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Three Keys to Better Outcomes for Populations Experiencing Homelessness

A young woman and elderly man are sitting at a table in a soup kitchen while volunteers serve food in the background.

Across the country, a silent storm is raging. Millions of people are grappling with homelessness — a complex issue intertwined with health disparities and chronic health conditions. While Medicaid has long played a crucial role in supporting clinical needs of unhoused populations, a critical health-related social need has remained largely unaddressed: stable housing.

Enter Section 1115 waivers and their potential to transform how states address people’s social needs — including the fundamental need for shelter. 

With Section 1115 waiver authority, states can add certain non-clinical services to the benefits they offer to Medicaid members. Approved for 18 states in 2022, these waivers open the door to home and community-based services (HCBS) to address housing instability in vulnerable populations. The future is promising. However, a crucial gap looms: the lack of robust data analytics to help shape and guide these new programs.

Such data analytics are within reach, as evidenced by recent work in supporting better services and outcomes for members with severe and persistent mental illness. Gainwell’s experience in architecting evidence-based solutions points to three keys to unlocking the value of analytics in service of better outcomes.

1. Harness the Power of HMIS Data

At the heart of effective housing interventions lies HUD’s Homeless Management Information System (HMIS). This treasure trove of data is critical to understanding the demographics, challenges and trajectories of homeless populations. By applying the right analytics engine to HMIS data, it becomes possible to build a foundation for designing, executing and continually improving housing-related supports. Use HMIS to inform:

  • Population needs. Identify high-risk groups struggling with housing instability and tailor interventions accordingly.

  • Resource allocation. Pinpoint areas with underserved populations to optimize program reach and impact.

  • Outcome tracking. Measure the effectiveness of interventions and make data-driven adjustments for continuous improvement.

2. Weave a Holistic Web of Data

Though powerful, HMIS data is a single thread in a complex tapestry. States also need the ability to integrate HMIS data with other relevant datasets to create a more complete picture of each individual and their environment. Such datasets include:

  • Medicaid claims data, which helps illuminate the health conditions and service utilization patterns of people experiencing homelessness. These insights enable targeted interventions that address both housing and healthcare needs. 

  • Social determinants of health data. These data sources help to uncover broader factors contributing to homelessness — such as poverty, food insecurity and mental health challenges — and support the development of more comprehensive, multi-pronged approaches.

3. Build a Blueprint for Transformation

Using data analytics to construct more effective whole-person interventions isn’t a one-time project. It’s an ongoing effort that benefits from a well-constructed plan. At Gainwell, we start by working to understand the unique needs of each state and its target population. From there, we can create a customized analytics framework that guides program implementation, tracks progress and informs policy decisions. A transformation blueprint should cover the following elements:

  • Predictive modeling. Identify individuals at risk of homelessness to enable interventions before they fall through the cracks.

  • Real-time reporting. Equip states with up-to-date information on program performance to support course correction and resource optimization.

  • Data visualization. Present complex data in clear, actionable dashboards, empowering stakeholders to make informed decisions.

For states and their citizens experiencing homelessness, the opportunity is immense. Data analytics can and should become the tool states rely on to build effective and enduring solutions to housing instability within Medicaid-eligible populations. This is not just about numbers; it’s about human lives. In the fight against homelessness, how can Gainwell help your state build the bridge between promising possibilities and tangible change? Contact us to discuss the opportunities.