In 2018, Penobscot Community Health Care (PCHC), a Federally Qualified Health Center and The Hope House Health and Living Center in Bangor began a unique collaboration between health care and homelessness services utilizing HealthInfoNet’s Analytics and Reporting Platform (HARP). This tool identifies patients at high-risk for readmissions and connecting them to appropriate community and health services to prevent readmissions.

The Use Case Report features workflow, documentation and impact.