Vail Place launches new pilot program – the Results Focused Model!

Vail Place launches new pilot program – the Results Focused Model!

Vail Place recently developed an innovative service model targeting individuals who are experiencing a variety of challenges and barriers to stability. Based on the many occasions where we’ve seen people fall through the service cracks, we had a vision of creating a “wrap-around”  program that could pull from a variety of Vail’s services and programs to support individuals at their most vulnerable, with the goal of ultimately linking people to the Clubhouses for ongoing support and connection to the community.

This vision led to the development of the Results Focused Model (RFM) which was marketed to insurance providers to support their members who are difficult to engage, may be homeless/have unstable housing, and often have chronic health conditions.  It’s not uncommon for these individuals to have frequent Emergency Department visits ​or hospitalizations, as evidenced by the following snippets from recent referrals:

…homeless and has had 14 inpatient admissions throughout 2018 and 2019 for diabetes complications related to alcohol use. Recently hospitalized for complications from diabetes.

…diagnosed with depression, PTSD, and struggles with substance use.

…lives with Bipolar Disorder, Depression, Anxiety, PTSD, and ADHD. Typically visits an Emergency Department 10 or more times a month and has occasional hospitalizations. Difficulty connecting to outpatient care.

…at risk of homelessness, does not take medications as prescribed, has had several hospitalizations this year, one that lasted over two months. Has schizoaffective disorder, bipolar disorder, depression, anxiety and diabetes and needs assistance with transitions of care.

The RFM program premise is based on a Navigator, employed by Vail, who meets the referred individuals where they are at and follows them, working to address their needs and promote stability in the community. The team will focus time on connecting individuals to resources, healthcare and other providers, as well as to community supports to address the barriers they are facing.

HealthPartners was excited to contract and partner with Vail Place for an 18-month pilot. The goal is to help stabilize individuals, improve their quality of life and reduce unnecessary costs to the healthcare system through connection to community providers and resources.

The RFM team functions under the Integrated Care program umbrella at Vail and supported by our Vail Care Program. The RFM program may be the difference between living life in the community and bouncing between shelters and Emergency Departments and finding support and stability through Vail Place.