Connecting the Dots: Using Integrated Data to Drive Whole-Person Care
At NHHA, timely, accurate and robust data is critical to the work we do. Whether it’s a client’s diagnosis, their journey through our programs, or their long-term health outcomes, data helps us understand the full picture of each individual we serve. Our Integrated Model of Care allows us to further connect insights across health, housing, and social services, creating a more complete and responsive support system for our clients.
Why Data Matters in Whole-Person Care
In healthcare and housing, data is more than just numbers—it’s the roadmap that guides decision-making. At NHHA, our data team works with our Community Care Campus client demographics, program enrollment, diagnosis codes, and referrals/exit outcomes. These aren’t just isolated sets of data, they’re pieces of a larger puzzle that connect and give us insight into how to better serve individuals through a coordinated, whole-person care approach.
By leveraging this information, NHHA we cancan better support multidisciplinary teams, identify gaps in care, and inform how our different partners can work together.
Key Data Insights That Drive Our Work
Understanding Our Client Population
Our client demographic data—age, race, ethnicity, gender, and language—is essential for shaping service delivery. This information, stored in an Electronic Heath Record (EHR) system,[CC1] allows us to monitor trends, address disparities, and make informed decisions about workflow adjustments. Because our model integrates healthcare, housing, and social services, we use demographic data to ensure that outreach, care coordination, and program design are suitable to those we serve—including families with children, seniors, individuals with chronic health conditions or behavioral health challenges, LGBTQ+, and other historically underserved communities.
Our integrated data gives us a comprehensive view of our clients’ needs and the services they’re receiving. It helps us coordinate care across programs, identify and fill gaps in support, and ensure that both individual clients and those with similar circumstances receive the right interventions at the right time.
-Karin Kalk, Senior Advisor, Quality Improvement & Advanced Project Management
Tracking Program Enrollment for Holistic Support
A client’s journey often involves multiple touchpoints across NHHA’s programs. We track service enrollments, length of stay, and outcomes to understand how individuals move through our system—for example, someone entering Recuperative Care may transition to Housing Services a month later. By analyzing these transitions, we’re able to uncover patterns that wouldn’t be visible in siloed systems, giving us the ability to adapt services to evolving needs and ensure that clients don’t have to repeat their story.
Analyzing Diagnoses to Tailor Care
Each client’s diagnosis provides valuable insight into their health challenges. Our reports pull diagnoses codes from client charts, helping us identify common health conditions—ranging from chronic illnesses to mental health concerns and substance use disorders. Because our partners work across disciplines, these insights are shared and acted on in real-time, allowing for integrated care plans that are both medically and socially informed.
Measuring Success Through Referrals and Exit Outcomes
The true impact of our work is reflected in where clients come from and where they go after receiving care. Referrals help us understand the level of care clients need upon entry, while exit outcomes allow us to track improvements in their well-being. These are more than just data points—they’re part of a larger journey to stability. With our Integrated Model, we’re able to follow a person’s story from entry to exit and beyond—capturing not only physical and mental health improvements but also housing stability and further self-sufficiency.
Looking Ahead: The Future of Data-Driven Care at NHHA
Our use of data is rooted in collaboration, not just collection. By aligning our data strategy with our Integrated Model of Care, we’re building bridges across teams and systems to ensure that individuals receive comprehensive, person-centered support.
As NHHA continues to grow, so does our commitment to using data not to simply measure impact, but to inform action, strengthen partnerships, and elevate the voices of the people we serve.
By turning numbers into impact, we’re not just tracking change—we’re helping create it, one story at a time.
About National Healthcare and Housing Advisors
National Healthcare and Housing Advisors (NHHA) partners with communities across the nation to provide innovative solutions that bridge healthcare and housing for individuals experiencing homelessness. Through initiatives like the Community Care Campus Long Beach and Recuperative Care programs, NHHA strives to address the root causes of homelessness and empowers individuals to rebuild their lives.