Shared Care Model in a Federally Qualified Health Care Center for the Homeless

• health care team
• underserved populations

The Daily Planet offers a continuum of comprehensive care, including general and urgent primary medical care, optometry, dental services, behavioral health services, enabling services, and medical outreach to the community. The Daily Planet has developed an academic community partnership with a university to enhance patient care and to add clinical pharmacists to the medical team.¹

An estimated 4900 patients annually use The Daily Planet's comprehensive services. The majority (91%) speaks English and are men (54%). Patient race/ethnicity is African American (52%), non-Hispanic white (29%), Hispanic (16%), Asian-American (2%), and other (1%). All patients have an income ≤200% of the poverty level and 95% are uninsured. Homeless people have a higher prevalence of chronic disease than the population as a whole, and the ability of someone who is homeless to manage disease optimally is severely impaired by a lack of control over living conditions and limited opportunities to follow an optimal treatment plan consistently.²

The medical clinic at The Daily Planet developed a Shared Care Model, which integrates collaborative team care, evidence-based medicine, and shared decision making between providers and patients in a patient-centered medical home. The team consists of one full-time physician, who also serves as the medical director, and one full time and 3 part-time family nurse practitioners. There are 3 medical assistants, one front desk coordinator, and 2 health educators. A part-time dietician and a clinical pharmacist provide services 4 full days a week. An optometrist and optician are available 1 day a month.

Our interprofessional team works together and avails ourselves to the patients in a variety of capacities. Expectations are that all staff participate in multiple levels of patient care and functionality of the clinic. The roles and level of participation overlap and depend on the needs of the patient and the clinic. Providers deliver primary care and participate in medical outreach, which includes screening, triage, and education to recruit new patients to the medical home. The medical assistants triage, participate in medical outreach, assist providers, and keep records. In addition to providing patient education and management, our dietician participates in medical outreach and staff education. The clinical pharmacists co-manage patients and participate in patient education, medical outreach, special programs, and staff education.⁴

The team of providers and staff collaborate to identify patient needs for development and implementation of special programs, including identification of potential funding sources. This cross-training of providers and staff has helped with the pressures of lack of manpower as the number of uninsured patients grows and the number of patients accessing the services at The Daily Planet increases. It also provides flexibility to offer comprehensive services in one place, take care of a variety of patient needs, and address barriers to transportation and accessibility, which is unique to our population. The team is integrated through a shared electronic medical record and vision for patient care.

The Shared Care Model in the medical clinic at The Daily Planet is an approach to team care that is benefitting those at risk of or who are experiencing homelessness. It allows patients access to the expertise of multiple providers and staff and helps patients manage their health-related problems and distinctive needs.

• Received for publication May 1, 2011.
• Revision received November 30, 2011.
• Accepted for publication December 7, 2011.