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A Model Population Health Initiative: Reducing Costs by Going Upstream

Category: Program

Related Categories: Quality Improvement Results

Location: Webinar

Start Date: 10/23/2017

End Date: 10/23/2017

October 23, 2017, 1:30-2:30 PM (EDT)


This webinar highlighted the winner of the 2017 Future of Population Health Award, telling the story of Harbor Place, which provides temporary transitional housing for homeless patients discharged from the University of Vermont Medical Center. The webinar included exploration of the success factors, the challenges faced, and the future expansion of this model initiative.


The Challenge: The medical center observed a vicious cycle in which homeless hospital patients who were ready for discharge had no stable, safe place to go and no coordinated access to support services to continue their rehabilitation. People were falling through the cracks and unable to get back up, leading to high readmission rates and soaring hospital costs. Many patients had given up. There was a need to address homelessness as an upstream cause of repeat hospitalization for chronic diseases. 


The Solution: This required reaching outside the traditional domains of medicine. The medical center launched an effort to reduce  readmissions, bringing together a litany of partners that raised the capital to create and reserve temporary housing spaces for patients upon discharge. And that housing -- known as Harbor Place -- made everything else possible.

The Result: The program has significantly reduced use of hospital services and costs. After three years, the program had led to a 68% drop in inpatient readmissions, a 59% drop in cost per hospital visit, and an 83% drop in the overall cost of care -- a savings of $1.6 million. This was related to caring for just 153 patients.


Speakers from the University of Vermont Medical Center included:

  • Stephen Leffler, MD, Chief Population Health and Quality Officer 
  • Penrose Jackson, Director, Community Health Improvement

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A Model Population Health Initiative: Reducing Costs by Going Upstream