was hired. Natalie Shapiro, RN, joined the M Health Fairview University of Minnesota Medical Center team but can be found at the OSH Emergency Shelter five days a week. She offers medication management, assists with self-care and prescription refills, provides wound care and blood pressure checks, and manages care coordination such as finding a client a primary care provider and making follow-up appointments.
Staying at the shelter gives patients more time to secure resources and follow-up care, which helps prevent further emergency department and hospital visits.
“If clients can heal, then it’s easier for them to focus on other aspects of their lives such as finding housing, registering for county benefits, and securing medical assistance and mental health support,” said Cassie Nelson, OSH shelter manager. “Having Natalie onsite helps clients gain confidence in talking to medical providers – they learn how to advocate for themselves. We are grateful for M Health Fairview’s partnership.”
Housing is health
M Health Fairview’s mission and vision extend beyond traditional healthcare settings, driving a healthier future for the communities we serve. Our health system is committed to addressing the social determinants of health, such as housing access.
“We believe that housing impacts health and that is why we are working to address this critical need in our community,” said John Swanholm, vice president of Community Advancement with M Health Fairview. “Without stable housing, people face challenges like not having a safe place to care for their medical condition or not being able to get a job or earn enough money to pay for food and healthcare.”
