Overview
The Hospital to Housing program, supported by BJC HealthCare and Barnes-Jewish Hospital in St. Louis, is a leading example of how health care systems can address housing instability as a health care intervention. To evaluate the program’s outcomes, the Missouri Hospital Association’s Hospital Industry Data Institute leveraged its Master Patient Indexing solution to analyze patient utilization across 55 hospitals, revealing the program’s impact on cost and care use.
The H2H program provides transitional, supportive housing for eligible patients, along with integrated case management, mental and behavioral health services, and social support to address long-term needs.
The Challenge
Housing instability is a significant social driver of health as defined by CMS that can contribute to frequent emergency department visits, hospital admissions and fragmented care. Before the H2H program, BJC faced the challenge of measuring the full impact of housing interventions across hospitals and systems, especially for patients whose care spanned multiple locations. To overcome these barriers and support rigorous evaluation, HIDI partnered with BJC and Barnes-Jewish Hospital to analyze systemwide data using advanced patient-matching tools.
Key barriers included the following.
- fragmented patient data across health systems
- difficulty tracking patient utilization over time and geography
- limited insight into longitudinal care patterns for unhoused patients
The Solution: Leveraging HIDI Master Patient Indexing
HIDI’s MPI solution allowed for comprehensive analysis of BJC’s program outcomes, enabling researchers to do the following.
- accurately link patient records across hospitals using advanced entity resolution
- track longitudinal utilization patterns across inpatient and emergency department settings
- evaluate systemwide impacts of the H2H program on hospital use and costs
Through a 6.5-year dataset (May 2018-October 2024), HIDI achieved a 98.6% match rate between BJC-supplied medical record numbers and hospital records across 55 hospitals — allowing for accurate longitudinal analysis of H2H participants.
Measurable Results
Using propensity score modeling, HIDI compared H2H participants with statistically matched control patients to evaluate the program’s effectiveness. The findings were significant.
- $2.1 million in total hospital cost savings in the first-year post-placement, producing an ROI of $1.88 saved per dollar invested in the program
- $30,978 in savings per patient per year
- 47% reduction in ED utilization
- 2.8 fewer inpatient stays PPPY
- 19.2 fewer inpatient days PPPY
These results directly demonstrate how linking patient data longitudinally can quantify the return on investment in social care interventions like transitional housing.
“It’s clear that by reducing utilization by almost 50% in some cases, the patient benefited, but the system of care also benefited.”
– John Lynch, M.D., president, Barnes-Jewish Hospital
Key Takeaways
- Longitudinal tracking is essential: Without cross-system data linkage, it would have been impossible to capture the true utilization patterns and cost impacts for this highly mobile population.
- Housing is health care: Stable housing for high-risk patients can lead to measurable reductions in emergency department visits, inpatient stays and overall health care costs.
- HIDI MPI drives data-informed decisions: HIDI’s ability to follow patients across health systems provided critical insights that helped BJC sustain and scale the H2H program.
“These are people, and these are real lives that we’re able to rebuild. We are actually shifting the narrative and supporting programs that really have a meaningful impact to do community good.”
– Calencia Mitchell, community health improvement manager, BJC HealthCare
Evaluating the Impact of Social Care Programs at Scale
This case study illustrates how HIDI’s MPI solution can power real-world evaluations that go beyond clinical walls to measure the true impact of social care. The BJC H2H program continues to serve as a model for addressing nonclinical factors through hospital-community partnerships.
“And when we succeed together, we build trust. We fulfill each other’s missions, and we help our community improve their health status.”
– John Lynch, M.D., president, Barnes-Jewish Hospital
Ready to Harness MPI?
The success of this evaluation highlights the importance of robust data tools and analysis for understanding nonclinical factors that affect health outcomes.
Interested in learning more about how HIDI’s MPI can support your social care strategies?
