Housing Is Healthcare

Crisis Response Network Uses Data-Sharing to Take Holistic Care to Another Level

By: Solomon Collins

The Director of HMIS at the Crisis Response Network in Maricopa County gives a masterclass on how he uses the federally funded program to coordinate better care for people experiencing homelessness, COVID symptoms or both.


Before the days of social distancing, and over-extended healthcare workers, Rosensteel was researching how to defeat cancer. Little did he know, his additional volunteer work at a local homeless shelter would bring him to his biggest passion: social work. He found most of the effects of research to be “very downstream” and that a lot of its benefits lie in “increasing scientific knowledge.” Things like having an immediate impact, unlocking potential and directly changing lives – were missing from his work and ultimately led him to switch paths. “I was really impassioned by the fact of being able to immediately meet the needs of individuals right where they were at,” he said. “And really, that shifted my emphasis from research into social work.” And it’s not a one-dimensional type of social work either – Rosensteel’s new career embodies holistic career for clients in an era where wholesome care is needed like never before.


When it comes to his own work, Rosensteel recognizes that everyone has unique scenarios that lead them to specific obstacles. As a result, he takes it upon himself to dive deep and unmap others’ stories to learn how clients have gotten to where they are in order to get them back on track. “A person generally doesn’t get into crisis overnight,” he said. “There’s a path that a person goes down and on that path there’s a lot of social determinants of health that could be addressed to prevent that crisis along the way.” These types of nuances have shaped how his organization, the Crisis Response Network (CRN), takes holistic and proactive approaches to client care to address social determinants, ebb the “crisis of the crisis” and improve people’s overall well-being.


“Our real mission is that there are places and times in people’s lives where hope is hard to find, and our goal is to be able to help people find that.”

 A decade after its founding, CRN has spread hope locally, regionally and nationally through its programming. They have a 211 support hotline to connect people with the appropriate tools to beat their obstacles. “Our real mission is that there are places and times in people’s lives where hope is hard to find,” he said. “And our goal is to be able to help people find that.” And in these times, the importance of this mission has never been more significant. According to Rosensteel, people are nervous about what lies on the horizon for those who’re experiencing homelessness due to the housing epidemic within the COVID pandemic. In fact, the joint crises have caused lawmakers and policymakers to change how they think about data use, information use and solving historical issues so they can create momentum around solving these complex problems. And the amount of people poised to be impacted by these issues is the most diverse set of clients in the CRN’s history.


While Rosensteel and his team have taken a case by case approach when working with diverse ranges of clients to meet their unique needs, he has found one concept to be consistent in his work: Issues specific to homelessness cross geographic, economic, racial and religious barriers – much like mental health issues do. Instead of prescribing specific groups certain resources, effectively limiting accessibility, Rosensteel’s team and the broader CRN organization make the majority of their services available to the public based on their needs. Rosensteel, in particular, takes pride in this because it lets him see the community members they serve and gauge the true impact they’re having on communities – instead of assuming that the public feels supported.


Overall impact is great, but how does one man impact this many people? Why does his work effect so many others? With his daily work, Rosensteel has two main goals – the first is to inspire data-informed change to improve the homeless system from a third party lens. Put simply, he and his team are not policymakers or political influencers – instead, they specialize in data collection, analysis and interpretation. Rosensteel and his team give a framework for policymakers and planners so they can make better-informed decisions. The second goal he has is to create a trusted partnership and empowering relationship with policymakers. By taking on the collection and analysis process, and sharing observations from his daily work, Rosensteel and his team are letting change makers know that the information they’re acting on has the best interests of the communities they’re serving rather than reinforcing biases or assumptions. Ultimately its about establishing consistency and trust – and it’s not just a one-sided approach, he and his team are actively working to build relationships with communities who do the grassroots work as well.


“The place of trust comes from being an active partner.”

From Rosensteel’s observations, being consistently engaged with involved with people doing the ground work has been key to understanding why creating partnerships, providing information to each other and building mutually beneficial bonds are important. He and the communities have a mutual goal: improve health outcomes for the people they share a common interest for. And for him, the core components of building trust come from understanding shared values they have, sharing common terminology and being able to have sizable impact on the system. Take Maricopa County’s homeless sector, for example – instead of creating data-specific positions, CRN has made community work positions where staff attend community meetings, work with program directors and agencies to get a feel for how and when to “insert data into the everyday conversations”. By working on the process alongside people and encouraging improvement, Rosensteel says that the team is simultaneously encouraging people’s participation in data sharing and also giving people more chances to talk about what they need. “The perspective that we take at Crisis Response Network is primarily grassroots,” Rosensteel said. “We’re working with the agencies that’re doing the work and being able to understand that story and better able to understand what exactly is needed on the ground.” This proactive approach to groundwork and engagement also helps his team engage with legislators, state officials or people who’re in positions of policy creation or funding decisions because it lets them add a unique perspective. When they get called upon by people on the policy side, Rosensteel and CRN can discuss their first-hand findings from work in the community spaces and with members in the programs to present an informed insight into how data can be best used to make impactful and positive policy decisions.


The biggest challenge with their grassroots approach so far, has been “minding your lane”. Growing pains from new types of engagement have arose when members feel like CRN personnel are overstepping boundaries as it relates to non-CRN led programs, clients, etc. but Rosensteel’s team recognizes the importance of commitment and doing things the right way for long-term success. “The biggest piece that they [team members on the social service side] have is to maintain personal relationships with individual stakeholders,” he said. “That’s how we’re going to be successful in building long-term trust – individual stakeholder engagement.” This is especially key, because when big events like COVID-19 occur, an existing framework for steady, trusted collaboration suddenly becomes a life-death difference for hundreds if not thousands of community members.


With great crises, come great opportunities to reset and improve quality of life for others. This is not lost on Rosensteel, as he says that COVID has impacted our society’s view on housing and the field that he works in, in two fundamental ways: 1) People understand the role of housing as healthcare and 2) More funding opportunities for housing have been presented.

“I think the real piece that is happening right now is that people, a lot more broadly, are beginning to understand the importance of housing as healthcare.” he said. “The importance that a house and a roof over you head [has], and [having] walls that separate you from your neighbor is a real vital part to a person’s health.” According to Rosensteel, as a society, we’re understanding our systematic process of dealing with medically vulnerable people is flawed. Currently, people are placed to live in shelters, they can risk contracting COVID and die as a result and we do not accept this as a public from a health lens, let alone from the standpoint of standard of living or human decency. Rosensteel also notes that larger funding opportunities are happening right now because of the attitude toward these types of outcomes – communities are viewing homelessness as a social determinant of health that needs to addressed as a person’s healthcare. As a result, partnerships are forming between health care and organizations dealing with homelessness to ensure that people’s needs are resolved.


Take state funded Medicaid managed care organizations, for example – Rosensteel says that they have been doing a great job at giving support and services to those experiencing homelessness and that a lot of healthcare groups are trying to connect people with homeless services to provide better care. In Arizona, specifically, they have individual health care plans that’re Medicaid funded to ultimately impact people’s housing status and health outcomes. As a result, supportive services have been created to provide people housing in hotels as well as a data matching project between the homelessness and health system. In this project, health navigators and community health workers are assigned to individual people with questionable or no housing status to make sure they have the care they need.


“Unless you have the data — it’d be very hard to look at changes & significance from a system wide perspective.”

Overall, Rosensteel says that HMIS has elevated the public’s understanding of homelessness in the area. Historically, the most accurate count of people with homes was annual account of people in shelters or on the streets and the work was based on trying to understand the scope and needs of Arizona’s homeless population based off of a “single night’s count”. Working within this limited data inspired Community Solutions to build a framework called the Built for Zero campaign that encouraged communities to submit their data to form an “active list” or an updated, live list of those who’re experiencing homelessness. This innovation greatly transformed the field and the daily work of Rosensteel and his team because now it gave them new information that let them “tell you on a month by month basis what homelessness looks like” as well as recap observations from the past month too. By comparing now to last month, for example, they could see movement trends, housing trends, and they had access to more community-geared metrics to contextualize changes in the data. As a result, they began to implement “change ideas” or interventions that address specific needs that arise at specific times. Take summer housing for example, from the live list, they noticed that “during the summer our numbers increased in the number of newly homeless persons,” he said. “Why is that – well we opened a number of new shelters in response to heat relief.” Without access to these kinds of innovations and data from the HMIS system, Rosensteel said identifying specific community needs  would be even more challenging. “It’d be very hard to look at changes and signify from a system wide perspective – providers will have individual insight, “ he said, “but unless you have the data and a systemic process, it’s going to be largely anecdotal.”


While he applauds the work that advocates are doing to promote a better understanding of housing as a social determinant of health, Rosensteel said the biggest work to be done revolves around what people think of “homelessness” in general and people who are going through it. “I think anytime that there’s a substantial economic fluctuation, people have a better understanding of what homelessness can look like because they, or their family members,  or people that’re very close to them are much more closer to homelessness than they realize,” he said. “So in a space where we have eviction moratoriums across the country and we have a lot of rental assistance that are being poured into the individual communities, I think that there’s a broader awareness about homelessness being an unacceptable societal norm that we have.” Now, the biggest difference is the willingness of stakeholders to look at homelessness from a new view – instead of solely putting to focus on people’s personal life choices, the focus is now shifting to viewing homelessness as an unacceptable social norm and how it’s not good for ind., society or public health – a reckoning that is long overdue.


The following excerpts are in-depth explanations examining the major components, organizational strategies and support work that go into constructing and implementing an HMIS system. Tyler outlines the specific mindset that Crisis Response Network in Maricopa County had regarding how it implemented its own HMIS system for community betterment. We hope that his deep dive into their strategy, functionality and more can help you learn more about the positive ways in which data sharing mechanisms can help people receive the care they deserve, especially amidst times of crises.


Tyler: HMIS stands for Homeless Management Information System – every community in the United States enters data into an HMIS system, it’s a federally mandated but it’s going to be locally operated. So the US Department of Housing and Urban Development has mandated that any community  that receives federal dollars from HUD for homeless assistance programs must utilize this database in their community. And the recipients of the money, the federal assistance, must use this system. So the primary user base of this are: your publicly funded and federal dollar pass through funded organizations and the primary intent and purpose as described by HUD is really around “providing better data and better information around unduplicated counts of people. Being able to say: here is the real impact of the dollars, here’s the system performance, etc.


Tyler: When you get to actually organizing an HMIS and implementing an HMIS, every community has a decision that they get to make. They get to decide: are we going to do exclusively that, where we are entering the data in order to appease the federal requirements and collect the data exclusively for the purposes of federal reporting. That’s one approach that you can take.

The other approach you can take is, you can say: we’re going to use this HMIS system and leverage the fact that there is public funding for a system like this and actually coordinate work and we’re going to improve the system of care and we’re going to make data-driven decisions based off of the information that comes out of this system. And when you do that, you have the potential to get the buy-in of a lot broader audience – you have the potential to get privately funded shelters, privately funded rental assistance programs, social service organizations that provide supportive services only. Things like providing meals, soup kitchens, providing IDs – -all of these programs that provide ancillary services to the persons that are experiencing homelessness once you use this tool to better coordinate care. And then you’ve increased the amount of data that’s in the system to where you actually are able to then produce better and more meaningful data.


Tyler: We want to build this as a tool to really improve and coordinate individual service and to then therefore make this to be a broader community impact system rather than something that is going to be exclusively for federal use. So in Maricopa County and Arizona we have over 100 agencies that participate in the system and share data between each other and over 1,000 users throughout the state that’re utilizing this system and entering data on a daily basis. Our average monthly client roster is around 15,000 clients – the data is entered into the system and that covers everything from persons that’re on the street to persons in emergency shelter, to also those receiving rental assistance and ongoing housing subsidize. So it becomes a really valuable set of data to be able to have broader conversations.


Tyler: Standard HMIS data collection has some basic demographic information about persons being served but it also includes service information. So it describes: what’re the dates of service that a person was receiving service at the shelter or the day program. And so in regards to HMIS data collection, the data entry and data collection really hasn’t changed all that much. Our providers are still entering – still standard type of information but what has changed are the programs that respond to homelessness in the COVID-19 space. So, previously to COVID19 we really didn’t have any hotel voucher programs where an agency would rent hotel rooms for a person and operate that as emergency shelter. And in the needs of quarantine and to isolate individuals, we need to have that type of emergency shelter available and so we have a number of programs that are not operating, collecting information on persons that are having their stay paid for in a hotel. And so the data collection has remained pretty much the same, which means our reporting on homelessness is able to remain pretty much to same but what has drastically changed is the service delivery model. And the other piece that’s really interesting is that with COVID19, there’s a lot of different funding streams that are available to help individuals. That’s certainly true on a public health level where the state and the city and the county and the federal government are all pouring resources in different ways to be able to curb this epidemic. The same is actually true with homelessness – there are a lot of different venues, where people are saying: homelessness in the midst of COVID19 is really dangerous because these are persons that are very medically vulnerable. And therefore, there’s a lot of different funding streams to really be accountable to and to really be mindful of for the response to homelessness. So I can’t say that our community is the most successful at this but we certainly have a lot of these funding streams having their data entered into HMIS even though it’s not mandated. Even though its not “required” by the money that it came from, because we built up a system where good coordination of care happens, people want to enter the data into the system to be able to report consistent outcomes, to do standardized reporting and to ensure appropriate service delivery for people.


Tyler: The first thing is that after the public health crisis of COVID, there’s going to be the economic crisis and the economic fallout of COVID. And so the biggest pieces that our team is doing right now is really preparing to support the agencies in transitioning to that additional work. That there’s going to be more work ahead and really ensuring that we’re in a place of being able to capture the data, tell the story, and be able to understand what is the cause of a person’s homelessness and be able to share that information better. I think in a post-COVID world, I believe that there is a lot of reasons to be hopeful about systems working together to be able to address individual needs. If you look at some of the federal dollars that have come through the state of Arizona to support homelessness initiatives – one of them is, there was over 5 million dollar allocation of emergency solutions grant money given to the state of Arizona. About 20% of that is being allocated through our state Medicaid office. And so there is an understanding that these systems need to be working together, and funding is actually happening in ways that are encouraging that type of cross sector participation. And so I would hope in a post-COVID world that we see more of that. of being able to say: “ if you really want to impact homelessness, we need to bring corrections and we need to take money that is traditionally from one funding stream and move it to another to be able to improve the outcomes in both systems. And that’s a very hard thing to do on an individual programmatic level but it’s very important for policymakers to be able to have that view. I hope that COVID is opening our policymakers’ eyes more and more to the understanding of the interconnectedness of homelessness with healthcare.


Tyler: I think whether or not COVID lingers, there are a number of societal impacts that are unseen right now, that there isn’t good data around. I think that all of us that’ve experienced this, have experienced the emotional impacts of social isolation and I think that there’re a lot of potential underlying issues that’re going to really become more apparent as time progresses and as time goes on. And so I think that communities investing in crisis services like what is offered at Crisis Response Network of being able to provide phone support and in community support and provider support is absolutely vital to be able to help persons address their need in really a progressive engagement style. Right, that not everyone is going to need the highest level of care. There may be some type of crisis counseling program that maybe more appropriate for a person or there may be additional social supports that a family might need in order to get through the emotional impact of COVID19. So I think there’s a lot more to come in that space and I don’t know that we have enough data to really project what that’s going to look like.


Tyler: The model is driven by the desire to ensure that persons that are at risk of death due to COVID-19 or those that are symptomatic or have tested positive to COVID 19 are receiving adequate healthcare. So our public health authorities have done an incredible job and are working on all of the pieces of curbing the epidemic. So all of the data around actual transmission rates of COVID19 within homelessness and curbing the epidemic response – that’s really maintained by public health.

The initiative that we are running on the ground is much more about the individual care that a person receives and ensuring that that person gets the appropriate attention for the needs they have. So we set up custom fields within the homeless management information system where our social services providers could identify if a person had tested positive for COVID19 or is experiencing symptoms of COVID19. And we entered into a business associates agreement with our state Medicaid office to deliver that identifying information of those persons that are in that scenario of being affected by COVID19 to deliver that to our state Medicaid office so that they would deliver that information to the individual healthcare plans that those persons have. Now, the process that we have – the biggest accomplishment was getting this through the public information office and being able to ensure that we had an appropriate BAA agreement, and we were aided by the fact that this is an epidemic and there were a number of waivers that were given under the Health and Human Services HIPPA waiver. And there are pieces within our privacy notice on the homeless side that allow us to share information for the coordination of care in response to public health emergencies. So all of the privacy pieces kind of worked out in relation to the public health emergency – the piece that has not been worked out, and it’s been primarily a financial difficulty, is the technology of this. Right now we have people that will manually look up these individuals – 70 to 75 members on a daily basis – and find out what their individual health care plan is, find out diff demographics that are useful for prioritization of housing and different resources and provide that to those health care plans. Right now we have a manual process but we’re looking at what would it take to use some of the additional resources that’re in the community around COVID19 to make this process more automated. And right now we’re really creating those use cases of being able to provide individual care and support in a multi-sector collaboration so that we can then talk about doing this more broadly. Hopefully one day the COVID pandemic and epidemic is behind us, and we’re able to recover from this. We hopefully will be in a better space to be able to ensure that these multi sector collaborations continue and grow and thrive based off of the use cases that are built into it right now.


Tyler: The biggest piece that I would encourage is to ensure that you are actively working with your public health communities. So the people that’re working in public health are actively working to curtail the COVID19 crisis but they also are generally the people that have the eye toward overall public health initiatives. And being able to work side by side with them and to build those relationships and build that trust in the space right now, where providing data to public health can help in: contract tracing efforts or in other public health type initiatives building those initiatives now to demonstrate outcomes later would be my first recommendation.

Second recommendation is to find those opportunities to demonstrate examples of coordinated care – like I had mentioned, we haven’t figured out the data sharing technology for the entire HMIS system but we figured out a way to do manual lookups on people that are particularly effected by COVID19 and are working to find supportive services, solutions to be able to help them in this crisis. And the development of those use cases will be really vital in future conversations around multi-sector data-sharing.