Dr. Bjorn Westgard bristles at the unkind term "frequent fliers," which some use to describe people who use hospital emergency rooms for regular medical care.

But Westgard, a HealthPartners emergency room doctor at St. Paul's Regions Hospital, understands the challenges in treating these "very difficult patients," who typically suffer from a litany of chronic conditions such as mental illness, chemical abuse and homelessness.

"There is personal responsibility, but once you're under the tsunami, it's tough to swim on your own," Westgard said. "We're trying to get to the place where folks can get on top of it."

An innovative pilot program, Hospital to Home, is helping them do just that. It partners Westgard and other Regions doctors with Hearth Connection, a nonprofit dedicated to ending homelessness; Guild Inc., whose mission is to help people with mental illness lead quality lives, and the Minnesota Department of Human Services.

The pilot program was small -- seven individuals with tremendously challenging personal stories -- but so promising that HUD has awarded Hospital to Home nearly $258,000 to expand by another 18 to 20 individuals this summer.

Among early results: A dramatic decrease in emergency room and inpatient stays, which lessens the hefty financial and resource burden on hospitals and taxpayers, as well as greater self-sufficiency for participants and even a drop in crime.

"We want to show policymakers that we have solutions to ending long-term homelessness for people who have already cycled out of other places, such as jails and shelters," said Richard Hooks Wayman, Hearth Connection's executive director. "We bring intensive case management in ways that give [participants] control, autonomy and self-respect."

Intensive is right. Not a day goes by that participant Bill Anderson, 45, doesn't have somebody checking in on him. Chemically dependent and diagnosed with bipolar disorder and chronic obstructive pulmonary disorder (COPD), Anderson bounced around for about two years -- sleeping in a bar's back room, then in a friend's basement where the owner's dog used to defecate, then at a homeless shelter -- growing increasingly desperate.

In 2009, he visited emergency rooms at least 20 times, sometimes "hoping for a place to sleep."

Anderson smiles recalling the day Beth Allen, a registered nurse with Guild Inc., asked him: "How would you like to be in your own place by next month and never be homeless again?" Three weeks later, Anderson had his own apartment.

The transition sounds simple, but planning and collaboration to pull this off were a strategic marvel.

Hospital to Home is based on similar programs on the East and West Coasts. Patients were identified after using Regions ER five or more times in the past year, and having one or more chronic medical conditions, mental illness and a long history of homelessness. One patient had been homeless for 22 years.

Guild moved in, assigning each client to a primary care doctor and team of nurses and mental health professionals, as well as service providers responding to the unique needs of each. Anderson, for example, gets regular visits from a personal care attendant and an employment specialist.

Hearth Connections brought the financing and administered rental subsidies, which got participants into permanent housing within three months. Clients pay 30 percent of their income toward rent, something they are happy, and proud, to do.

"Once you get into our program," Wayman said, "we stick with you. If you fail in your first apartment, we find you another."

With that support, total emergency room visits decreased from 68 visits to 38 within months. Inpatient stays were shorter. And while six of the seven participants had a criminal history, only one was charged with a crime after enrollment: misdemeanor theft.

Wayman and others remain realistic about this "deep-end population." Two of the seven have died. But even they experienced improved quality of life at the end, he said. And the trajectory for the others is good.

Anderson was in the ER recently with breathing difficulties. But he was hard-pressed to remember when he'd been there before that. He just moved into a bigger apartment that offers more services and opportunities for healthy socialization. He's working part time, paying rent and making plans.

"I'm feeling pretty good all over," said Anderson, whose goals are to be chemical-free, walk every day, eat more healthful foods and get his GED.

"My future plans?" Anderson said. "I wish they were here already."

gail.rosenblum@startribune.com • 612-673-7350