Database helps Flagler Hospital, others get services to those in need

CHRISTINA.KELSO@STAUGUSTINE.COM Brittany Cubbedge, service point coordinator for Flagler Hospital, demonstrates the Homeless Management Information System, or HMIS, in her office on Wednesday, July 12, 2017. Flagler Hospital is now maintaining the database, which keeps track of the area’s homeless who are receiving services through various organizations in the county.

When Flagler Hospital assumed control of the database used to track services provided to the county’s homeless population last year, the move was indicative of one of the hospital’s larger goals.


“Basically the whole vision behind it was becoming a national model for community-based care,” John Eaton, Flagler Hospital’s director of community health improvement, said of the broader initiative on Wednesday.

Seated in a conference room with hospital service point coordinator, Brittany Cubbedge, Eaton explained what the Homeless Management Information System, or HMIS, had to do with that vision.

The database, he explained, is the “backbone” of the county’s Continuum of Care, or COC — an umbrella organization made up of community members and various agencies that provide services to the area’s homeless.

For years, HMIS was managed by the Emergency Services &Homeless Coalition of St. Johns County. Not long ago, amid a restructuring of the COC, Catholic Charities took it over until COC membership voted to place it in the hands of Flagler Hospital in November.

“For the hospital, it was probably perfect timing for other projects we were working on,” Eaton said.

Among those is St. Johns Care Connect.

As a partnership between the hospital and the St. Johns County Health Leadership Council, the project is meant to “connect area residents in need with available services and address social determinants of health in a coordinated way,” according to literature provided by Eaton.

Those determinants, the literature says, include “social/environmental factors and individual behaviors.”

St. Johns Care Connect can get those in need in touch with prescription assistance, rental and utility assistance, food banks and other services. It can also provide transportation vouchers and other services.

“And that’s all coordinated through the Care Connect office,” Eaton said, explaining that they oftentimes learn that someone who, for example, is having trouble managing his or her diabetes is not doing so on purpose, but because he or she doesn’t have access to transportation for doctors appointments or is lacking something else that would make health care easier.

“Our community has so many resources,” he said. “And that’s the goal of this — increasing access and coordination of those resources.”

Since beginning with a “soft opening” in May, the Care Connect program has already served 150 patients and secured $60,000 in free medication through prescription assistance.

Eaton said he and others envision a day where similar efforts could be coordinated for everyone in the county, but explained that the hospital is currently, with its new duties as a steward of HMIS, focusing on the homeless as a pilot population to get things working smoothly.

“For right now it’s the perfect kind of testing ground with this smaller population,” he explained. “And the most in need.”

Not only does the database track those receiving services, it also serves as a case management tool, can provide users a list of resources for clients, and track project outcomes.

Eaton said all of that makes it a useful tool with an eye toward the hospital’s larger goals of community-based care, but it also means improvements can be made in the homeless services arena.

“Right now there are six or seven that are actually using it,” Cubbedge said of current service providers.

Cubbedge has been a constant with HMIS since its days at the Homeless Coalition. She moved with the database to Catholic Charities and then again to Flagler Hospital.

Eaton said the goal is to get HMIS into the hands of more service providers, but the problem, at least for now, is that there is only one Cubbedge to get people trained. As they both explained, each addition requires a round of training for the new agency to add the input process into their work flow.

And it’s the input process, which involves filling out a questionnaire, that is key to identifying those in need as well as being important to the more distant goal of expanding the reach of the system, Eaton explained.

“We are looking at everyone from libraries to physician’s offices to have access to the system,” he said.

“In reality this is something that we want everyone, regardless of income, to have access to.”