Scattergood Foundation

Advancing Innovative Strategies for Change in Behavioral Health

Pathways to Housing PA

Name of Innovative Program: 
Pathways to Housing PA Integrated Care Program
Sponsoring Organization
Pathways to Housing PA
Name of Innovative Program Lead: 
Lara Carson Weinstein
E-mail Address of Innovative Program Lead:
Project Description: 
Grounded in the belief that housing and healthcare are human rights, Pathways to Housing-PA offers immediate access to permanent, scattered site apartments and fully integrated, comprehensive behavioral and primary healthcare to some of the most vulnerable people in our society: those with experiences of homelessness and serious mental illness.  Our housing first services are delivered by a transdisciplinary team of professionals including: social workers, nurses, psychiatrists, a family doctor, peer specialists, substance abuse specialists, and community integration specialists.  On-site health services include basic primary care, individual psychotherapy, and team based home and street visits Through a unique community-academic partnership, we are able to extend our services to include comprehensive primary care at the Project HOME Wellness Center and specialty and inpatient care at Thomas Jefferson University Hospital for participants that choose these services.  We are dedicated to improving health on an individual and population health level in partnership with our participants. We rigorously track quality assurance measures and as a group we systematically review the health status of our most vulnerable participants on a regular basis. We have a robust program of community based participatory research to include the voice of our participants in current and future program planning. 
Creativity and Innovation: 
Our integration program is unique in its structure, its dedication to population health improvement, and its partnerships.  We have moved beyond co-location of services to have the primary care physician directly embedded in the team structure. We have developed the following innovations to improve the health of our population:·      Monthly interdisciplinary medical rounds are held on each service team to review complex ongoing care issues.·      Monthly health fairs on “check day” where participants come to receive their benefits and can be screened for obesity, hypertension, and diabetes.·      We track all hospitalizations, ED visits, and crisis center evaluations and review these monthly in our integrated care meetings, where cross team dialogue leads to creative problem solving. ·      In our community based participatory research program, we include our participants in all aspects of research: study design, implementation, analysis, and dissemination of results 
We have presented our work at several national and international forums including the American Psychiatric Association Annual Meeting, the American Public Health Association Annual Meeting, the Inaugural Housing First Partners Conference, and the International Homelessness Research Conference. Our executive director, Christine Simiriglia has been appointed as a National Team Leader for the TEDMED Challenge on Poverty and Healthcare. Our medical director, Lara Carson Weinstein recently participated on a national workgroup on integrated healthcare held by the Patient Centered Outcomes Research Institute (PCORI) 
In the past we have relied on grant funding and in kind donation of services from Thomas Jefferson University Department of Family and Community Medicine for our primary care services.  However, our program is now sustainable through our partnership with Project HOME.  Project HOME was recently awarded Federally Qualified Health Center designation, allowing us to bill Medicaid and Medicare for our onsite primary care services and home visits.  Our psychiatric and social services are sustainable under the Philadelphia Department of Behavioral Health Intensive Case Management structure. 
Procedures and policy that have emerged have already been piloted for reproducibility internally as new teams have developed at the Pathways to Housing-PA site.  Our model is predicated on a strategic use of medical services integrated into an Assertive Community Team (ACT) model.  Resources are maximized to identify, track and treat chronic illness among a highly vulnerable population, which usually experiences a host of barriers for medical services.  The strategic and integrated (in house) nature of this model focuses sparse medical resources to achieve maximal effect.   This model is replicable because ACT teams throughout the nation work with similar populations with chronic illness, have difficulty integrating medical services and need to maximize sparse resources. We are happy to consult with any supportive housing programs to help develop and implement our model of Pathways Housing First with embedded primary care through our Pathways to Housing National consulting and technical training team. 
Pathways to Housing currently provides services to 300 people on 5 teams (teams 4 and 5 receive medical services primarily through the VA) The primary care physician provides direct clinical services to about 30% of the population (this number is expected to increase as the FQHC partnership will greatly expand capacity).  In 2011 we measured health status and care quality data.  We found that 76% of our population has a chronic disease and almost 60% have 2 or more.  The most common diseases in our population include hypertension, diabetes, and asthma/COPD.  For the subpopulation receiving care from the both the onsite primary care physician and psychiatrist the screening rates for hypertension, obesity, diabetes, and hyperlipidemia were 97%, 72%, 45%, and 50% respectively.  As of October 2013, over 80% of the subpopulation of people on antipsychotic medications had been screened for 3 out of 5 of the elements of metabolic syndrome.