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St Johns Continuum Of Care Brings New Thinking to the Intersection of Healthcare and Human Services

As communities grow more aware of the connection between homelessness and health, many forward-thinking leaders are taking action. Various studies have pinned the cost of just one homeless individual to a community at anywhere from $30,000 to $50,000 per year.

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As a result, government agencies, non-profit groups and community organizations have stepped up their support of homeless programs. But few communities can match the innovation of St. Johns County in eastern Florida.

A Visionary Approach to Healthcare and Homelessness

The St. Johns County Continuum of Care named Flagler Hospital its lead agency in December of 2017. The hospital is in a unique position to serve, having both a clear incentive to solve the problem, and the resources to bring the community together.

“Our vision is to be a model for community-based care,” said John Eaton, Director of Community Health Improvement at Flagler. “We’re proud to say that St. Johns County is statistically the healthiest county in Florida. But homelessness was an opportunity for us to improve. We looked at our social determinants of health and identified new opportunities to do better.”

For Eaton, those opportunities include health services, transportation, food, power…and a home. “What can we do when we discharge someone to a homeless camp?” Eaton continued, “There needs to be responsibility before, during and after a hospital stay.”

Leveraging the Power of ServicePoint

The St. John’s CoC coordinates roughly 10 providers and nearly 50 programs for the homeless. The CoC uses Mediware’s ServicePoint software to manage its efforts. “We’re lucky to have ServicePoint and to work with Mediware. Now we have a system customized and made for community.”

Through a grant, Flagler pays for most healthcare services and also the user licenses for ServicePoint. In exchange, they ask that providers use ServicePoint to report back to the CoC.

ServicePoint provides the necessary visibility into the problem, and also facilitates coordinated care, explained Brittany Coronado, the HMIS lead. “We have some great resources for homeless individuals, but the system can be hard to navigate. Now our approach allows all access points in the care system to feed into one coordinated entry hub. When you track needs this way, you can reallocate resources as a community, not just as a hospital.”

The CoC has served 83,000 clients since 2003. And just like medical records improve care at the hospital, those ServicePoint records speed care for clients who visit any agency or provider on the ServicePoint system. A client doesn’t have to hear the same question over and over, because the answers are already in the system.

Lessons Learned

“People ask, ‘Why is a hospital doing this,’” Eaton said. “The truth is, our president is committed to building healthier communities, our community is committed to partnership, and Flagler Hospital is known for innovation, so this couldn’t make more sense.”

Fortunately, the St. Johns County government plays an active role on the CoC. The County’s own research pegged the cost of a homeless individual at $30,000. This realization supported the county’s commitment to work toward a more centralized, coordinated approach.

“Sometimes it feels like we’re building the runway as we fly,” Eaton said. For example, they have found it works best to integrate providers in a more gradual process that moves them toward ServicePoint eventually instead of instantly. They also understand that not everything they try is going to be a success. “When we make a decision that doesn’t work, we change,” Eaton said.


As St Johns grows its network, they will be able to add even more services and offer a more complete solution to the problem of homelessness. Mediware is proud to partner with St Johns and support their innovative approach.

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