Advancing integrated care for individuals experiencing homelessness: harnessing data partnerships and coordination

ABSTRACTBridging gaps in care coordination for homeless populations is a complex task that requires addressing attitudinal and behavioral changes, as patients hold more control over chronic and preventive care. Despite these challenges, organizations like the Patient Care Intervention Center (PCIC) have made significant strides in improving health equity for vulnerable populations in Houston. PCIC integrates data, fosters collaboration between social services and medical providers, and provides comprehensive and targeted services, positively impacting the health and social outcomes of 98,838 individuals. By addressing diverse needs and integrating medical and social care, PCIC offers a model for developing comprehensive solutions to prevent and reduce homelessness while improving health equity for socially and medically vulnerable populations.PCIC’s approach involves data sharing partnerships and care coordination initiatives with various agencies in Harris County and Houston. This cross-sector collaboration, integrating data from multiple sources such as hospital systems, managed care organizations, and government agencies, enables the development of more effective interventions.PCIC demonstrates the limits of fragmented interventions and the importance of integrating medical and social care. PCIC’s model serves as an example of how collaboration, targeted services, and data integration can improve health equity and contribute to the prevention and reduction of homelessness.KEYWORDS: Homelessnesscare coordinationmedical and social data integrationhealth equityprevention and chronic disease approachesdecolonizing healthcarereferral management and social data integration AcknowledgementsWe are grateful for the countless emails and interviews with Kallol Mahata, CEO of Patient Care Intervention Center who contributed to the content of this manuscript. Dr Buck serves on the board of the non-profit PCIC (volunteer) and founded it in 2009.Disclosure statementNo potential conflict of interest was reported by the author(s).