From Services to Long-Term Stability: How Your HMIS Builds the Bridge

When people experiencing homelessness connect with services, they get housed, find jobs, improve their health, and rebuild their lives. 

Often, outcomes like these involve an element of magic and an element of science. They happen because of thousands of small, human moments — moments where someone notices a neighbor in need and reaches out. It might be a case worker, a volunteer, or a complete stranger. They notice, and they seek to support. That’s the magic. 

But for large CoCs advancing homelessness resolution initiatives, there’s more to it than that. There’s the data collection, analysis, and interpretation going on behind the scenes. There are the assessments, workflows, and case-specific notes that make progress possible. There are dozens of providers collaborating in real-time to provide holistic, trauma-sensitive care. That’s the science.

In this piece, we’ll explore how your CoC can create the science that supports the magic by putting your HMIS to good use. We’ll also touch on strategies to keep clients engaged and help you make the most of a user-friendly HMIS like Clarity Human Services. 

But first, a story about Marcus.

Marcus’ Story: Why Access to Services Matters 

Marcus sat in his tent at the edge of the encampment he was living in. He was 62, diabetic, and had been unhoused for two weeks after losing his apartment of three years due to a steep rent increase. Most people would have moved in with family at this moment of crisis, but he had none.

A field visit from an outreach worker ended up changing the course of Marcus’ life.

An Outreach Worker Makes First Contact and Brings Basic Necessities

On the day they met, Kevin, an outreach worker, connected with Marcus at the encampment where Marcus was staying. Within an hour, Kevin helped Marcus complete an initial assessment and entered his basic information into the community’s HMIS. Marcus was hesitant to provide too much personal information, so he just gave Kevin his name and told him that he was a diabetic.

While Marcus waited for a shelter bed to open up, Kevin returned to the encampment a couple times and brought him a new pair of socks, a bus pass, and directions to the nearest shower facility. The bus pass let Marcus, a diabetic, keep his medical appointments, and reestablishing hygiene habits at the nearby facility added a helpful sense of routine to his life. 

Soon, Marcus got a shelter bed placement to keep him off the streets as the cold winter temperatures rolled in. He was assigned a case manager named James. James tried to learn more about Marcus to find out what kind of services he might need most, but Marcus was a bit suspicious. After all, he didn’t know Kevin, so why should he trust him? 

A few days later, Marcus had a medical emergency and ended up in the hospital with low blood sugar. 

Because the hospital EHR had an integration established with the local HMIS, the hospital social worker was able to find out that Marcus was homeless and staying in a shelter. She reached out to the HMIS liaison who was able to contact James and the shelter to let them know Marcus was in the hospital but would be back at the shelter after a night in the hospital. 

Regular Check-ins Build a Bridge of Trust

Marcus initially only used services for urgent medical needs. However, with steady case management meetings with James, trust grew. James offered not only practical assistance, but also consistent kindness—something Marcus hadn’t had from anyone for a long time. 

When Marcus had another health crisis, he reached out to James. James secured Marcus a medical respite bed, where regular healthcare monitoring helped stabilize his situation.

Marcus began to share more of his story and feel comfortable engaging with more services such as a job-skills program and a cooking class. James helped Marcus apply for disability benefits. 

A Cooking Class Serves as a Turning Point

One of the services Marcus received was enrollment into a cooking class. Through this class, Marcus rediscovered a long-dormant love for cooking. The class got him excited to learn some new cooking skills. He was thrilled to show another resident how to make his mother's cornbread recipe. The class and the friends he made in it became his reason to stay engaged with services.

From Survival to Stability: Housing and Purpose

Today, Marcus lives in a small, supported housing apartment. His diabetes is under control. The job-skills program helped him find part-time work as a kitchen prep cook. He also earns a small stipend for teaching the same cooking class that lit the inner spark in him.

Marcus often reflects on that first conversation with outreach worker Kevin and how that interaction set off a series of events that created real change for him. From the initial assessment, to the bus pass, to the hospital social worker who helped him keep his shelter bed, to the cooking class, to the trust building with James over time, these steps helped Marcus get to where he is today.

Behind many of these steps, often invisible, is the impact of an HMIS (and the thoughtful data sharing and collaboration that it enables). Each of the people helping James used the HMIS to manage his care plan, provide him with the services needed, and propel him to the next step on his journey out of homelessness.

How Your HMIS Can Help

Modern homeless response systems need more than data storage. They need tools that connect services, track progress, and guide decisions, helping more folks like Marcus find stability and long-term housing. 

Tracking Client Progress

An HMIS can connect clients to essential services when they enter a program. One enrollment links them to housing navigation, healthcare, meals, and transportation. By tracking this data in the HMIS, case managers can add specialized support as needs change.

The system lets case managers set and monitor incremental goals, such as:

• Appointments attended
• Job skills training completed
• Employment attained

In Clarity Human Services, the client profile is a comprehensive record of what the client has experienced in their housing journey. Upon opening a client profile, Clarity users find everything they need to know about that client.

This approach prioritizes the clients, allowing community care providers to read case and service notes, among other background information, to gain greater insight into a client’s progress. With everyone on the same page, unhoused people won’t be required to relive traumatic episodes or repeat the same information over and over.

For Marcus, this functionality meant his story traveled with him from that first outreach visit through his current housing placement.

Identifying Service Gaps

Your HMIS should offer real-time reports that show which programs fill up fast and which populations need better options. 

Bitfocus’ Report Library and Data Analysis Tool help communities spot these gaps quickly. They see which programs need expansion and where new services could help.

Case managers can turn HMIS data into persuasive funding requests by showing where service gaps exist and what solving them would cost. For example, if HMIS data shows 250 people need mental health services, case managers can request precise funding: Two new counselors would serve 80 clients annually, expanding treatment access by 32% of the documented need.

Coordinated Entry referral tracking lets case managers see if referrals are being improperly denied, helping communities identify areas for improvement in service delivery and equitable solutions.

On a client level, outreach worker Kevin used his mobile-friendly HMIS to access Marcus' profile and case notes from his tablet during their park bench meetings. Kevin could update records, schedule appointments, and check service availability without returning to the office. Best of all, the HMIS’ integration with GIS allowed him to stay looped into where Marcus was staying and how close he was to crucial services.

Instant access to information and location-based insights helped Kevin respond to Marcus' needs on the spot and helped his case manager James stay in touch with him throughout his journey. 

Measuring and Reporting Outcomes

CoCs track service delivery and sustained housing outcomes to determine program success. You can track program outcomes in the HMIS, but you have the potential for greater efficiency and better outcomes when data is shared between other key entities (hospitals, courts, community organizations, and more).

With Clarity Human Services, pre-built reports show success rates across programs.

Custom reports answer targeted questions about specific initiatives. Visual dashboards help leaders make informed decisions about improving their homeless response systems.

Marcus' journey proves why this reporting matters. His path from an encampment to stable housing required coordinated support. Seeing the success of each step gives a clearer picture of how Marcus was able to attain housing security and offers a potential path to housing for other people in a similar situation. 

Keeping Clients Engaged: Tips and Strategies 

Optimized service utilization only works if your clients agree to the next steps in their journey out of homelessness. Of course, every person will be in a different place and mindset. Some folks may be ready to look for services, employment, and housing right away; others may be focused on where they’ll sleep or how they’ll find their next meal. 

Here are some tactics to develop strong connections that move your clients forward.

Build Trust Through Consistent Engagement

Meeting clients at their starting point defines successful outreach. An unsheltered person might initially share only their first name. That's enough to begin. With Clarity’s geospatial analytics, an outreach worker can create a client profile from the field and geolocate the client at that encampment location, enabling outreach staff to find that person again during the next visit.

Maintain regular contact and let relationships develop naturally. The outreach worker who appears every Tuesday with water becomes a steady presence. The case manager who remembers details about someone's pet creates authentic connections that build trust.

Continue this engagement with the client until they’re comfortable enough to accept services.

Enable Client Autonomy

Clarity’s Client Portal enables people to independently check housing status and upcoming appointments without visiting physical offices.

This digital framework supports autonomy. When individuals can view their information and monitor progress, they shift from passive recipients to active participants in their housing journey.

Find Personal Motivation

Small steps create momentum. Someone might not be ready for permanent housing but will accept a bus pass or shower facilities. Each positive interaction opens doors to additional services.

Clarity's adaptable data collection captures these incremental changes. As trust develops, staff can gather deeper information to provide comprehensive support.

Personal interests often reveal pathways to engagement. Marcus discovered meaning in teaching cooking classes. Others connect through art programs or peer support. When services align with individual passions, participation strengthens naturally.

Technology enhances relationship-building without replacing human connection. Tools like Clarity track data and advancement while allowing genuine human bonds to form.

Data Sharing: Key to Service Delivery

Sharing data across systems creates better outcomes for people experiencing homelessness. When service providers can access comprehensive client information, they can offer more effective, coordinated support.

With Thoughtful Data Sharing

With thoughtful data sharing, care coordination improves, and clients receive faster, more targeted assistance. 

This method of sharing data is also more empathetic. For example, when systems connect, providers see a client's complete service history. This coordination prevents duplicate assessments from being created. Most importantly, it offers a trauma-informed assessment approach, as clients don't have to share difficult personal experiences repeatedly.

Data alongside empathy creates positive results for CoCs. Our friends in the San Diego CoC recently leveraged Clarity HMIS to integrate 211 San Diego, a contact center for housing-related services, with Community Information Exchange (CIE), a technology ecosystem that allows organizations to share information responsibly. Thanks to integrated data systems, clients enrolled with CIE stayed housed at seven times the rate of those unenrolled. (Check out the details of the case study here!)

For Marcus, thoughtful data sharing meant his medical history traveled seamlessly from the emergency room to the medical respite program. This enabled him to receive consistent diabetes care without repeated explanations.

Without Thoughtful Data Sharing

Fragmented data creates barriers to reducing homelessness. 

Service gaps widen when systems can't communicate. As one Family Health Centers of San Diego provider noted, before integrating 211 San Diego and CIE, “We couldn't locate patients or know where they were connected, making proactive outreach impossible." 

Clients miss housing opportunities because their information isn't visible across providers. Service histories remain incomplete, complicating eligibility determination.

In Marcus' case, without data sharing between the hospital EHR and HMIS, he might have left the emergency room without a shelter bed to return to.

Bring More People Home With Clarity

Marcus' journey from an encampment to supportive housing shows how service utilization shapes real lives. Each data point in your HMIS represents a person at a crossroads like Marcus.

When your CoC optimizes its service delivery through thoughtful HMIS implementation and usage, its impact can be felt in individual lives and throughout entire communities.

Your CoC has the components for better outcomes. The right platform helps you connect them effectively and bring more people home. To learn more about the ultra-user-friendly HMIS that is Clarity, give us a shout.