Homelessness rates in both Canada and the United States have increased dramatically over the past 10 years.1,2 Among the homeless, there is a high prevalence of mental illness and substance use disorders.3,4 The weighted prevalence of schizophrenia in homeless persons has been estimated at 11%,5 and the prevalence of homelessness among individuals with serious mental illness has been estimated at about 15%.6 In addition to high rates of mental illness and substance use, homeless persons are more at risk for chronic medical conditions and have a higher mortality rate than those who have housing.1,7-10 Although most people are able to exit homelessness within weeks or months, 10% to 20% of persons living in shelters are chronically homeless. Homeless persons with substance use and psychiatric disorders are at increased risk for chronic homelessness.11-13
Several studies have supported the effectiveness of assertive community treatment and intensive case management for this population.14-17 Treatment and housing placement of homeless individuals with mental illness has been associated with reductions in psychiatric hospitalizations,18 decreased psychiatric symptoms and substance use,19 and improved neuropsychological functioning.20 In many urban centers in North America, however, resources for assistance with treatment and housing are scarce or inaccessible to homeless individuals with mental illness, who face several barriers to accessing mainstream health services and appropriate disease management.1,21-23 Many homeless persons rely on emergency department (ED) visits or inpatient hospitalizations for health care.24-26 When admitted to a hospital, they have longer stays with higher costs.27,28
In order to end chronic homelessness related to illness and disability and make effective use of existing resources, alternative interventions to improve the health of the homeless are urgently needed.
Collaborative mental health care is an important component of mental health care reform in many countries.29 Collaborative mental health care describes models of practice in which patients, their families, their caregivers, and health providers from a variety of primary care and mental health settings work together to provide better-coordinated and more effective services for individuals with mental health needs.29 Given the complex physical, mental, and social services needs of the homeless, who require multidisciplinary interventions, collaborative mental health care offers an opportunity for comprehensive, coordinated care and enhanced clinical resource management.
Despite their intuitive appeal, collaborative mental health care models have not been subjected to rigorous evaluation to determine their effectiveness.30 Furthermore, despite the growing literature on collaborative interventions targeting specific populations in the United States and abroad, the homeless population is mostly absent from the investigative literature.29
The purpose of this article is to describe an integrated, shelter-based, collaborative mental health care team in an urban center and the profile of the clients it serves. The team was designed to enable rapid evaluation and treatment of patients with a wide range of psychiatric disorders, to improve the ability of shelter staff to manage these disorders, to improve the education of shelter staff and trainees on the needs of homeless individuals with mental illness, and to reduce the number of ED visits and referrals to specialty mental health care.
Program descriptionDifferent models of collaborative mental health care have been described in the literature.29,31 Fusion of Care, developed at Seaton House, one of Canada's largest shelters for homeless men, involves a partnership with St Michael's Hospital, an inner-city hospital affiliated with the University of Toronto. It refers to an integrated continuum-of-care model, with on-site medical support of shelter staff and clients, and a flexible referral process. In this model, shelter staff and St Michael's Hospital physicians work as a single team and share a common client record.32 Using knowledge transfer through partnerships and in-house case management within this model, the program designers saw the leverage or mechanism to assist homeless clients meet their health and social services needs. The impetus for adopting this model of service delivery was the communication breakdown and lack of coordination in care when case management or medical care was brokered to external agencies.32
The team, in operation since March 2004, provides medical care and case management to the clients of the 240-bed Hostel Program, one of Seaton House's 7 programs, and has the capacity to serve 40 clients at any one time. The target population is chronically homeless persons whose health needs exceed the hostel's resources and who are unable to access community-based services.
The team consists of a client service worker, a counselor, a nurse, and a team leader/counselor (all Seaton House full-time staff) as well as a family physician and a psychiatrist (who are on staff at St Michael's Hospital). The 2 physicians offer concurrent clinics at the shelter half-a-day weekly. They work collaboratively, through both direct and indirect consultations.
Once a client is identified by hostel staff as a candidate for the program, the client meets with a counselor for 1 hour to set goals and complete a comprehensive psychosocial assessment. The client subsequently meets with the team nurse for a comprehensive health assessment. Once the main health issues are identified, the client is referred, depending on the complexity and acuity of health needs, to either a family physician or a psychiatrist. A comprehensive care plan is developed during weekly multidisciplinary team rounds for each client.
The client service worker facilitates adherence to the plan by escorting clients to appointments off-site, helping replace identification cards and keep appointments, and providing team members with feedback and information about the client's function, hygiene, and behavior. Medications are dispensed daily to clients by the team's nurse.
The program is supported by an alternative payment plan, remunerating physicians on an hourly rate for their clinical and administrative responsibilities. It has required no additional external funding but has necessitated reorganization of shelter-based resources.
Program logic modelLogic models are an important planning and evaluation tool in health and human services programs. They facilitate description and communication of programs, negotiation of deliverables, and the development of performance measures for ongoing monitoring.33,34 The Fusion of Care team program logic model, including the logical linkages between program components, activities, outputs, and goals is outlined in Table 1. The program has 6 main components, identified in consultation with shelter staff and clients:
- Eligible client identification.
- Interdisciplinary education.
- Comprehensive client assessment.
- Case management.
- Client referrals and partnerships.
- Program evaluation.
In the Fusion of Care model, identification of eligible clients is facilitated by a close working relationship of the multidisciplinary team leader with hostel staff, hostel staff training and education on the symptoms and signs of mental illness, and ongoing feedback about the appropriateness of referrals.
