1. Integrated Health Home for the Homeless in Philadelphia Lara Carson Weinstein, MD, MPH Assistant Professor, Thomas Jefferson University Monica Medina McCurdy, PA-C Vice President, Healthcare Services, Project HOME

2. Disclosures (LCW) We are family medicine primary care providers No financial disclosures 2

3. Objectives (MMM) Describe an integrated health home “work in progress” for the homeless, in terms of: – Services delivered: Primary care & behavioral health co-location or integration – Physical spaces – Agencies involved – Academic Medical Center-Community partnership – Future plans – Outcomes 3

4. Who we serve (LCW) In multiple locations, we serve: People who are chronically or episodically homeless… Many of whom are mentally ill or dually diagnosed…in various stages of recovery… With complex chronic diseases… With histories of trauma… With little to no social supports… Who have traditionally experienced fragmented health care 4

5. Services and Service Locations

6. Where are we located (MMM) St. Elizabeth’s Wellness Center – North Philadelphia (MMM) – Jefferson/Project HOME 18 yr partnership (LCW) Pathways to Housing - PA (LCW) – Housing First Model – Scattered site Hub of Hope (MMM) – Winter Initiative operated by Project HOME in Suburban Station 6

7. Services Offered: Primary Care & Behavioral Health Co-Location (MMM) St. Elizabeth’s * Primary Medical Services Behavioral Health Health Classes, Support Groups Coordination with Specialty and Hospital-Based Care Off-site services and screenings Links to Community Services, Drug Treatment, Affordable Housing, Employment and Education Hub of Hope Housing placement Medical evaluations for housing Psychiatric evaluations for housing Linkage to primary care Linkage to treatment 7*DBH-funded three-year coalition

8. Services Offered: Primary Care & Behavioral Health Co-Location (MMM) Service providers involved @ St. Elizabeth’s Coalition:* Women Against Abuse Thomas Jefferson University Dept. of Family and Community Medicine Council for Relationships Albert Einstein Medical Center, Dept. of Psychiatry Project HOME *DBH-funded three-year coalition8

9. Services offered: Integrated Care Model @ Pathways to Housing (LCW) Psychiatry Primary care Social Work Nursing Peer Specialist Vocational Specialist Substance Abuse specialist Supporting Informed Activated Patient Partner 9

10. Pathways to Housing PA: Integrated Care Teams (LCW) 300 program participants 4 ACT modeled teams – Team 1-10 chronic inebriate – Team 2 -20 HOPWA – Team 3-medically fragile – Team 4- Veterans 1 full time psychiatrist, 2 part time psychiatrists, 1 part-time medical doctor

11. Outcomes

12. Pathways Outcomes- Programs (LCW) Metabolic syndrome screening program – People on antipsychotics – Monthly health fairs VFAAR Nursing health groups Peer wellness groups 12

13. Pathways Outcomes: results 13

14. Keystone Mercy (First) Pilot @ St. E’s (MMM) Two year pilot 60 patient cohort of KF members who are Jefferson patients who receive primary care at St. E’s We have health care utilization results so far Year 1 results compared two groups (intervention group who received care at St. E’s and non-intervention group) – Both groups in-patient costs went up pre- vs. yr 1 pilot – Both groups ER costs went down pre- vs. yr 1 pilot – Intervention group was sicker – HOWEVER, % increase in in-patient costs for intervention group was MUCH LOWER than for non-intervention group; same for ER cost comparisons 14

15. Hub of Hope Outcomes (MMM) 1919 social service visits from 640 unique individuals 484 medical visits from 184 unique individuals 298 essential medical assessments and forms completed for housing, services, and benefits 157 individuals placed into shelter, treatment, and other housing options around the City 240 total placements made 14 individuals referred to PCPs Engaged individuals on the margins of care during a “treatable moment” Provided coordinated health care and housing, along with the ability for consistent follow-up Connected individuals who are difficult to locate with supports around the City 15

16. Future Plans (MMM) 16

17. We’re working to consolidate all three sites and services under a single Health Home for the homeless – different entry points under one billing entity: A “Federally Qualified Health Center” operated by Project HOME to serve a special needs population… (MMM) A work in progress… 17

18. Stephen Klein Wellness Center

20. Stephen Klein Wellness Center Services In addition to services at the three sites above: MORE Health Classes, Support Groups Exercise Classes Dental Pharmacy Fitness (with child care) Physical Therapy Hospitality Program Stephen Klein Wellness Center