Creating a Medical Home for Homeless Persons With Serious Mental Illness

Individuals with a serious mental illness, especially those who have experienced homelessness, have high rates of medical comorbidities and early mortality. Our “housing first” program combines supported housing, assertive community treatment (ACT), and primary care in order to address these complex service needs. The program began in October 2008 and serves 125 individuals who have met the federal definition of chronic homelessness and have an axis I diagnosis of serious mental illness. Two separate city departments in Philadelphia, the Office of Supportive Housing and the Department of Behavioral Health, made the program possible. U.S. Department Housing and Urban Development funds (Shelter plus Care) provide housing subsidies with the expectation that consumers pay one-third of their income (usually Supplemental Security Income or Social Security Disability Insurance) toward rent. Medicaid funding for intensive case management supports consumers' independent living. Services are configured and staffed as two ACT teams.

Through collaboration with a local academic medical center, a primary care physician has been embedded within the ACT teams from the program's outset. This physician provides on-site primary care services for two half-days per week, joining each team's morning meeting on those days and working closely with the team nurses to provide overall health assessment and coordination, including a disease registry. When needed, the primary care physician also makes home visits with an ACT team member to actively engage individuals who would not otherwise receive medical treatment. Follow-up care and specialty care referrals occur either at the housing-first agency or at the physician's hospital-based practice. Consistent with ACT's multidisciplinary operational approach, key relationships between nursing, psychiatry, and primary care have been established during usual ACT service provision, with the addition of both monthly integrated care program meetings and team “medical rounds” allowing for a sustained focus on consumers' ongoing health needs.

This integration of primary care is made possible through the combination of an individual research fellowship that allowed for flexibility in the physician's schedule and institutional support from the academic medical center that is committed to piloting innovative approaches to care. The sustainability of integrated primary care within these teams is based on soliciting ongoing grant funding. Through the first full calendar year of the program (October 2008–December 2009), 106 clients enrolled in the program, and housing stability exceeded 90%. Epidemiological monitoring during this period revealed that 92% of clients had a chronic medical condition in addition to a serious mental illness. Thirty-two clients received integrated primary care based on consumer choice and specific team referrals. (Thirty-six clients reported having an outside primary care doctor, and 34 clients had no regular contact with a primary care physician and declined further health care evaluation.) With assertive community treatment as a platform to deliver primary care services, a majority of these clients were screened for hypertension (97%), diabetes (81%), obesity (88%), and hyperlipidemia (63%), as recommended by the National Association of State Mental Health Programs Directors. Those with positive screens are receiving ongoing treatment. During our second year of program operation, 15 more individuals began receiving integrated primary care through this focus and continued outreach.

Providing integrated primary care within ACT has also enabled clients to receive, when necessary, comprehensive, coordinated tertiary care services, such as treatment for cancer and chronic kidney disease. Although the affiliation with the medical center has facilitated referrals for additional care, there continues to be a high rate of missed appointments (approximately 30%), which underscores the need for proactive, ongoing team support. For clients receiving care from outside primary care providers, it has been difficult to maintain open communication and exchange of timely information in order to medically support consumers' health conditions, which underscores the need for integrated care.

Given the challenge to provide a person-centered medical home for people with multiple diagnoses who are currently not well served by the existing system of clinic-based care, a modified ACT team is well suited to provide effective comprehensive treatment. Thus far, our program demonstrates that through collaborative primary care partnerships (such as primary care physicians or family nurse practitioners) ACT can serve as a medical home for individuals with psychiatric disabilities and co-occurring serious health problems. With ongoing effort to measure outcomes, this program can help inform the development of a comprehensive model of integrated care.