Harnessing Apps to Improve Coordinated Care Among the Housing Insecure

Lack of housing and homelessness often go hand-in-hand with poor health outcomes. Individuals experiencing homelessness face higher rates of chronic illness, mental health challenges, and substance use disorders. They also have more difficulty accessing and navigating healthcare services. This leads to overuse of emergency services and hospital readmissions, disrupting the continuity of care.

With over half of the world’s adults owning smartphones, community information exchange (CIE) apps offer a promising solution for those experiencing homelessness. Currently, providing continuous, coordinated care across multiple access points poses major communication and privacy hurdles for providers serving the homeless population. Many programs still rely on outdated paper records to track client health information and care services, resulting in a fragmented approach severely limiting the ability to share data and connect care across street medicine teams, shelters, clinics, social services, and hospitals.

By securely connecting patients, healthcare providers, social workers, housing services, and other partners, these apps facilitate real-time coordination and information sharing that address social determinants of health. This helps build a holistic picture of an individual's needs, provides them with a safe place to interact with the network, and an easier interface to manage cases and enhance coordinated care.

For example, when a homeless patient is discharged from the ER, their care plan and follow-up instructions can be immediately accessed and, coupled with an encrypted, open messaging protocol such as NOSH, they can safely and securely message their providers. Shelter staff and outreach workers are notified and can assist with transportation, medications, and appointments and communicate with their patients to coordinate care.

CIE apps also allow individuals to securely access their health records, care plans, and provider information and directly message their providers from their smartphones. This puts care coordination directly in the hands of vulnerable patients who may struggle to navigate complex systems. Features like medication reminders, health education, appointment reminders, and telehealth access further empower individuals to manage their health proactively.

While initially focused on homeless populations, these same principles of coordinated, patient-centered care enabled by secure technology could be applied to other groups with high needs and barriers to traditional healthcare, like incarcerated individuals re-entering the community, immigrants, refugees, patients with serious mental illness, migrant farm workers, and more.

As the healthcare landscape increasingly focuses on whole-person, value-based care, cross-sector collaboration is essential. Thoughtfully designed CIE apps that follow WHO Smart Guidelines have immense potential to break down silos, promote health equity, and improve outcomes for our most vulnerable.