An Interprofessional, Embedded Practice Model for Improving Healthcare Access Among Homeless Men in Recovery

Patients with co-morbid substance abuse, mental health disorders, and chronic health conditions face difficult challenges when attempting to access health care. In the first ever United States Surgeon General's Report on Alcohol, Drugs, and Health, the Surgeon General called for improved access to evidence-based services integrated with mainstream health care for clients with substance use disorders. Baltimore City Maryland is home to one of the oldest gospel-rescue missions and one of the largest faith-based residential addictions recovery programs for homeless men in the country. The Mission has a 500-bed facility that incorporates a full continuum of care for homeless men seeking recovery from addiction. Historically, primary care services at the Mission were provided off-site by community partners. At times, the off-site partnership model resulted in fragmentation of services, communication challenges, and revenue losses. The model also created silos, making it difficult to integrate services, foster collaboration across multiple providers, and promote an organizational culture that valued the integration of faith and health. As a result, the Mission leadership identified the need for a controlled, integrated model of health care delivery, envisioning an on-site health home as a way to address the gap created by fragmented off-site partnerships.

The goal of population-focused nursing practice is to provide evidence-based care to targeted at-risk populations in order improve health outcomes. Public health nurses are uniquely qualified to partner with all dimensions of the health system and to lead health system efforts to develop innovative, integrated, inter-professional public health intervention models. As a clinical specialist in public health nursing and as a member of the Board of Directors, I was appointed to chair the Mission's first ever "Medical Committee." This Committee was charged with developing strategic goals and priorities for the establishment of the Mission's first ever Center for Health and Wellness, an onsite health home and wellness center based on a fully integrated health care delivery model. The Center model integrates primary care with behavioral health, specialty care referrals, and wrap around wellness services to address the multifaceted needs of the population. This paper describes the steps taken to lead the organization in developing goals and priorities for its first health home and to describe the impact of an embedded practice, inter-professional health home model on population health outcomes.

A Board level committee was convened to address the issues of care fragmentation and to research new models for health care delivery. Emerging health issues, population trends, quality improvement initiatives, and outcomes tracking guided the Board in the planning of a system of care that enhanced inter-professional collaboration, promoted seamless integration of primary and specialty care services and improved performance outcomes. Standardized health care performance measures and resident and staff feedback support the effectiveness of the model in promoting improved health care access and treatment adherence. HEDIS measures are in the exceptional compliance rate and consistently exceed benchmark standards. Staff report improvements in treatment delivery and outcomes, due to the enhanced communication and collaboration among providers and the improvements in treatment adherence. Students report the experience has dramatically changed their perception of the homeless and increased their desire to work with homeless and underserved populations. Clients report improved health care access and value the compassion and sensitivity demonstrated by health care providers who share the vision and core values and the culture of recovery that is pervasive throughout the organization. Future directions for program expansion include infrastructure development, expanded community outreach, and evaluation of effectiveness of the onsite health home through systematic program evaluation and research.