Sonoma County Director of Innovation Carolyn Staats oversees a program that helps keep at-risk young people from becoming homeless.

Apr 11 2024

Local Governments Break Down Data Silos to House Vulnerable Citizens

Through cloud-powered solutions, agencies are analyzing data to address homelessness.

As 2024 dawned the Sonoma County, Calif.-based nonprofit Social Advocates for Youth made an urgent announcement: It would need to close Northern California’s only homeless shelter for youth if it couldn’t raise funds. A flurry of support temporarily postponed the move, but with homelessness an ongoing challenge — including among teens — county officials have been piloting technology solutions to help manage the issue, serve those in need and even prevent individuals from becoming homeless.

“We wanted to do something to move further upstream and build a program for transition-age youth, which are about 13 percent of all homeless individuals in the county, according to 2023 research,” says Carolyn Staats, director of innovation for Sonoma County. “Compared to the chronic, high-need homeless population, the TAY population uses technology to a much higher extent, and they are often attending school and working when possible.”

With part of a $2 million earmark from the federal government, Sonoma County recently sought to expand its already successful Accessing Coordinated Care and Empowering Self-Sufficiency (ACCESS) Sonoma program to directly address young people at risk of homelessness, complete with a smartphone app designed to help them obtain services and organize resources.

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The solution combines Merative, a Software as a Service front-end that integrates with IBM’s Connect 360 and InfoSphere Master Data Management, forming a data integration hub that combines client data from the siloed systems. It runs in the Microsoft Azure Government cloud and integrates with various platforms, including SimpliGov electronic workflows.

It’s an architecture that more state and local governments are starting to adopt as they seek to improve services.

“Any sort of social or human services benefit from better data integration, because case management of people and families always involves multiple agencies and departments,” says Ruthbea Yesner, IDC vice president for government Insights, education, smart cities and communities.

“Tight access controls and data governance to protect privacy are important. And every government will have many different applications for data, so managing a hybrid cloud becomes really important, since data may be on-prem in some agencies, in a cloud application in others and so on,” Yesner adds.

LEARN MORE: IT officials can take small steps for big advances in data management.

Sonoma County Provides Help with An App

Sonoma County originally established ACCESS Sonoma in 2017 with a hybrid cloud-based solution for sharing data among departments and helping users of safety net services.

“We’ve never specifically dealt with the younger population before,” Staats says. “So, we did a two-day design thinking workshop with transition-age youth, case managers from the departments of health and probation, and community partners to identify their needs and serve them through ACCESS Sonoma. With the youth population, one thing they rely on is their phone.”

Currently in its pilot phase, Sonoma’s youth program has already shown promise. Among pilot participants, 58 percent achieved housing, Staats says. Sixteen percent joined a coordinated program to connect them with housing, and 31 percent were connected to mental health services. The county also tracks participants who successfully access training, medical care and employment.

“With the app, they can schedule important appointments and get alerts. If they’re in the justice system, they can receive court notifications. And they can upload important documents to secure cloud storage, such as report cards, certificates for completing programs and identification,” Staats explains. “ACCESS Sonoma is about providing the tools and services that help clients achieve the basic stability needed so they can work on issues that may lead to or are made harder by homelessness.”

Carolyn Staats
With the app, they can schedule important appointments and get alerts.”

Carolyn Staats Director of Innovation, Sonoma County

County Establishes Solutions Through Data Sharing

ACCESS Sonoma began when directors of the county’s safety net departments got together to discuss improving outcomes for their citizens.

“We weren’t talking about homelessness at first, but we realized that unstable housing was a common attribute shared across safety net department clients,” Staats says. “And as we started discussing homelessness, we realized that each of us had contact with others’ clients, whether they were in the criminal justice system or experiencing behavioral health or substance abuse issues.”

Citizens using safety net services were “bouncing from one department to another,” she adds, which complicated the efforts of each.

“Stable housing is a key factor that needs to be resolved in order to address so many other issues. Without a coordinated care effort across departments, the clients would continue moving in and out of the silos without the ability to change their trajectory in a more positive, sustainable direction,” Staats says. “The ability to share data across these departments was an obvious barrier.”


El Paso County Opens a Virtual Path to Resources

El Paso, Texas, is focused on using technology to streamline access to social and human services for an at-risk population that includes a significant number of migrants.

“Unfortunately, we're seeing a rise in the instances of homelessness, but on the positive side, we have also seen an increase in our ability to get in front of it,” says Nicole Ferrini, El Paso’s director of community and human development.

The city began turning the tide during the COVID-19 pandemic, when it approached Cisco to help implement Webex conferencing solutions to serve the homeless population without risking the health of workers and citizens.

“Emergency shelters are not equipped to separate people 6 feet apart,” Ferrini says. “We started using the Webex platform to process individuals coming in. I’m proud to say not one case of COVID originated in our shelters.”

READ MORE: How San Diego improved homeless services.

Post-pandemic, El Paso collaborated with Cisco and its development partner to build an online portal called El Paso Helps. Ferrini says that research showed that roughly 70 percent of the at-risk population own smartphones, plus El Paso offers free municipal Wi-Fi and other computing resources around the city. When users access El Paso Helps, they can click an icon for the services they need and be connected to live social workers.

“Originally, the design required people to download Webex, but that wouldn’t always be feasible. So, the developers integrated the functionality into the portal,” Ferrini says.

Ferrini hopes to deploy El Paso Helps in kiosks around the city for people without smart devices.


The percentage of people living in families with children while homeless in January 2022

Source:, “State of Homelessness: 2023 Edition,” May 2023

Los Angeles County Seeks to Predict Homelessness

In Los Angeles County, data integration has been central to an initiative that uses computer modeling to predict homelessness and take preventative action. Implemented by the LA County Department of Health Services and developed by the California Policy Lab at UCLA, the analytics platform draws data from seven county agencies and considers hundreds of factors when identifying trends that could signal a risk of homelessness.

“Prevention is really hard to target,” says Janey Rountree, executive director of the CPL’s UCLA site. “Here in LA, there are several million people receiving public assistance but only about 1 to 2 percent of those people will ever experience homelessness. Government agencies that want to fund prevention aren’t sure it will reach the right people and make a difference. That is where our work comes in. We were inspired to use advances in data science to see if we could help identify who is at highest risk of homelessness.”

The analysis is performed on anonymized data, which county workers then match back to names and other information when the solution identifies potential risks. CPL “risk lists” are sent to authorized agencies, which then mine case management and clinical records to determine housing status before reaching out to individuals.

Rountree says that the overall data set comprises about 80,000 individuals, and risk lists can include about 1,000 people. As of December 2023, the county’s Homelessness Services Authority has worked with more than 600 people identified through the CPL platform.

“This project wouldn’t be possible without efforts by the LA County CIO to link and de-identify data across different county systems,” she says.

Photography by Cody Pickens

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