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

Background: People with histories of homelessness and serious mental illness experience profound health disparities. Housing First is an evidenced-based practice that is working to end homelessness for these individuals through a combination of permanent housing and community-based supports.

Methods: The Jefferson Department of Family and Community Medicine and a Housing First agency, Pathways to Housing-PA, has formed a partnership to address multiple levels of health care needs for this group. We present a preliminary program evaluation of this partnership using the framework of the patient-centered medical home and the “10 Essential Public Health Services.”

Results: 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.

Conclusion: The Pathways to Housing-PA/Jefferson Department of Family and Community Medicine partnership represents a community of solution, and multiple measures provide preliminary evidence that this model is feasible and can address the “grand challenges” of integrated community health services.

Those who emerge from the shadows of homelessness bring the disparities in the U.S. health care system into sharper focus. We describe the development and evaluation of a community of solution1 that addresses the dual problems of chronic homelessness and poor health outcomes experienced by people with serious mental illness (SMI) through a partnership between an academic medical center and a Housing First program. Housing First, an innovative and effective housing and treatment model,2 works to end homelessness for people with SMI by offering immediate access to permanent supportive housing and intensive community-based interdisciplinary supports. However, once housed, people continue to face numerous, often untreated chronic health conditions, suggesting that a systematic approach to population health improvement is needed. Primary care and patient-centered medical homes (PCMHs) can play a significant role in helping to meet public health needs.3,4 This article offers an example of this process, in which an extended PCMH in the Thomas Jefferson University Department of Family and Community Medicine (DFCM) and a local nonprofit Housing First agency, Pathways to Housing-PA (PTH-PA), have partnered successfully to better meet the individual and population health needs of formerly homeless people with SMI. Through a fusion of a PCMH model with elements of community-oriented primary care and a public health outreach, a unique and synergistic community of solution emerged.