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Strength in numbers: How data is helping solve homelessness in Santa Cruz County

Presented by Housing Matters
Homeless encampment known as the San Lorenzo Park Benchlands.

Counties all across the U.S. use the federally mandated Point-in-Time count to assess how many people are experiencing homelessness on a given night. But the PIT count, traditionally conducted every two years, is considered a snapshot in time that is quickly out-of-date. Is there a better way to learn just how many people are experiencing homelessness at any given time? And could data be the key to reducing and even ending homelessness in Santa Cruz County? Proponents of data-centric strategies say yes, and believe that data sharing, analytics, and by-name lists can make a huge impact in resolving homelessness, one person or family at a time.

beth sandor headshot
Beth Sandor directs the Built for Zero initiative for the national nonprofit Community Solutions.

Beth Sandor, who directs the Built for Zero initiative for the national nonprofit Community Solutions, is one of the most vocal proponents of using data — and specifically, by-name lists — to reduce homelessness. She believes that many counties are struggling to make headway in addressing the crisis because they don’t have a clear picture of who, why, and how people are experiencing homelessness in their communities.

To solve a problem you first have to understand it

— Beth Sandor

That understanding, she says, has to come from quality data that’s updated at least monthly, if not weekly or daily. Yet many communities rely heavily on periodic PIT Counts to inform their homelessness response strategies. That, she says, makes it incredibly difficult to know which housing and prevention strategies are working, and where to direct additional resources. “PIT counts are useful, but they aren’t the right tool for assessing progress,” says Sandor.

Screenshot of 2022 point and time data
A snapshot of the 2022 Point in Time data set. Read the full report here.

It’s the data that counts

Tom Stagg, Chief Initiatives Officer at Housing Matters, agrees that monitoring homelessness as it changes from month to month is essential for coordinating supportive services. He explains that Housing Matters pulls data from a variety of sources to measure the effectiveness of its own programs, which in turn informs the nonprofit’s decisions about making improvements to those programs.

Tom Stagg
Tom Stagg, Chief Initiatives Officer at Housing Matters.

Every month, Housing Matters staff are presented with data gleaned from “the Dashboard,” a graphic database interface that presents real-time data summarizing how many people have “exited” homelessness within a specific time frame and going back to 2017 — usually, the prior week or month. Numbers can also be crunched down to the program or service level, so the team at Housing Matters, which last year served more than 2,800 people experiencing homelessness in Santa Cruz County, can see just where demand is greatest.

Viewing data this way allows us to focus on performance and outcomes. We can see which areas might need improvement, and where we’re getting results.

— Tom Stagg, Housing Matters

Seeing the big picture

The Housing Matters Dashboard is a microcosm of what Community Solutions’ Sandor advocates on a City or County-wide level. But achieving that level of coordination and data sharing requires a combination of planning, collaboration, data expertise, and training — an undertaking that, according to County officials, has been in the works since 2019.

“Over the last two years we’ve really been diving into improving the quality of our data,” explains Jessica Scheiner, Housing for Health Manager at the County of Santa Cruz.

That effort, says Scheiner, includes a “reboot” of engaging service providers throughout Santa Cruz County to make better use of a commonly used tool for collecting, sharing, and viewing data. That tool is known as the Homeless Management Information System (HMIS), a secure, online database developed by the U.S. Department of Housing and Urban Development (HUD).

Counties that receive Continuum of Care (CoC) funding for addressing homelessness are required to use the HIPAA-compliant HMIS to record and store client-level information about people experiencing homelessness, their situations, and the services they receive. The intent is to give service providers operating within a specific region a common platform for exchanging information, thus eliminating duplication of services and making coordinating care more efficient. Data collected via the HMIS is also meant to provide insights for informing policies and decision-making at local, state, and federal levels.

But in practice, different service providers have tended to use the HMIS differently, and with varying degrees of frequency. Up to now, this inconsistency has made sharing, analyzing, and reporting on data stored in the HMIS difficult.

We very much want to be more data-driven in the work we’re doing, and in order to do that we need to have higher quality data.

— Jessica Scheiner, Housing for Health Manager at the County of Santa Cruz

She says that poor data — incorrectly entered, missing, or outdated information about clients served, their housing status, and the programs in which they’re enrolled — originated from a lack of training and understanding among the 25 or so service provider organizations tasked with using the HMIS. Now, however, the County is taking steps to change that.

Recently, the County’s Housing for Health division developed guidelines and expectations for entering HMIS data to address common pitfalls. And, it hired a dedicated staff person to oversee the HMIS and work with partner organizations to provide much-needed support. Caseworkers, outreach staff, and program managers are among the frontline workers who will receive training and assistance in working with data more effectively.

Housing for Health

“These folks took the job to work with people,” not necessarily data and databases, points out Monica Lippi, Housing for Health Manager and Scheiner’s colleague at the County of Santa Cruz. But by educating frontline staff on how they can use the HMIS to better support their clients, the County hopes to transform the quality of its data overall. A new outreach module, for example, will allow staff to record data on an interactive map; a new bed inventory feature will provide a view into available emergency shelter units. “The more we can support folks in valuing data, the more they will want to make sure their data is reflective and up to date,” says Lippi.

Leaning into by-name lists

The renewed emphasis on generating quality data is a critical first step in reaching what has become a clear goal: using analytics and by-name lists to measurably reduce homelessness in Santa Cruz County.

By-name lists — lists of every person in a community experiencing homelessness, updated in real-time and shared across service provider organizations — are what Community Solutions’ Sandor sees as a necessary tool for ending homelessness. Through her Built for Zero initiative, Sandor has worked with more than 100 communities across the country to implement such lists, which aim to solve homelessness by focusing on one individual or family on the list at a time.

The idea is to promote collaboration among service provider organizations, with everyone working from the same list to evaluate the health, housing needs, and histories for each person on a case-by-case basis. Participants must give their consent to allow their data to be shared among homeless service providers; as with HIPAA, similar privacy rules and regulations apply. By-name lists have proven successful in significantly reducing homelessness in at least 15 cities, including Bakersfield, California; Eugene, Oregon; and Abilene, Texas.

Communities that use by-name lists start by focusing on one group at a time: veterans, youth and families; and adults experiencing chronic homelessness. Communities are said to have reached “functional zero” for a particular group when fewer people are entering homelessness than a community has the proven ability to house in a single month. In other words, homelessness becomes rare and brief for specific groups.

By-name lists sound simple to implement but in reality, they require a sophisticated use of data — both in sharing, accessing, and updating client data in real-time, and in measuring a community’s success. “Homelessness is dynamic in that it changes every night,” explains Sandor. To resolve it, you need data that is at least as dynamic. “The pivot we all need to make is toward data,” she says.

Santa Cruz County, which is in the midst of such a pivot, is already working with by-name lists with demonstrable success. Tom Stagg at Housing Matters credits by-name lists (maintained manually using spreadsheets) for reducing homelessness for families and also veterans to record lows. But a by-name list that integrates directly with the County’s HMIS is on the horizon.

According to Scheiner and Lippi, an “Active Homeless” by-name list is in development now that will update automatically each night using real-time HMIS data. This universal list will provide a comprehensive view of everyone experiencing homelessness in Santa Cruz County who has also signed up to receive services. Regular collaboration sessions will bring service providers together to prioritize resources and match individuals with services that best fit their needs.

But by-name lists won’t — and shouldn’t — replace Point-in-Time counts, agree both Scheiner and Lippi. “PIT counts and HMIS data tell different stories,” says Scheiner. PIT counts have their limitations, but they are particularly useful for identifying people who are not in HMIS because they are not yet connected to services. Also, the survey data that is collected as part of every PIT count is anonymous. That anonymity “gives us a different understanding” of the homelessness crisis in Santa Cruz County, and how best to respond, says Scheiner.

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