St. Peter’s Health Frequent User Systems Engagement (FUSE) program, also known as Housing is Healthcare, integrates healthcare and housing stability to support high-need patients. The program identifies individuals with frequent Emergency Room visits and housing instability and pairs them with a Community Health Worker to offer tailored interventions and support through collaborative efforts between the St. Peter’s Population Health and Complex Care teams.
By addressing root causes of health issues, such as unstable housing, FUSE aims to reduce strain on healthcare services and provide cost savings for the hospital and community. This innovative approach has already demonstrated great success, with early impacts evident since its inception in April 2022. Through community partnerships and proactive interventions, the FUSE program exemplifies St. Peter’s commitment to improving community health and well-being, setting a new standard for healthcare delivery in Montana.
Key Objectives
- Identify and support high-need patients
The primary objective is to identify individuals with frequent interaction with community crisis systems (such as Emergency Room and jail visits) and housing instability, ensuring they receive tailored support to address their complex medical and social needs. - Prevent unnecessary Emergency Room visits
By intervening proactively with at-risk individuals, the program aims to reduce the number of non-emergent visits to the Emergency Room, thus improving healthcare utilization and outcomes. - Maintain or secure stable housing
Another key objective is to help participants maintain their current housing situation or obtain stable housing if they are experiencing homelessness, recognizing the critical link between housing stability and health. - Foster a strong community system through collaboration and community partnerships
The program seeks to build strong partnerships with local organizations, community leaders, and stakeholders to maximize resources, share data, and coordinate care effectively. - Achieve cost savings and improve healthcare delivery
Through early interventions and holistic care, the program aims to reduce uncompensated care costs for the hospital and greater community and provide better outcomes for patients, ultimately improving the overall healthcare delivery system in the community.
Benefit to the Community
Through proactive interventions and holistic care approaches, FUSE has improved healthcare outcomes for patients, leading to better health and well-being outcomes for individuals in the community. It has also fostered collaboration among local organizations, community leaders, and stakeholders, leading to better coordination of care, resource sharing, and improved support services for individuals experiencing housing instability and high medical needs. Overall, the FUSE program has had a positive impact on both the hospital and the community by improving healthcare delivery, reducing costs, and fostering collaboration to address the complex needs of high-need patients.