The question for health care leaders is not whether health systems have a role to play in reducing homelessness. They do. The question is how to make the most meaningful impact.
How health systems can drive reductions in homelessness
Through a three-year pilot with health and homeless response systems across five communities, Community Solutions and the Institute for Healthcare Improvement identified three pillars of effective cross-sector collaboration. Read the full findings in Health Affairs.
Building bi-directional awareness and commitment
Lasting collaboration starts with shared language and relationships across sectors — foundational before any specific project can succeed.
Establishing structures for cross-sector partnership
Data-sharing agreements, embedded liaisons, joint governance structures, and coordinated discharge protocols turn one-time collaborations into lasting practice changes.
Participating in a holistic system of care
Health systems can directly expand homeless response capacity through medically supportive housing, case conferencing, and financial investments aligned with housing outcomes.
Four roles health systems can play
Research and learning from communities working at the intersection of health care and homelessness point to four concrete roles health systems can play to help reduce homelessness in their communities.
1. Identifying patients experiencing housing instability
Social determinants of health (SDOH) screenings in clinical settings can identify people experiencing homelessness early, create referral pathways into the homeless response system, and help ensure community-level data is complete. Pilot sites found that effective screening requires trauma-informed, culturally responsive practice integrated into clinical workflows and a clear protocol for connecting patients to services.
In Chattanooga, local hospitals and health centers are now trained to conduct homeless assessments and enter data directly into the community’s shared database, expanding the reach of coordinated entry and ensuring more people experiencing homelessness are known to the system.
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2. Prevent discharge back into homelessness
Hospital discharge is one of the highest-leverage moments a health system controls. Without deliberate coordination, patients experiencing homelessness are often discharged back to shelters or the street and return to the emergency department predictably. Standardized discharge planning and housing referral processes, built in partnership with the homeless response system, can interrupt that cycle.
In Sacramento, Kaiser Permanente funded a dedicated liaison within the hospital whose sole focus is connecting patients to housing resources after discharge. Early data show increased connections to primary care and decreased hospital utilization. In Anchorage, a Complex Care Shelter gives patients with serious medical needs a place to recover after hospitalization and work toward permanent housing.
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3. Share data across systems
When health systems and homeless response organizations can see the same people across their records, they can coordinate care, target resources, and track outcomes at a population level. In Sacramento, data-sharing policies enacted through the state-level Medicaid CalAIM initiative enabled the Continuum of Care, Managed Care Organizations, and the Health Care delivery system to begin sharing information across these three sectors to identify clients with both health and housing needs. This data sharing enables cross-sector teams to identify clients who can receive benefits and resources offered through CalAIM like Enhanced Care Management and Community Supports.
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4. Coordinate care through cross-sector case conferencing
In Washington, Clackamas, and Multnomah Counties, cross-sector case conferencing meetings supported by data-sharing agreements bring together Kaiser Permanente, Providence Health, Health Share, and the local Continuum of Care to develop joint plans, close gaps in care, and build working relationships that extend beyond any single meeting.
Sacramento is also operating cross-sector case conferencing with housing providers, the CoC lead, health systems, and Community Based Organizations to identify clients who are eligible for CalAim supports (ECM and Community Supports) to provide dedicated case management and navigation support to connect clients to medical, social and behavioral health services that are funded through California’s medicaid program.
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Population-Specific Resources
Shared accountability, data sharing, and cross-sector case conferencing often illuminate opportunities for communities to collaborate around meeting the needs of specific populations of people experiencing homelessness. Community Solutions has developed resources to support health systems and homelessness practitioners working with special populations, beginning with older adults experiencing homelessness.
Older Adults
People 50 and older are the fastest-growing segment of the population experiencing homelessness in the United States. They present complex, compounding health challenges that demand coordinated responses from both health care and homelessness systems. Community Solutions developed the Older Adults Needs and Assets Assessment Toolkit to help communities identify and respond to the specific health, functional, and social support needs of older people experiencing homelessness.
Tools and Resources
The following tools, articles, and frameworks support health systems and communities building cross-sector collaboration to reduce homelessness.
Toolkits
Data-Sharing Toolkit: A practical guide for health systems and homeless response organizations establishing data-sharing agreements. Covers the spectrum of possible arrangements, legal frameworks, data governance, and implementation steps.
Liason Toolkit: Guidance for health systems creating embedded liaison positions that bridge health care and homeless response settings, including the Hartford Liason model.
Case Conferencing Toolkit: A step-by-step resource for establishing cross-sector case conferencing between health systems and homeless response teams.
Older Adults Needs and Assets Assessment Toolkit: A structured assessment tool for identifying the health, functional, and social support needs of older adults experiencing homelessness.
Articles and Research
Health Care’s Role in Reducing Homelessness: Published in Health Affairs, June 2024. Sandor, Chimowitz, Hardin, Arsenault, and Davis examine the four roles health systems can play, drawn from the Healthcare and Homelessness Pilot.
Data-Sharing Article: Research and guidance on establishing data-sharing infrastructure between health and homeless response systems.
Health Care Executive Article: An executive overview for health system leaders on cross-sector collaboration and anchor mission.
Healthcare Financial Management Article: Financing mechanisms and return-on-investment framing for health system investment in homelessness reduction.
Slides and Frameworks
Overview Slides: Health Care and Homelessness: An overview of the three pillars of effective cross-sector collaboration, from a Built for Zero Learning Session. For health system leadership and board audiences.
Systems of Change: A summary of the systemic changes communities made to integrate health care and homeless response during the pilot.
