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FIELD ACTION REPORT |
Adam J. Gordon is with the Mental Illness Research, Education, and Clinical Center of Co-Morbidity (VISN–4), the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, and the Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pa. Melissa L. Montlack is with the Mental Illness Research, Education, and Clinical Center of Co-Morbidity (VISN–4), the Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh. Paul Freyder is with the Salvation Army, Pittsburgh. Diane Johnson is with the Neighborhood Living Project, Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh. Thuy Bui is with the Program for Health Care to Underserved Populations, University of Pittsburgh, Pittsburgh. Jennifer Williams is with the Primary Care Health Services, Inc–Health Care for the Homeless Program, Pittsburgh.
Correspondence: Requests for reprints should be sent to Adam J. Gordon, MD, MPH, Center for Health Equity Research and Promotion, Mailcode 151-c , University Drive C, Pittsburgh, PA 15240 (e-mail: adam.gordon{at}va.gov).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONPROGRAM DESCRIPTIONRESULTSDISCUSSIONReferences |
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The Allegheny Initiative for Mental Health Integration for the Homeless (AIM-HIGH) was a 3-year urban initiative in Pennsylvania that sought to enhance integration and coordination of medical and behavioral services for homeless persons through system-, provider-, and client-level interventions.
On a system level, AIM-HIGH established partnerships between several key medical and behavioral health agencies. On a provider level, AIM-HIGH conducted 5 county-wide conferences regarding homeless integration, attended by 637 attendees from 72 agencies. On a client level, 5 colocated medical and behavioral health care clinics provided care to 1986 homeless patients in 4084 encounters, generating 1917 referrals for care.
For a modest investment, AIM-HIGH demonstrated that integration of medical and behavioral health services for homeless persons can occur in a large urban environment.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONPROGRAM DESCRIPTIONRESULTSDISCUSSIONReferences |
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Research has demonstrated that a significant gap exists between the medical and behavioral health needs of homeless individuals and the provision of health services to meet that need.7 Emerging community initiatives are designed to confront the many facets of homelessness, and significant resources have been allocated to assist local and regional efforts.8,9 One national initiative provided 12 community-guided grants to increase integration between Health Care for the Homeless primary care clinics and community mental health agencies. The goal of this initiative was to discover unique and collaborative strategies for reducing the morbidity of homelessness.
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PROGRAM DESCRIPTION |
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TOPABSTRACTINTRODUCTIONPROGRAM DESCRIPTIONRESULTSDISCUSSIONReferences |
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A mission statement and goals for AIM-HIGH were established early in the project. The mission of AIM-HIGH was "to improve the health of homeless individuals by integrating physical and behavioral health care services through the development and implementation of a delivery system committed to improving availability, access, and coordination of services." The goals of AIM-HIGH were: (1) to integrate mental health and medical health providers at system and service levels; (2) to promote and encourage county and health care provider partnerships; (3) to eliminate duplication and reduce fragmentation of homeless services; (4) to incorporate culturally sensitive age- and gender-appropriate strategies into all facets of health care; (5) to provide educational and cross-training activities for key community and political stakeholders, professional providers, and ancillary service providers; and (6) to evaluate the progress and outcomes of the integration activities.
KEY FINDINGS
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To achieve its mission and accomplish its goals, AIM-HIGH leadership established administrative and fiduciary relationships between behavioral health and free-care medical health providers in Allegheny County. In developing this integrated delivery system, AIM-HIGH embraced a "no-wrong-door" philosophy that encourages homeless individuals to access multidisciplinary services at numerous points of entry into the health care system. AIM-HIGH implemented a wide range of client-, provider-, and system-level interventions, and evaluated these interventions using a formative evaluation process.10
On a client level, AIM-HIGH established or enhanced behavioral health care services at existing homeless medical clinics. The integrated AIM-HIGH clinics were located in geographically diverse neighborhoods where homeless persons congregate. The clinics provided various combinations of medical, mental health, pharmaceutical, drug and alcohol, and case management services using multidisciplinary teams (Table 1
). AIM-HIGH service providers consulted with and referred patients to one another, and also referred patients to external agencies when needed services were not available on site. Integrated services were offered weekly at each clinic site, and the outcomes presented here reflect only "integrated" days. A subset of clients (n=162) participated in a Government Performance and Results Act (GPRA) survey that was required by the funding agencies. A research assistant approached clients at 2 colocated clinic sites to request participation in additional data collection for the subsample description.
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On the system level, a full-time county liaison was hired to facilitate communication between stakeholders, service providers, and Allegheny County administration. A full-time integration ombudsman was hired to assist the coordination of services among the partner agencies. AIM-HIGH established a homeless integrated delivery system workgroup to identify and confront facilitators and barriers to integration, an education core led by an education consultant to present conferences and trainings, and an evaluation core led by an evaluation consultant (Figure 1).
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RESULTS |
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TOPABSTRACTINTRODUCTIONPROGRAM DESCRIPTIONRESULTSDISCUSSIONReferences |
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). Over 1917 new referrals from medical, mental health, substance abuse, and case management staff to various outside and on-site services were documented (Table 3). The main referrals for clinic patients to internal or external health services were for pharmacy assistance (n=763; 40%), behavioral health care (n=443; 23%), and medical or surgical care (n=252; 13%). Dental (5%), medical assistance or insurance (5%), other social (5%), housing (4%), and substance treatment (3%) service referrals were more infrequent at the colocated clinics.
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System Level
AIM-HIGH established a formal network of integrated homeless service providers, though not without some difficulties. The homeless integrated delivery system workgroup, which included the county liaison and integration ombudsman, encountered many facilitators and barriers to integration and coordination of services for homeless persons (Table 4). For example, to confront funding issues, the AIM-HIGH team explored opportunities for additional and continuation funding from external agencies, the county, and Medicaid insurers. Eventually, Health Care for the Homeless successfully competed for Section 330 Bureau of Primary Health Care for the Health Care for the Homeless mental health expansion funding for the colocated clinic sites. Other major barriers included Health Insurance Portability and Accountability Act requirements, mistrust between large health care systems, and coordination of electronic medical record systems.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONPROGRAM DESCRIPTIONRESULTSDISCUSSIONReferences |
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AIM-HIGH confronted several key barriers to integration, and facilitated coordination of activities among disparate providers. AIM-HIGH leaders identified several of the barriers that they considered to be the most challenging, including the need for greater information sharing and formal agreements between agencies, and reconciling different missions and, at times, viewpoints of treatment delivery. Although solutions to all these challenges cannot reasonably be expected in 3 years, AIM-HIGH successfully initiated contractual arrangements between agencies, colocated behavioral health services within medical clinics, and implemented electronic medical records in most clinics.
Some limitations of AIM-HIGH should be noted. First, AIM-HIGH’s service and system integrations were slow to develop. Once clinics were established, the integrated providers were successful in engaging clients and providing sustainable services. Second, AIM-HIGH was unable to successfully integrate external homeless health care agencies into its collaborative effort. In part, this lack of external integration was attributable to the complexity of coordinating stakeholders and providers within AIM-HIGH, as well as to budget constraints. Third, AIM-HIGH had initial difficulty with integration efforts on the provider level. Joint trainings for providers and regular stakeholder meetings assisted in this regard. Finally, issues such as integration and sharing of computerized medical records and difficulties in transporting clients from one service provider to another were not fully solved during the course of AIM-HIGH. These barriers likely needed additional resources beyond the scope of AIM-HIGH. Despite these limitations, AIM-HIGH’s strongest attribute was the ability to address integration of homeless health care through comprehensive approaches.
The process evaluation for AIM-HIGH has helped shape several recommendations for future initiatives. First, because integration projects are often challenging to sustain, and require time and resource commitment, homeless integration projects should be viewed and undertaken as long-term efforts. Second, consistent with work from another community program,14 AIM-HIGH found that the leaders of integration projects should seek early investment and support from funding agencies, community leaders, and public policy leaders. Finally, hiring a dedicated staff member (i.e., county liaison or integration ombudsman) can facilitate communication among partner agencies. It was the experience of the AIM-HIGH team that such facilitation was most effective when the facilitator was (1) previously entrenched in the homeless system, (2) viewed by all partners as an unbiased party, and (3) in a position to build relationships with agencies and policymakers of diverse perspectives.
AIM-HIGH’s experience demonstrated that homeless service agencies can originate and sustain medical and behavioral health integration initiatives. Although health care integration is a challenging undertaking, lessons can be learned and built upon.
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Acknowledgments |
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The AIM-HIGH Team also included Natalie J. Hatcher, Chris Laemmle, Theda Sanders, and Rich Venezia.
Human Participant Protection
The University of Pittsburgh institutional review board approved this project.
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Footnotes |
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Contributors
All of the authors contributed to implementing the study, revising the article, discussing the research at all phases, and interpreting the results. A. J. Gordon originated the study and collaborated with M. L. Montlack on the original conceptualization and structure of the article. J. Williams, T. Bui, and A. Gordon collaborated on implementing the study. D. Johnson and P. Freyder further contributed to implementation and interpretation of the results.
Accepted for publication October 6, 2006.
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References |
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TOPABSTRACTINTRODUCTIONPROGRAM DESCRIPTIONRESULTSDISCUSSIONReferences |
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2. Brickner PW, Scanlan BC, Conanan B, et al. Homeless persons and health care. Ann Intern Med 1986;104: 405–409.
3. Wood D, Valdez RB. Barriers to medical care for homeless families compared with housed poor families. Am J Dis Child 1991;145:1109–1115.
4. Hwang SW, Lebow JM, Bierer MF, O’Connell JJ, Orav EJ, Brennan TA. Risk factors for death in homeless adults in Boston. Arch Intern Med 1998;158: 1454–1460.
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8. Cocozza JJ, Steadman HJ, Dennis DL, et al. Successful systems integration strategies: the access program for persons who are homeless and mentally ill. Adm Policy Ment Health 2000;27: 395–407.[CrossRef][Web of Science][Medline]
9. Dennis DL, Steadman HJ, Cocozza JJ. The impact of federal systems integration initiatives on services for mentally ill homeless persons. Ment Health Serv Res 2000;2:165–174.[CrossRef][Medline]
10. Stetler CB, Legro MW, Wallace CM, et al. The role of formative evaluation in implementation research and the QUERI experience. J Gen Intern Med 2006;21(suppl 2):S1–S8.
11. O’Toole TP, Arbelaez J, Haggerty C. The urban safety net: can it keep people healthy and out of the hospital? J Urban Health 2004;81:179–190.[Web of Science][Medline]
12. Rosenheck R, Morrissey J, Lam J, et al. Service system integration, access to services, and housing outcomes in a program for homeless persons with severe mental illness. Am J Public Health 1998;88:1610–1615.
13. Rosenheck R, Morrissey J, Lam J, et al. Service delivery and community: social capital, service systems integration, and outcomes among homeless persons with severe mental illness. Health Serv Res 2001;36:691–710.[Web of Science][Medline]
14. Steadman HJ, Cocozza JJ, Dennis DL, et al. Successful program maintenance when federal demonstration dollars stop: the ACCESS program for homeless mentally ill persons. Adm Policy Ment Health 2002;29:481–493.[CrossRef][Web of Science][Medline]
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| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
