Introducing Vail Place’s Results Focused Model Program

Introducing Vail Place’s Results Focused Model Program

In collaboration with HealthPartners, Vail Place is piloting a new program, the Results Focused Model (RFM). The goal is to improve the health and stability of individuals, which in turn reduces healthcare costs. Patients who are referred to the RFM program typically meet one or more of the following criteria:


  • Are frequently admitted to the Emergency Department or have a high rate of hospitalization
  • Have not been successfully engaged in other programs such as Targeted Case Management
  • Require intensive housing support because they are homeless, have insecure or unsafe housing or face barriers like poor rental history or criminal background
  • Have chronic and unmanaged health conditions that may benefit from consultation or intervention from a community Registered Nurse
  • Have unmanaged mental health or substance abuse disorders that impact their ability to function and remain stable in the community
  • Would benefit from assertive outreach from a Vail Place Navigator or connection with a nurse

We have served 50 members with RFM. The average length of stay in the program is 115 days, and we make an average of 9 contacts or contact attempts per month for individuals who are opened to the model.

RFM in Action: Client Snapshot

Vail Place client “Tim” was in a serious accident before he was referred to RFM, and had a history of homelessness. He experienced ongoing mental and physical health conditions and his substance abuse also made it difficult for him to get help. Tim came to the program facing many obstacles including mental and physical health needs that were not being met; lack of transportation and difficulty navigating public transportation because of the injuries from his accident; food insecurity; dissatisfaction with his living arrangements and a desire to relocate outside of the city; and a need for routine psychological, medical, dental and vision care.

The RFM team implemented the following interventions:

  • Researched new options for subsidized housing and helped avoid a housing crisis and provided ongoing housing assistance
  • Helped Tim access a community food shelf and meals and helped him improve long-term access to resources and skills for food security
  • Coordinated with HealthPartners to find a local primary care clinic, dental and vision care providers, as well as prescription medications
  • Provided information on mental health providers and clinics and resources for coping with anxiety and crises
  • Gave ongoing support to coordinate Tim’s care

For more information about RFM please contact Shelly Zuzek at 952-945-4250 or Download the brochure here.