Research ArticleOriginal Research

A Primary Care–Public Health Partnership Addressing Homelessness, Serious Mental Illness, and Health Disparities

Lara Carson Weinstein, Marianna D. LaNoue, James D. Plumb, Hannah King, Brianna Stein and Sam Tsemberis
The Journal of the American Board of Family Medicine May 2013, 26 (3) 279-287; DOI: https://doi.org/10.3122/jabfm.2013.03.120239

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    Pathways to Housing-PA/Department of Family and Community Medicine partnership. JFMA, Jefferson Family Medicine Associates; TJU, Thomas Jefferson University.

  • Figure 2.
    Figure 2.

    Addressing the grand challenges for integrating community health services. PTH-PA, Pathways to Housing-PA; SMI, serious mental illness.

Tables

  • Table 1. Elements of the Patient-Centered Medical Home (PCMH) at Pathways to Housing-PA (PTH-PA)14
    PCMHPTH-PA
    Personal physician25% of PTH-PA clients have the on-site family physician as their PCP. Efforts are ongoing to link all clients with a PCP either on site or in the community because almost 50% of clients do not have a known PCP.
    Physician-directed medical practiceA family physician is the medical director of PTH-PA.
    Whole-person orientationPTH-PA offers fully integrated primary and behavioral health care. The principles of mental health recovery are a core value.
    Care is coordinated and integrated across all elements of the complex health care systemAll care transitions are coordinated closely by the PTH-PA staff. On-site meetings frequently occur between PTH-PA staff and the staff of outside care facilities.
    Quality and safetyPTH- PA has developed the infrastructure for ongoing continuous quality improvement. Clients actively participate through community-based participatory research and a consumer health advisory board.
    Enhanced accessAppointment scheduling is open access and staff is available 24 hours a day.
    PaymentPayment for family physician time is not built into the behavioral health billing structure. Payment relies on contracts and in-kind support.

    • PCP, primary care physician.

  • Table 2. The 10 Essential Public Health Services and Pathways to Housing-PA (PTH-PA)15,16
    10 Essential Public Health ServicesPTH-PAScore*
    1. Monitor health status to identify community health problems.Infrastructure for monitoring health is being developed through the Pathways Population Health Database and Metabolic Syndrome Screening Project.3
    2. Diagnose and investigate health problems and health hazards in the community.On-site primary care is available for all clients. Larger health issues such as fire safety and summer heat assessments are monitored across the population.3
    3. Inform, educate, and empower people about health issues.PTH-PA has monthly wellness groups and periodic groups about specific health topics.3
    4. Mobilize community partnerships to identify and solve health problems.PTH- PA has multiple partnerships with community organizations, Thomas Jefferson University, and the Philadelphia Department of Behavioral Health.4
    5. Develop policies and plans that support individual and community health efforts.PTH-PA has policies on medication management and metabolic syndrome screening and is developing a fire safety policy.3
    6. Enforce laws and regulations that protect health and ensure safety.PTH-PA has developed clear safety policies and procedures.2
    7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.On-site primary and behavioral health care is available for all clients regardless of insurance status. Home visits are available for clients unable to come to the office. All clients are supported in community-based care linkages.3
    8. Assure a competent public and personal health care workforce.PTH-PA and Jefferson Department of Family and Community Medicine partner in training students using a homeless health rotation and clerkship model.4
    9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.PTH-PA has several ongoing quality improvement programs.3
    10. Research new insights and innovative solutions to health problems.The PTH Housing First model is based on dedication to research and innovation.4

    • ↵* 0 = No, 1 = minimal, 2 = moderate, 3 = significant, and 4 = optimal.

  • Table 3. Pathways Population Receipt of Preventive Services
    Preventive Service Measure*Clients Receiving Services
    Alcohol misuse screening152 (91)
    Tobacco use screening150 (90)
    Drug use screening148 (89)
    Hypertension screening130 (78)
    Obesity screening125 (75)
    Intimate partner violence screening100 (60)
    Type 2 DM screening88 (53)
    Hyperlipidemia screening54 (32)
    HIV infection40 (24)
    Hepatitis C infection32 (19)
    Pneumococcal vaccine (high risk)30 (19)†
    Cervical cancer screening10 (19)‡
    Seasonal influenza vaccine (2011)28 (17)
    Breast cancer screening7 (14)§
    Colorectal cancer screening13 (13)
    Seasonal influenza vaccine (2010)22 (13)
    Dental exam12 (7)
    Ophthalmology visit12 (7)
    Podiatry visit4 (2)
    Pneumococcal vaccine (≥65 years old)0 (0)‖
    Metabolic syndrome screening (n = 59)
        Blood pressure50 (85)
        Body mass index44 (75)
        Fasting glucose26 (44)
        Fasting lipids22 (37)
        Waist circumference3 (5)

    • Values shown as n (%).

    • ↵* Since entering the program, Pathways clients have received 167 preventive services.

    • ↵† Percentage of total population eligible for pneumococcal vaccination and <65 years old.

    • ↵‡ Percentage of the female population ≥21 years old.

    • ↵§ Percentage of the female population ≥40 years old.

    • ↵ Percentage of the total population ≥50 years old.

    • ↵‖ Percentage of total population ≥65 years old.

    • DM, diabetes mellitus.

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