Fellowship Openings

Advancing a Human-Centered, Holistic System of Care for Individuals Experiencing Homelessness

Project: Advancing a Human-Centered, Holistic System of Care for Individuals Experiencing Homelessness

Agency: San Francisco Department of Public Health

Location: City & County of San Francisco

Project Context  

Over the past two years, the city of San Francisco has taken aggressive steps to tackle its homelessness crisis. These efforts have led to double-digit declines in homelessness for veterans, families and young people, and a drop in the overall homeless population. Still, as housing prices in San Francisco reached record levels in 2018, some 7,500 people in the city continue to live without shelter daily and twice that many over the course of a year. Lack of housing is closely associated with declines in physical and mental health, a problem compounded by a decentralized and highly fragmented healthcare system in which high-needs patients are often referred to multiple disparate service providers. With little visibility or communication between providers, patient care for this highly vulnerable population can be disjointed, costly and inefficient.

The San Francisco Department of Public Health (SFDPH) is among a consortium of city and county agencies to receive funding under California’s Whole Person Care pilots, a series of state-wide pilot programs that will run through 2020 and are aimed at improving outcomes for Medicaid beneficiaries by better aligning health, behavioral health and social services. As part of this effort, SFPDH pioneered the Coordinated Care Management System (CCMS), an integrated data management system that establishes a “whole person profile” for over 450,000 vulnerable adults. Patient profiles span 20 years and include physical and mental health history, substance use history, housing status, justice involvement and more, giving service providers a more comprehensive understanding of patient needs.

These efforts have led to significant improvements and represent the cutting edge of healthcare innovation nationwide. Yet for the most vulnerable, service delivery remains fractured, with limited information-sharing across agencies. A small proportion of individuals who are heavy users of multiple systems, often due to homelessness, absorb an enormous amount of healthcare resources without improving their overall health outcomes. In California, just 5 percent of MediCal enrollees represent 50 percent of total program spending. As San Francisco grapples with a severe and persistent housing crisis, there is a pressing need to interrupt the cycle of homelessness and improve health outcomes through coordinated, human-centered care.

To support this work, SFDPH will partner with FUSE Corps to host an executive-level fellow for one year who will help identify technological and service delivery improvements that can help advance the vision of Whole Person Care: a comprehensive, seamless and human-centric system of care in which the most vulnerable individuals receive the services they need, with the ultimate goal of making homelessness rare, brief and one-time.

Project Summary & Potential Deliverables

The following provides a general overview of the proposed fellowship project. This project summary and the potential deliverables that follow will be collaboratively revisited by the host agency, the fellow, and FUSE staff during the first few months of the fellowship, after which a revised scope of work will be developed and agreed upon by the FUSE Fellow and the host agency.

Starting in September 2018, it is proposed the FUSE fellow will conduct qualitative research to map the experiences of Whole Person Care clients, potential clients and employees as they interact with the public systems. This mapping will document the various patient touchpoints to the system and evaluate the effectiveness of each touchpoint. Using human-centered design techniques such as stakeholder interviews, observation, immersion and/or journey mapping, the fellow will identify opportunities to streamline and improve the client experience through technology and service delivery improvements. The fellow will work closely with the Whole Person Care’s Chief Service Designer and IT personnel to design, prototype, develop, operationalize, and codify new methods of communicating and working within and across agencies. Working with project teams, the fellow will facilitate and support implementation of proposed new approaches.

San Francisco’s Whole Person Care pilot represents a unique and exciting opportunity for a fellow with a broad design sensibility to bring together best practices in user experience, product development, lean process improvement, and design strategy to improve care delivery for our most vulnerable clients.

  • Map the client experience: Using human-centered design techniques, ascertain the core needs of Whole Person Care clients, potential clients, employees and healthcare professionals, including key points of interaction with the system. Identify opportunities to improve the patient experience and eliminate redundancies through technology and service delivery innovations.
  • Develop prototypes to test new approaches: With the help of the Chief Service Designer and project teams, design prototypes to create, test and iterate new approaches across digital and non-digital spaces of service delivery. Build internal capacity of project teams to iterate and improve services on a continuous basis.
  • Support implementation: Facilitate the work of project teams, including scoping projects, establishing timelines and budgets, determining appropriate levels of stakeholder involvement, designing and executing pilot projects and/or beta tests, and establishing appropriate success metrics.

Key Stakeholders

  • Maria X Martinez, Director of Whole Person Care, San Francisco Department of Public Health
  • Amber Reed, Whole Person Care Chief Service Designer, San Francisco Department of Public Health


  • At least 15 years of professional experience in a relevant field, particularly with a strong background in service design, defined in this context as: taking a holistic approach to understanding the needs of clients, staff, and organizational stakeholders, identifying opportunities for improvement, designing and prototyping solutions to meet needs, and iteratively refining and implementing solutions.
  • Experience working in the healthcare context is beneficial but not required.
  • Superior critical thinking and analytical skills.
  • Ability to synthesize complex information into clear and concise recommendations.
  • Ability to relate to a wide variety of diverse audiences with strong emotional intelligence and empathy.
  • Excellent stakeholder engagement skills and the ability to use facilitative leadership techniques to coordinate stakeholder activities.
  • Self-motivated, goal-oriented, entrepreneurial leader who can also be an independent worker.
  • Persistent in obtaining information and creatively resourceful in identifying solutions to complex problems.
  • Ability to create direction and movement within potentially ambiguous
  • Exceptional written and verbal communication skills with an ease in public presentations.
  • Understands the need for solutions to support all people in a community regardless of race, religion, gender, immigration status, or ethnicity.