Connecting unhoused patients to coordinated care

For patients experiencing homelessness, navigating the health care system can be overwhelming, particularly after an emergency department visit. At Providence Saint John’s Health Center, community health care coordinators help ease the process by meeting patients where they are and connecting them to essential resources that support healing and long-term well-being.

Care coordinators work directly with unhoused patients to connect them to shelter, food, clothing, transportation and medical follow-up. Available seven days a week, the team focuses on building trust and ensuring patients are discharged with a clear path to continued care.

Through partnerships with community organizations such as Venice Family Clinic, the program strengthens care coordination beyond the hospital. Having access to a dedicated referral pathway allows patients to be quickly connected to primary care, mental health services and other critical support. These connections help reduce repeat emergency department visits and improve long-term health outcomes.

“Navigating health care services can be challenging for anyone,” said Christina Crawford, community health manager at Providence Saint John’s. “Having a dedicated team here at Saint John’s to serve our unhoused patients with compassion, while preserving their dignity, is critical to getting them connected to the ongoing care they need, while reducing avoidable ED visits.”

By removing barriers to care and building trusted community partnerships, Saint John’s continues to advance equitable access to health services for some of the region’s most vulnerable community members. 

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