Homelessness rates in both Canada and the United States have increased dramatically over the past 10 years. Among the homeless, there is a high prevalence of mental illness and substance use disorders.
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.
Different 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 model
Logic 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:
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.
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.
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 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).
|TABLE 2 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)|
|TABLE 3 Clinical characteristics of Fusion of Care team clients (N = 73)|
|Prior psychiatric assessment||52 (71.2)|
|History of psychiatric hospitalization|
|Within the past 2 years||28 (38.4)|
|Lifetime prevalence||38 (52.1)|
|History of incarceration||44 (60.3)|
|Schizophrenia/schizoaffective disorder||35 (48.0)|
|Psychosis NOS||12 (16.4)|
|Bipolar affective disorder||3 (4.1)|
|Major depressive disorder||5 (6.9)|
|Cognitive disorder||7 (9.6)|
|Alcohol use disorder||19 (26.0)|
|Substance use disorder||27 (37.0)|
|Personality disorder||19 (26.0)|
Table 4 summarizes interventions received by the clients. Clients had access to a variety of services, including appointment escorts, personal support with hygiene, and case management. All the cases were managed by the team physicians, averting referrals to specialty mental health services. Nevertheless, despite on-site support and access to the team nurse, only 32% of clients were treatment-adherent (receiving medication as prescribed 80% of the time or more). A rigorous program evaluation is currently being undertaken to determine the program's effectiveness.
|TABLE 4 Selected team interventions|
|Intervention||Mean (SD)||n (%)|
|Number of visits with family physician||2.0 (2.1)|
|Number of visits with psychiatrist||2.9 (3.7)|
|Assistance with appointment escorts||37 (50.7)|
|Assistance with income entitlements||28 (38.4)|
|Assistance with identification cards||47 (64.4)|
|Assistance with hygiene||46 (63.0)|
To end chronic homelessness related to illness and disability and prevent additional chronic homelessness, there is an urgent need for comprehensive and accessible health care.17,35 Collaborative mental health care models, integrating primary and specialist mental health care in the shelter setting, offer several advantages: they avoid long waiting lists for mental health services; they improve coordination of primary care and mental health services and integration of medical care with social work and other shelter-based services; they build on the strengths of the partners, relieving pressures from other parts of the health care system; and they promote academic medical linkages and community development.
Although collaborative care models have not been subjected to rigorous evaluation to determine their effectiveness, they are being widely adopted for diverse groups of patients. While a rigorous evaluation to establish our program's effectiveness has been undertaken, the program has received considerable praise from all stakeholders, including staff, clients, and community partners. All identified clients were treated in the shelter-based clinic, which eliminated referrals to specialty mental health services for treatment and the associated barriers. Shelter staff appreciated having easy access to specialty care, and the ability to retain primary care providers for clients. Clients appreciated being able to access culturally sensitive and flexible shelter-based services, since most had had negative experiences associated with mainstream service providers. Community partners identified the service as essential in eliminating service gaps and facilitating care coordination.
Program development is ongoing, focusing on strategies to promote treatment adherence. The high rates of treatment nonadherence found among our clients are consistent with previous reports of extensive nonadherence among patients with severe mental illness,36,37 and are associated with increased risk of relapse, hospitalization, and poor outcomes, including negative housing outcomes.38,39 A review of client treatment regimens revealed that injectable long-acting antipsychotics were underused, offered to only 3% (n = 2) of patients. Intensive multicomponent interventions may be needed to facilitate adherence and improve outcomes among these vulnerable individuals.
Emerging evidence suggests that shelter-based collaborative mental health care models are a possible alternative to traditional methods of providing mental health care to homeless persons who are mentally ill. In a health care system limited by scarce mental health resources, a collaborative effort that links physi- cal and mental health care and social services may be a possible solution to the complex health needs of this population.
Hwang SW. Homelessness and health.
Helping America's Homeless
. Washington, DC: Urban Institute Press; 2001.
Fischer PJ, Breakey WR. The epidemiology of alcohol, drug, and mental disorders among homeless persons.
Koegel P, Burnam MA, Farr RK. The prevalence of specific psychiatric disorders among homeless individuals in the inner city of Los Angeles.
Arch Gen Psychiatry.
Folsom D, Jeste DV. Schizophrenia in homeless persons: a systematic review of the literature.
Acta Psychiatr Scand
Folsom DP, Hawthorne W, Lindamer L, et al. Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system.
Am J Psychiatry
Breakey WR, Fischer PJ, Kramer M, et al. Health and mental health problems of homeless men and women in Baltimore.
Gelberg L, Linn LS. Demographic differences in the health status of homeless adults.
J Gen Intern Med.
Hwang SW. Mortality among men using homeless shelters in Toronto, Ontario.
Sullivan G, Burnam A, Koegel P, Hollenberg J. Quality of life of homeless persons with mental illness: results from the course of homelessness study.
Phelan JC, Link BG. Who are "the homeless"? Reconsidering the stability and composition of the homeless population.
Am J Public Health.
Kuhn R, Culhane DP. Applying cluster analysis to test a typology of homelessness by pattern of shelter utilization: results from the analysis of administrative data.
Am J Community Psychol.
Caton CL, Dominguez B, Schanzer B, et al. Risk factors for long term homelessness: findings from a longitudinal study of first time homeless single adults.
Am J Public Health
Wolff N, Helminiak T, Morse GA, et al. Cost-effectiveness evaluation of three approaches to case management for homeless mentally ill clients.
Am J Psychiatry
Lehman AF, Dixon L, Hoch JS, et al. Cost-effectiveness of assertive community treatment for homeless persons with severe mental illness.
Br J Psychiatry
. 1999; 174:346-352.
Jones K, Colson PW, Holter MC, et al. Cost-effectiveness of critical time intervention to reduce homelessness among persons with mental illness.
Hwang S, Tolomiszenko G, Kouyoumdjian F, Garner RE. Interventions to improve the health of the homeless: a systematic review.
Am J Prev Med
Culhane D, Metraux S, Hadley T. Public service reductions associated with placement of homeless persons with severe mental illness in supportive housing.
Housing Policy Debate.
Clark K, Rich A. Outcomes of homeless adults with mental illness in a housing program and in case management only.
Seidman LJ, Schutt RK, Caplan B, et al. The effects of housing interventions on neuropsychological functioning among homeless persons with mental illness.
North CS, Smith EM. A systematic study of mental health service utilization by homeless men and women.
Soc Psychiatry Psychiatr Epidemiol
Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in Los Angeles.
Am J Public Health
Robertson MJ, Cousineau, MR. Health status and access to health services among the urban homeless.
Am J Public Health.
O'Toole TP, Gibbon JL, Hanusa BH, Fine MJ. Preference for sites of care among urban homeless and housed poor adults.
J Gen Intern Med
D'Amore J, Hung O, Chiang W, Goldfrank L. The epidemiology of the homeless population and its impact on an urban emergency department.
Acad Emerg Med
McNiel DE, Binder RL. Psychiatric emergency service use and homelessness, mental disorder, and violence.
Kushel MB, Vittinghoff E, Haas JS. Factors associated with the health care utilization of homeless persons.
Salit SA, Kuhn EM, Hartz AJ, et al. Hospitalization costs associated with homelessness in New York City.
N Engl J Med.
Craven MA, Bland R. Better practices in collaborative mental health care: an analysis of the evidence base.
Can J Psychiatry
. 2006;51(suppl 1):7S-72S.
Podymow T, Turnbull J, Coyle D, et al. Shelter-based managed alcohol administration to chronically homeless people addicted to alcohol.
Craven MA, Bland R. Models of sharing mental health care.
Can J Psychiatry.
Svoboda T, Manuel A. Fusion of Care. Presented at: the International Society of Urban Health Annual Meeting; October 17, 2003; New York.
Porteous NL, Sheldrick BJ, Stewart PJ. Introducing program teams to logic models: facilitating the learning process.
Can J Program Eval
Dwyer JM, Makin S. Using a program logic model that focuses on performance measurement to develop a program.
Can J Public Health
Frankish CJ, Hwang, SW, Quantz, D. Homelessness and health in Canada: research lessons and priorities.
Can J Public Health
. 2005;96(suppl 2):S23-S29.
Lacro JP, Dunn LB, Dolder CR, et al. Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature.
J Clin Psychiatry
Valenstein M, Blow FC, Copeland LA, et al. Poor antipsychotic adherence among patients with schizophrenia: medication and patient factors.
. 2004;30: 255-264.
Svarstad BL, Shireman TI, Sweeney JK. Using drug claims data to assess the relationship of medication adherence with hospitalization and costs.
Stergiopoulos V, Dewa C, Rouleau K, et al. Factors associated with positive outcomes for homeless men with mental illness. Presented at: Annual Meeting of the American Psychiatric Association; May 20-25, 2006; Toronto.