A Primary Care-Public Health Partnership
This article describes initial efforts to monitor and improve the health of a population of formerly homeless individuals with SMI who are now in the PTH-PA Housing First program through a partnership with the Jefferson DFCM. Preliminary program evaluation results suggest that this partnership is evolving to function as an integrated person-centered health home and an effective local public health monitoring system. In addition, we have raised significantly staff and client awareness of physical health issues, resulting in increased engagement in ongoing care and screenings. Efforts are underway to quantify continuity rates and to track use of emergency services. The most recent analysis of the expanded population health database confirms high rates of chronic disease, as found in initial studies. The finding of relatively low rates of preventive health and screening for metabolic syndrome has resulted in ongoing quality improvement projects to address these deficiencies. Through the community-based participatory research projects, clients have been empowered to take ownership of their ongoing health issues, and, importantly, a core group of clients have become local and national advocates for programs that combine housing with health care for homeless people. The group has presented at national conferences, such as the American Public Health Association annual meeting, and homeless service reform movements, such as the 100,000 Homes Campaign.
Our partnership forms a community of solution in which "the problem can be [better] defined, dealt with and solved." In 2010, the Folsom Group produced an updated series of 13 grand challenges to "facilitate a vision for nation-wide integrated patient-centered community health services." We realized that the funding, structure, organization, and leadership of PTH-PA made it uniquely situated to impact positively population health outcomes, and we aligned our focus to meet these goals. This resulted in a community-tailored union of a full-scope health care home and a Housing First organization, which explicitly addresses some of the "grand challenges" of the Folsom Report, specifically grand challenges 2, 3, 9, and 10. Figure 2 shows how the PTH-PA community of solution addresses these grand challenges.
(Enlarge Image)
Figure 2.
Addressing the grand challenges for integrating community health services. PTH-PA, Pathways to Housing-PA; SMI, serious mental illness.
One positive element of the funding mechanisms that have made these partnerships possible has been HRSA grants, which have as their focus health care systems research and evaluation and primary care training, and have provided an integral funding mechanism for these partnerships. For example, HRSA funding partially supported the pilot work of the primary care physician, and continues to support many of the educational activities. This blending of funding mechanisms to include those which address health systems research, medical and behavioral health outcomes research, and 'social determinants of health' studies is important to realize the goal of fostering better population health through community partnerships.
Although we are somewhat satisfied with our initial efforts with the PTH-PA program, significant challenges remain. The greatest of these is sustainability. The services of the embedded primary care physician are not able to be reimbursed under current insurance mechanisms. Services currently are provided through a DFCM contract with PTH-PA combined with in-kind departmental support. New models of reimbursement through the PCMH structure and accountable care organizations may improve this situation. However, while federal and nonfederal behavioral health organizations such as the Substance Abuse and Mental Health Service Administration and the National Council of Behavioral Health care are developing and reporting on the integration of this type of specialized care for individuals with SMI, these models have not been discussed widely in the family medicine literature.
Another significant challenge is that of workforce development and enhancement, both in family medicine and community psychiatry. We believe that our educational programs for residents and medical students will begin to increase the comfort level of medical providers when working with individuals with SMI and collaborating with behavioral health providers in community settings. Both the issues of sustainability and workforce training limit the potential for scaling up and disseminating our current model. The "community health champion" is the embedded primary care physician. This model requires training of primary care physicians in more population-centric models of care. We believe the program itself helps facilitate this goal. In addition, a HRSA-funded interdisciplinary and interprofessional joint graduate degree 5-year grant to the DFCM is developing multiple cohorts of students with population health knowledge, skills, and attitudes.
Discussion
This article describes initial efforts to monitor and improve the health of a population of formerly homeless individuals with SMI who are now in the PTH-PA Housing First program through a partnership with the Jefferson DFCM. Preliminary program evaluation results suggest that this partnership is evolving to function as an integrated person-centered health home and an effective local public health monitoring system. In addition, we have raised significantly staff and client awareness of physical health issues, resulting in increased engagement in ongoing care and screenings. Efforts are underway to quantify continuity rates and to track use of emergency services. The most recent analysis of the expanded population health database confirms high rates of chronic disease, as found in initial studies. The finding of relatively low rates of preventive health and screening for metabolic syndrome has resulted in ongoing quality improvement projects to address these deficiencies. Through the community-based participatory research projects, clients have been empowered to take ownership of their ongoing health issues, and, importantly, a core group of clients have become local and national advocates for programs that combine housing with health care for homeless people. The group has presented at national conferences, such as the American Public Health Association annual meeting, and homeless service reform movements, such as the 100,000 Homes Campaign.
Our partnership forms a community of solution in which "the problem can be [better] defined, dealt with and solved." In 2010, the Folsom Group produced an updated series of 13 grand challenges to "facilitate a vision for nation-wide integrated patient-centered community health services." We realized that the funding, structure, organization, and leadership of PTH-PA made it uniquely situated to impact positively population health outcomes, and we aligned our focus to meet these goals. This resulted in a community-tailored union of a full-scope health care home and a Housing First organization, which explicitly addresses some of the "grand challenges" of the Folsom Report, specifically grand challenges 2, 3, 9, and 10. Figure 2 shows how the PTH-PA community of solution addresses these grand challenges.
(Enlarge Image)
Figure 2.
Addressing the grand challenges for integrating community health services. PTH-PA, Pathways to Housing-PA; SMI, serious mental illness.
One positive element of the funding mechanisms that have made these partnerships possible has been HRSA grants, which have as their focus health care systems research and evaluation and primary care training, and have provided an integral funding mechanism for these partnerships. For example, HRSA funding partially supported the pilot work of the primary care physician, and continues to support many of the educational activities. This blending of funding mechanisms to include those which address health systems research, medical and behavioral health outcomes research, and 'social determinants of health' studies is important to realize the goal of fostering better population health through community partnerships.
Challenges
Although we are somewhat satisfied with our initial efforts with the PTH-PA program, significant challenges remain. The greatest of these is sustainability. The services of the embedded primary care physician are not able to be reimbursed under current insurance mechanisms. Services currently are provided through a DFCM contract with PTH-PA combined with in-kind departmental support. New models of reimbursement through the PCMH structure and accountable care organizations may improve this situation. However, while federal and nonfederal behavioral health organizations such as the Substance Abuse and Mental Health Service Administration and the National Council of Behavioral Health care are developing and reporting on the integration of this type of specialized care for individuals with SMI, these models have not been discussed widely in the family medicine literature.
Another significant challenge is that of workforce development and enhancement, both in family medicine and community psychiatry. We believe that our educational programs for residents and medical students will begin to increase the comfort level of medical providers when working with individuals with SMI and collaborating with behavioral health providers in community settings. Both the issues of sustainability and workforce training limit the potential for scaling up and disseminating our current model. The "community health champion" is the embedded primary care physician. This model requires training of primary care physicians in more population-centric models of care. We believe the program itself helps facilitate this goal. In addition, a HRSA-funded interdisciplinary and interprofessional joint graduate degree 5-year grant to the DFCM is developing multiple cohorts of students with population health knowledge, skills, and attitudes.