A primary care-public health partnership addressing homelessness, serious mental illness, and health disparities

J Am Board Fam Med. May-Jun 2013;26(3):279-87. doi: 10.3122/jabfm.2013.03.120239.


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.

Keywords: Community Medicine; Delivery of Health Care; Homeless Persons; Mental Health; Public Health.

Publication types

  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Aged
  • Chronic Disease / epidemiology
  • Chronic Disease / rehabilitation
  • Comorbidity
  • Cooperative Behavior*
  • Cross-Sectional Studies
  • Delivery of Health Care / organization & administration
  • Delivery of Health Care, Integrated / organization & administration
  • Feasibility Studies
  • Female
  • Health Services Accessibility / organization & administration
  • Health Services Research / organization & administration
  • Healthcare Disparities / organization & administration*
  • Homeless Persons* / statistics & numerical data
  • Housing*
  • Humans
  • Interdisciplinary Communication*
  • Male
  • Middle Aged
  • Patient-Centered Care / organization & administration*
  • Pennsylvania
  • Preventive Health Services / organization & administration
  • Primary Health Care / organization & administration*
  • Program Evaluation
  • Psychotic Disorders / epidemiology
  • Psychotic Disorders / rehabilitation*
  • Public Health Administration*
  • Public Health Surveillance
  • Quality Assurance, Health Care / organization & administration
  • Social Work / organization & administration*
  • Uncompensated Care*