Building a Truly Unified Care Plan: How Your HMIS Can Help

We believe that your HMIS can be the heart of providing unified care: care where every provider in your CoC is aligned, the right information is shared with the right people, and more unhoused folks have a path to services, housing, and stability.

But what does it take to get there? How can your community overcome the very real challenges — competing demands, limited resources, complex delivery systems, and more — to make unified care possible?

Our team at Bitfocus has been digging into this very question, and we can’t wait to share what we’ve found. Let’s jump in.

Why Is It So Hard to Provide Unified Care?

Before tackling the beast that is unified care, it helps to understand what sort of challenges we’re up against. Here are the key areas where our partner communities consistently face barriers in the pursuit of unified care.

Challenge #1: Data Sharing + System Integration

If you’re running a housing agency, keeping track of the relevant data points and staying on top of things isn’t easy, but it’s doable.

Add an entire homelessness response system to the mix — including state, government, and legal entities that don’t use your HMIS and probably never will — and the task becomes far greater. You’ll have to tackle questions like:

• Which systems talk to each other (and how)?
• How can we keep those integrations secure?
• Who gets access to what information?
• How do we maintain data quality with so many sources?

Here’s a simple example: Imagine you have a client who is receiving services through your housing agency, and they’re also seeking out medical care with a local healthcare provider.

To make sure you’re providing whole-person care, there should be a two-way exchange of information: Your agency is aware of your client’s medical appointments, and the doctor’s office knows about your team’s efforts to support this client.

But how much should the doctor’s team know? What information is your client comfortable with you sharing? Plus, how can you make sure any messaging around sensitive information is encrypted and properly safeguarded?

Even in this oversimplified example, you can see how easy it is to muddy the waters. Sharing data thoughtfully is difficult — but when done properly, it can have a huge impact on the clients you serve. (Here’s one of our favorite case studies on the impact of smart data sharing. Check it out if you’d like to learn more!)

Challenge #2: Maintaining Data Quality

In addition to maintaining multi-source data quality within your HMIS, there’s the added layer of complexity that comes with non-HMIS users.

Revisiting the above example: If there’s an information gap between your housing agency and your client’s doctor, your client’s health outcomes may suffer. And if that medical care doesn’t go according to plan, a little bit of trust in the system will be lost. Over time, this erosion of trust can derail your client’s journey toward housing and stability.

Ensuring that everyone has the appropriate data at the right time is vital — as is promptly reconciling any differences between systems. That way, each provider can offer the best possible care, and your clients can know that their care team is truly working to help them.

Challenge #3: Providing Trauma-Informed Care

We’ve mentioned this already, but it bears repeating: providing holistic, trauma-informed care is one of the single most important elements of a unified care plan.

The Path Forward: Two Tips

Before we dive into the details of unified care, a quick word of advice:

1. Don’t overcomplicate things. Data sharing, coordinated entry, whole-person care — it’s easy to get overwhelmed by the idea of creating a unified care plan. With that in mind, our best advice is to…
2. Choose one or two meaningful goals. Once you’ve established these “starting place” initiatives, build a structure to support them. Do them, and do them consistently. You’ll notice that, once you’ve taken the first couple of steps, the rest of the journey becomes far more manageable.

What Does the Ideal Unified Care Plan Look Like?

Join us in a thought experiment.

We know that, in practice, getting everyone in your CoC aligned and maintaining A+ data quality is tremendously difficult (though we do believe that our built-for-real-humans HMIS, Clarity Human Services, can make the job a little easier). We’ve had the privilege of partnering with dozens of CoCs like yours, and we’ve seen firsthand the challenges that come with rolling up your sleeves and doing the work.

But what if you didn’t have to worry about the practical elements? What if there was no training burden for new tools, no funding to win, no stakeholder buy-in to earn, and no other barriers to excellent care? What if you could snap your fingers and bring about any transformation, no matter how big?

In that world, what kind of care plan would you envision for your clients? Here are a few of our favorite ideas:

• Permanent Housing, ASAP: This one’s obvious, but — bringing more people into shelters and then long-term housing is the ultimate goal. The faster we can make those connections, the faster we reach Functional Zero.
• Set Up for Thriving: It doesn’t stop with housing. A unified approach means facilitating all types of flourishing: finding a job that pays enough to cover basic needs and then some, getting back on top of neglected medical and dental care, and building new social support networks along the way.
• Raising the Bar: How stable is “stable enough” for services to end? If resources were unlimited, we’d raise that bar as high as possible, continuing check-ins and follow-ups well after program enrollment has been finished. CoCs could support clients for much longer without neglecting other people in crisis.
• Getting Systems Talking: If your HMIS and EHR (for example) were integrated, there would be far fewer gaps in client care. A client could enter the hospital for a brief stay, knowing that their shelter bed is reserved and they won’t be back on the streets when they return.
• Never Back to Square One: Bumps in the road should be just that — bumps, not derailments. A unified care plan, at its best, minimizes the impact of setbacks so that clients can make steady progress and maintain momentum.

What do you think? What did we miss? Give us a shout and let us know. We love making new connections and dreaming big with our partners in ending homelessness.

HMIS: The Heart of Unified Care

Now, it’s time for the rubber to meet the road. In the real world, with limited time, resources, and energy, how can we bring those ideal outcomes to life?

Call us biased, but we truly do believe it starts with your HMIS—a home for your data, a home for the stories and metrics that matter, and a tool for demonstrating progress, gaining funding, and, most importantly, collaborating to provide stellar care.

Sharing Data

A great HMIS is an open, flexible, and secure platform for data integration. It allows system administrators to import and export data without a hitch, sharing the relevant information with agencies that need to know.

Clarity uses two APIs to communicate with other systems, easing the burden of sys admins through automation and offering real-time insight into client data and system performance for better reporting. Plus, with the right data-sharing agreements in place, Clarity’s client pool can be expanded to agencies that don’t participate in coordinated entry so more people can be connected to housing programs.

Tracking Client Progress

Understanding where clients are at in their journey — and facilitating smooth handoffs between agencies along the way — is crucial to reaching Functional Zero. With a unified care approach, your CoC should always know who’s responsible for what so that your clients don’t slip through the cracks.

Your HMIS coordinated entry system can be an end-to-end partner, helping you efficiently create more housing victories through:

• Better Reach: Geospatial analytics and mobile responsiveness for outreach teams ensure that clients have fair and equal access to your homeless response system.
• Quicker Connections: Once you’ve entered the relevant info, Clarity’s eligibility engine automatically shows you which programs your clients are eligible for.
• Stronger Alignment: Your HMIS can serve as a single source of truth for your systems of care.
• Easier Collaboration: Where is your client in their journey, what are their next steps, and what’s needed to accomplish them? A user-friendly HMIS makes these moves friction-free.

Empowering All Decision-Makers

Remember, your HMIS cannot make decisions — it can only inform them. And when it comes to resolving homelessness, there’s no shortage of voices in the room. A recent piece from the Terner Center at Berkeley acknowledges the competing needs and perspectives of:

• Local governments
• Elected officials
• Community-based organizations
• Housing developers
• Corporations
• Philanthropists
• Advocates
• People with lived experience of homelessness

To serve each, your CoC should strive to make information as easy to access as possible. Tailor data collection so that every key player can get the answers they need. Use API integrations to make sure the data is rich and complete. Publish public-facing dashboards to showcase the success of your initiatives and make the case for more resources.

In our Bitfocus partner communities, we encourage CoCs to leverage our 175+ pre-built reports to learn more about ongoing efforts while also building and monitoring custom reports to keep an eye on what’s most important to your community’s policymakers, stakeholders, and funders.

Outcomes of Unified Care Planning

If you’re making the most of your HMIS as you deliver truly unified care, your CoC will experience:

• Greater efficiency in service coordination and provision
• Faster connections to housing for folks in need
• More holistic care for clients
• Less duplication of services or assessments
• A rise in trauma-informed care for your community

A note on that final bullet point: Trauma-informed care is not just past tense. When your service providers ask the right questions in a trauma-sensitive way, it stops the perpetuation of trauma and builds trust in the system. You won’t just avoid the resurfacing of difficult memories — you’ll lessen the impact of ongoing trauma and prevent new trauma from occurring.

That’s a key piece of providing unified care and a surefire way to, in the long run, help more unhoused people find permanent housing and stability.

The Road to Functional Zero Starts With Unified Care

At Bitfocus, we believe that providing unified care is one of the quickest routes to making homelessness rare in your community and ensuring that episodes of homelessness are brief and non-recurring.

Your HMIS can be the heart of this initiative. Today, there might still be challenges with data sharing, with coordinated entry, with offering trauma-informed care. No, those challenges won’t vanish overnight. But with the patience and persistence of your community’s champions, unified care is possible — and the progress you make each day is a small step toward it.

If you’d like to chat more about this topic, or learn about the care-unifying features built into Clarity Human Services, let us know. We’re confident we can help you bring more people in your community home, and we’d love to show you how!