Interdisciplinary team rounds offer an opportunity for both informal interprofessional learning and formal presentations on a variety of topics, including best practices in the management of health conditions prevalent in this population. Patient care is integrated with scholarly activities as much as possible. The team offers an ideal training environment for a broad range of disciplines, including medicine, nursing, and social work. A curriculum has been developed for medical student and resident training, and community-based research is strongly encouraged and facilitated.
Client assessment and case management is integrated and multidisciplinary in a seamless continuum-of-care model. Patients with acute care needs are directed to St Michael's Hospital, and discharge planning is facilitated and coordinated by a cooperative relationship with the psychiatric inpatient unit and other hospital programs.
A close working relationship with other Seaton House programs and community partners facilitates prompt client referral to appropriate services and eliminates service gaps by allowing for better coordination of available in-house, hospital, and community-based services. Less well resourced shelters and other hospitals have the opportunity to refer potential program participants directly to the program for stabilization and management. The Fusion of Care team provides ongoing support to clients after their reintegration into the community until other community partners are able to incorporate them successfully into treatment.
Like most social services agencies, Seaton House has limited evaluation capacity. Identifying evaluation as a program component helped establish a learning culture and institute evaluation as part of the daily work of the organization. Team members participate in research projects and quality improvement efforts and present their work locally and internationally.
Because the program is an integration of primary, mental health, and social services interventions, it has many desirable and interdependent end points, as listed in Table 1. Although program development is ongoing, the use of a logic model was instrumental in enabling coherent programmatic development and evaluation in this community agency.Client description
Using a standardized abstraction form, data were collected from Fusion of Care program charts and the hostel databases for all 73 clients referred to the program between March 2004 and February 2005.
The demographic characteristics of the clients are summarized in Table 2. Clients were male, middle-aged (38 ± 9 years), and mostly white (n = 49) or black (n = 21). None of the clients were married or had full-time employment. Table 3 summarizes the clinical characteristics of the clients. Diagnoses were established by a clinical interview conducted by the team psychiatrist or clinical records of previous psychiatric assessments. Many of the clients had a previous psychiatric hospitalization (52%), and 60% had a history of incarceration. The prevalence of severe and persistent mental illness, alcohol(Drug information on alcohol) use disorders, and substance use disorders was 68%, 26%, and 37%, respectively. The most common diagnosis was schizophrenia, which affected 48% of the clients referred (n = 35).
Demographic characteristics of Fusion of Care team clients (N = 73)
|Mean (SD): 37.9 (8.7)|
|Part-time employment||2 (2.7)|
|Less than high school||29 (42.6)|
|High school diploma or higher||39 (57.4)|