Helping Patients Navigate the Next Step
For people experiencing homelessness, poverty, or unstable housing, getting medical care is often only the first challenge.
The next challenge is follow-through.
Patients may need help getting to appointments, replacing documents, understanding referrals, accessing medication, communicating with providers, or reconnecting with care after a hospital visit.
Miami Street Medicine’s Care Coordination program helps bridge those gaps.
Our care coordinators work with patients during street runs and follow-up outreach to identify medical and social needs, create individualized service plans, and help patients move toward more stable care.
What Is Care Coordination?
Care coordination is the process of helping a patient connect the pieces of their healthcare and support plan.
For Miami Street Medicine, that means meeting patients where they are, listening to what they need, identifying barriers, and helping them take realistic next steps.
Care coordination may involve medical referrals, appointment support, documentation help, insurance navigation, transportation planning, case updates, and communication across fragmented systems of care.
Our work at Miami Street Medicine is goal-oriented and patient-centered. Our goal is not to take over a person’s life, but to help each patient move through one meaningful next step at a time.
How Miami Street Medicine Care Coordinators Help
Miami Street Medicine care coordinators go out with the street team during outreach visits. During conversations with patients, they screen for medical and social needs, assess risk, and help create an individualized service plan.
Our Care Coordination Services Include:
Medical referrals
Follow-up planning
Appointment coordination
Help reconnecting with care
Support obtaining government IDs
Help navigating insurance or benefits
Transportation support when available
Bus pass coordination when available
Communication with partner organizations
Progress updates for active cases
Coordination with street medicine providers
Connection to broader Dade County Street Response services
Support transitioning toward primary care or clinic-based care
How Care Coordination Works
We Meet the Patient Where They Are
Care coordinators join street runs to connect with patients directly in the community. This may happen outdoors, near shelters, under bridges, in encampments, or wherever outreach is taking place.
We Listen and Identify Needs
Through conversation, the care coordinator listens to the patient’s concerns, strengths, priorities, and barriers. This may include medical needs, social needs, safety concerns, documentation issues, or follow-up care challenges.
We Create a Goal-Oriented Plan
The care coordinator helps create an individualized service plan focused on realistic next steps. This plan may include medical referrals, document support, transportation planning, medication access, or connection to partner services.
We Follow Up Over Time
Care coordinators submit progress updates and communicate case information with the interdisciplinary team during sync meetings before street runs. This helps the team stay aligned and continue supporting the patient across future outreach.
Frequently Asked Questions about MSM Care Coordination
What is care coordination?
Care coordination helps patients connect to the next step after initial street outreach or medical care. For Miami Street Medicine, care coordination may include medical referrals, appointment support, documentation help, insurance or benefits navigation, transportation planning, communication with providers, and follow-up during future street outreach.
Who does Miami Street Medicine provide care coordination for?
Miami Street Medicine provides care coordination for patients connected to its street medicine outreach, curbside consult requests, partner referrals, and broader community care efforts in Miami-Dade County.
How does care coordination help people experiencing homelessness?
A patient may need to attend an appointment, fill a prescription, replace an ID, arrange transportation, follow up after a hospital visit, or reconnect with a provider. Care coordination helps organize those next steps so patients are not left to navigate the healthcare system alone.
Can Miami Street Medicine help with referrals, appointments, IDs, insurance, or transportation?
When possible, Miami Street Medicine may help patients work through barriers such as medical referrals, follow-up appointments, government ID needs, insurance or benefits navigation, transportation planning, bus pass coordination, and communication with healthcare providers.
Can partner organizations refer someone for care coordination?
Yes. Partner organizations, outreach workers, case managers, social workers, shelters, clinics, hospitals, and community groups can contact Miami Street Medicine or submit a curbside consult request when someone may need street-based follow-up or care coordination.
Is care coordination the same as emergency medical care?
No. Care coordination is not emergency medical care and does not replace urgent or emergency services.
If someone is experiencing a life-threatening emergency, severe injury, overdose, chest pain, difficulty breathing, or another urgent medical crisis, call 911 or seek emergency medical care immediately.
Care Without Insurance, ID, or Judgment
We believe everyone deserves access to care, regardless of income, housing status, insurance status, documentation, or ability to pay.
Support Free Healthcare in Miami-Dade
Miami Street Medicine exists because people in our community believe healthcare should reach the people who need it most.
Whether you need care, want to make a donation, are interested in volunteering, or represent an organization that wants to partner with us, your next step matters.