Impact of a Data-Driven Centralized Care Coordination Program in a Large Urban Shelter System

Impact of a data-driven centralized care coordination program in a large urban shelter system for single adults


A pilot program of centralized data-driven care coordination integrated within a large urban shelter system was guided by Hawk’s et al. (2017) principles of universal harm reduction. This conceptual approach was hypothesized to improve effective health service utilization and reduce harmful incidents in shelter in this highest need population with little existing social support.


Approximately 52,000 people per day received shelter services in 2021 in this urban center. Of those, about 16,000 were single adults. Of single adults with Medicaid who had healthcare visits and were unhoused in 2016-2018, based on data analyzed by an academic partner, 62% had chronic mental illness, 66% had a substance use disorder and 41% had an alcohol use disorder. The same analysis found highly elevated rates of chronic medical conditions. In addition, the population has high rates of incarceration, with 1,045 arrests in this shelter system in 2021.

Program Description

An initial group of 50 very high-risk clients were identified using administrative data from the shelter case management system, followed by outreach and coordination of services through a centralized care management team with medical and social work backgrounds; multiple local and state agencies participated. The program focused on reducing harms associated with health conditions, addressing client preferences and needs, and providing structured engagement plans that followed clients across multiple settings, including shelters, hospitals, and jails.


After six months, there was an average 46% reduction in reported negative incidents in shelter, followed by an additional 30% reduction in months six through twelve. In the first year of the intervention, 20% of clients moved to permanent housing, 28% were incarcerated, and 6% died.


Centralized care coordination for people experiencing homelessness with complex health conditions that prioritized humanism, pragmatism, incrementalism, and accountability without termination of services was associated with a decrease in shelter-reported negative incidents among these clients.


Jessie Schwartz: Clinical Coordinator, New York City Department of Homeless Services; Eve Cleghorn: New York City Department of Homeless Services; Dr. Fabienne Laraque: Medical Director, NYC Department of Homeless Services

Session Materials: 

Categories: Research and Data, Shelter Health
Tags: 2023 National HCH Conference
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