It’s long been known that health and housing go hand in hand. Health challenges can be a factor leading to homelessness while homelessness creates health challenges of its own.
“Your baseline of health is diminished just by the reality of being unsheltered, underfed and underresourced. Lack of nutrition, lack of shelter, not being able to use the bathroom — those can all lead to adverse health outcomes,” said Jenny Greenberg, a senior program specialist at the Homeless Services Department. “People's lifespans are shorter because our human bodies are not going to do well in the elements without support. And the stress and trauma of all of that, it also takes its toll.”
But the systems providing healthcare and housing are separate and often siloed, which can keep providers across those different sectors from working together effectively to support a person experiencing homelessness.
“Our service providers are often overwhelmed and confused on how to navigate not only the homeless services system, but how to get those unmet healthcare needs met,” Greenberg said.
Breaking down silos
Funded by the Supportive Housing Services measure, the Cross-Sector Case Conferencing program is designed to help break down those barriers and support clients facing challenges at the intersection of housing and health.
The program is the result of regional coordination between Metro, the three Portland-area counties and Health Share of Oregon, and is designed to better coordinate resources across the multiple sectors supporting people who have experienced homelessness. It began as a Washington County pilot in 2023 and has since expanded to all three Metro counties — each of which runs its own case conferencing meetings as part of the regional program.
Central to the program are regular meetings that bring together people from across homeless services, housing, healthcare and other social service providers. Each conference is focused on a handful of “cases” — specific program participants facing hardships or barriers to health and stability.
A provider bringing forward the case will share information about the individual, what barriers they are facing, what they’ve already tried and what they need help with. Other meeting participants ask questions and share information, resources and potential solutions.
Greenberg, who leads Multnomah County’s Cross-Sector Case Conferencing program, said that while it’s not unusual for providers to convene and discuss cases, what makes the Cross-Sector Case Conferencing program unique is that participants sign information releases that give providers permission to discuss their case in detail — often including medical history — with people from other relevant sectors.
“Through our data sharing and a release of information, we’re able to break down the silos and help with communication and coordination on the spot, in real time,” Greenberg said.
Promising early results
It’s a simple concept, but it can be absolutely transformative for the clients it serves. According to Health Share of Oregon, more than 300 of its members have gotten support from Cross-Sector Case Conferencing across the three counties. Preliminary data shows that six months following a case conference, participants have fewer emergency room visits, fewer inpatient hospital admissions, increased engagement in substance use disorder treatment and decreased total cost of care.
Drew Grabham, director of outreach services at Central City Concern, is a regular participant in the meetings. He said that he hasn’t experienced a space quite like it in his years of working in homeless services. While healthcare and housing systems do often work together, he said it’s rare for them to center individuals like they do at the meetings.
“It’s one of the few examples where so many of our systems are really coming together with the human in the center — not from a 10,000-foot point of view,” Grabham said. “Whether they know the person or not, everyone in that meeting is thinking about the human that we're talking about and how we can best serve them.
“That warms my heart and gives me hope.”
'One more tool in my toolbox'
Haylee Hinkle, Shelter Plus Care Case manager on Northwest Pilot Project’s retention team, has brought a couple of her clients’ cases to Cross-Sector Case Conferencing meetings, and said it’s been a helpful way to get additional information and resources she doesn’t normally have access to.
In her role, Hinkle works with clients who are in permanent affordable housing, helping them achieve stability and retain their housing long-term. In alignment with the mission of Northwest Pilot Project, her clients are all low- or zero-income older adults.
Because her work is focused on supporting each client with their individual needs, her work changes day-to-day. It could include helping a client secure eviction prevention services, mediating interactions with property managers, helping get access to a caregiver, or connecting them to food and other community resources.
One aspect of her work that can be especially complex is helping her clients navigate the healthcare system, including scheduling appointments and accompanying clients on those appointments. But because she isn’t a healthcare provider herself, she sometimes runs into barriers when trying to get clients the help they need.
She shared that one of her clients needed medical care, but “wasn't sure exactly what insurance he had. He was pretty sure he had a primary care provider, but he hadn’t seen her in a while and wasn't sure if he was even still a patient there.”
Presenting his case to the Cross-Sector Case Conferencing meeting helped Hinkle figure out a path forward for getting her client the care he needed.
“I found out exactly what insurance plan he has. I was able to get more information on what exactly he was eligible for. They were able to tell me that he did have a primary care provider and what office they were out of,” Hinkle said. “And then they were also able to connect me with a social worker at that primary care office that I could reach out to, to work together to support the client.”
She said the connection with the social worker at her client’s primary care office was incredibly helpful. “I still work with her about this client. I don't know that I ever would have gotten connected with her otherwise.”
“A lot of the time it really is just throwing things at the wall and seeing what sticks,” Hinkle said of her work. The Cross-Sector Case Conferencing meetings are “one more thing, one more tool in our toolbox, that we have to help us navigate these really complicated situations.”
