Building a Coordinated System to Meet Housing and Health Needs of High Healthcare Utilizers in Tulsa, Oklahoma

May 28, 2025

Chronic health problems and housing instability often create a harmful cycle where unmet health needs lead to housing loss, and the experience of homelessness exacerbates physical and mental conditions. Homelessness poses its own risks to health and safety while also making it difficult for individuals to manage chronic illnesses, maintain regular medical care, follow treatment plans, and reduce stress. These challenges not only compromise individual health and well-being; they also contribute to the high utilization of acute care and emergency healthcare services, which increases healthcare system costs.

To address this challenge in Tulsa, OK, a team of housing and healthcare organizations partnered over the past year to develop a more coordinated approach for meeting the housing and health needs of homeless patients who frequently utilize healthcare services. The partnership includes the lead agency for Tulsa’s HUD-funded Continuum of Care, Housing Solutions, and Morton Comprehensive Health Services (Morton), an essential primary care service provider. 

Supported by a Housing Solutions Lab housing and health catalyst grant, the team set out to pilot a more collaborative strategy by 1) improving data sharing and transparency between Morton and Housing Solutions; 2) identifying high utilizers of health services and assessing their housing needs; and 3) connecting these clients to stable housing and wrap-around services.

Data sharing and coordination

As a first step, the Center for Housing Solutions analyzed Morton Health Clinic data from the Homeless Management Information System (HMIS) to identify high users of healthcare resources experiencing homelessness. The team identified a cohort of 20 individuals for the pilot and created a new project type, called Healthcare FUSE (Frequent Users Systems Engagement) in HMIS to monitor clients’ interactions with all healthcare providers, including hospitals and emergency rooms. This was the first time the organizations focused exclusively on a population of high utilizers, fostering a deeper understanding of their unique needs and patterns of service use. 

Upon identifying the cohort and establishing a new tracking system, the team developed a weekly case conference, bringing together staff from both organizations to review shared client cases and develop a coordinated housing-focused case management strategy. Client needs typically included permanent supportive housing, mental health or substance use services, and financial assistance. Importantly, all participants had active health insurance at the time of their initial assessment due to the enrollment services provided by Morton. 

Outcomes and challenges

During the pilot year, Housing Solutions and Morton successfully developed a new system for identifying and tracking high utilizers, increasing both organizations’ understanding of their needs, challenges, and gaps in available services in Tulsa. The project helped the organizations strengthen their partnership and allowed them to work towards a more holistic approach to serving their most vulnerable populations. The success of this partnership relied on setting short-term goals, creating a shared project management infrastructure, and implementing a clear communication strategy.

As of this reporting, 15 percent of clients in the project’s cohort have transitioned into permanent housing, while 40 percent accessed sheltered homeless placements. While the sample size is small, early data analysis shows that individuals who obtained stable housing had fewer emergency room visits and hospitalizations. 

The remaining 45 percent of the cohort’s clients have received support with documentation needs and housing applications but remain unsheltered due to a lack of available housing options, particularly Permanent Supportive Housing. 

Key takeaways

• Data sharing can be a beneficial first step for housing and health care organizations to understand their high-utilization population and align service strategies. Due to the sensitivity of health information and the complexities of integrating HMIS and healthcare data systems, organizations may need to allocate extra time and engage legal support to help establish data sharing agreements and address concerns about HIPAA compliance. 
• Many high-utilizing clients are hard to track after healthcare encounters and often need more intensive outreach and case management to navigate the lengthy and complex housing assistance process. Coordination between social service, health, and housing agencies is critical for serving this population, who frequently receive multiple services.
• Permanent supportive housing is often the most appropriate housing solution for this population, but placements are difficult to secure. It is essential to set realistic expectations for clients and access emergency and short-term housing options while working toward long-term placement.

Looking ahead

Housing Solutions will continue tracking housing and healthcare utilization outcomes for the cohort while working to secure housing placements. They will also prioritize strengthening partnerships with other housing and social service organizations and reducing referral times. Although currently limited to this project, they ultimately aim to expand the use of the new Healthcare FUSE data system to other service providers in Tulsa.