Abstract
The Allegheny Initiative for Mental Health Integration for the Homeless (AIM-HIGH) was a 3-year urban initiative in Pennsylvania that sought to enhance integration and coordination of medical and behavioral services for homeless persons through system-, provider-, and client-level interventions.
On a system level, AIM-HIGH established partnerships between several key medical and behavioral health agencies. On a provider level, AIM-HIGH conducted 5 county-wide conferences regarding homeless integration, attended by 637 attendees from 72 agencies. On a client level, 5 colocated medical and behavioral health care clinics provided care to 1986 homeless patients in 4084 encounters, generating 1917 referrals for care.
For a modest investment, AIM-HIGH demonstrated that integration of medical and behavioral health services for homeless persons can occur in a large urban environment.
HEALTH PROVIDERS FACE significant challenges to provide comprehensive healthcare to homeless persons, as care is often fragmented and lacking in coordination and continuity between providers. Such lack of integration may be detrimental to health care of homeless persons who are prone to significant medical, mental health, and substance abuse comorbidities.1–4 Health care needs of urban homeless persons are often addressed at emergency rooms, urgent care sites, and free-standing clinics.5,6 Care at these clinics is often provided by medical or behavioral health providers, but rarely both.
Research has demonstrated that a significant gap exists between the medical and behavioral health needs of homeless individuals and the provision of health services to meet that need.7 Emerging community initiatives are designed to confront the many facets of homelessness, and significant resources have been allocated to assist local and regional efforts.8,9 One national initiative provided 12 community-guided grants to increase integration between Health Care for the Homeless primary care clinics and community mental health agencies. The goal of this initiative was to discover unique and collaborative strategies for reducing the morbidity of homelessness.
PROGRAM DESCRIPTION
In the fall of 2002, Primary Care Health Services, Inc.–Health Care for the Homeless Program, in collaboration with the Allegheny County Department of Human Services, was awarded a 3-year grant, titled “AIM-HIGH” (Allegheny Initiative for Mental Health Integration for the Homeless). Primary Care Health Services, Inc, is a federally funded community health center authorized by Section 330 of the Public Health Service Act. Primary Care Health Services, Inc, receives funds from the Health Resources and Services Administration, Bureau of Primary Health Care, for the Health Care for the Homeless Program, which is operated by the staff of Primary Care Health Services, Inc.
A mission statement and goals for AIM-HIGH were established early in the project. The mission of AIM-HIGH was “to improve the health of homeless individuals by integrating physical and behavioral health care services through the development and implementation of a delivery system committed to improving availability, access, and coordination of services.” The goals of AIM-HIGH were: (1) to integrate mental health and medical health providers at system and service levels; (2) to promote and encourage county and health care provider partnerships; (3) to eliminate duplication and reduce fragmentation of homeless services; (4) to incorporate culturally sensitive age- and gender-appropriate strategies into all facets of health care; (5) to provide educational and cross-training activities for key community and political stakeholders, professional providers, and ancillary service providers; and (6) to evaluate the progress and outcomes of the integration activities.
KEY FINDINGS.
Integration of medical, mental health, and substance abuse services health care for the homeless can be accomplished in a large urban environment.
AIM-HIGH integration activities have facilitated the homeless clients’ access to behavioral and medical health care.
Structure of clinics by colocation of behavioral health care services with physical health care services at the same time and place is an effective strategy to effectively integrate services for homeless populations.
To achieve its mission and accomplish its goals, AIM-HIGH leadership established administrative and fiduciary relationships between behavioral health and free-care medical health providers in Allegheny County. In developing this integrated delivery system, AIM-HIGH embraced a “no-wrong-door” philosophy that encourages homeless individuals to access multidisciplinary services at numerous points of entry into the health care system. AIM-HIGH implemented a wide range of client-, provider-, and system-level interventions, and evaluated these interventions using a formative evaluation process.10
On a client level, AIM-HIGH established or enhanced behavioral health care services at existing homeless medical clinics. The integrated AIM-HIGH clinics were located in geographically diverse neighborhoods where homeless persons congregate. The clinics provided various combinations of medical, mental health, pharmaceutical, drug and alcohol, and case management services using multidisciplinary teams (Table 1 ▶). AIM-HIGH service providers consulted with and referred patients to one another, and also referred patients to external agencies when needed services were not available on site. Integrated services were offered weekly at each clinic site, and the outcomes presented here reflect only “integrated” days. A subset of clients (n=162) participated in a Government Performance and Results Act (GPRA) survey that was required by the funding agencies. A research assistant approached clients at 2 colocated clinic sites to request participation in additional data collection for the subsample description.
TABLE 1—
AIM-HIGH Integrated Clinics, by Neighborhood Setting, Clients Served, and Services Provided
| Clinic | Setting (Neighborhood) | Clients | Medical Health Services | Mental Health Services | Colocated Servicesa |
| Northside Clinic | Salvation Army drop in (North Side) | Adults | Existing | New | Yes |
| The Birmingham Clinic | Salvation Army drop in (South Side) | Adults | Existing | New | Yes |
| The Hub Clinic | Adolescent drop in (strip district) | Adolescents | Existing | New | |
| The East End Cooperative Ministries Clinic | Cooperative Ministries drop in (East Liberty) | Adults | Existing | Existing | Yes |
| The Family Crisis Center Clinic | Salvation Army family crisis residential unit (downtown) | Families | Existing | New |
Note. AIM-HIGH = Allegheny Initiative for Mental Health Integration for the Homeless.
aColocated services defined as medical and mental health providers on location at same times.
On a provider level, AIM-HIGH sponsored 5 county-wide conferences for homeless service providers, each focusing on a theme relating to integration: (1) integrating homeless services, (2) creating a resource manual for the homeless, (3) learning about housing and homelessness, (4) improving networking between providers, and (5) encouraging sustainability of the integration model. The aims of these conferences were to engage service providers, provide education about the philosophy and implementation of service integration, identify facilitators and barriers to integration, and offer a forum for networking between diverse providers. Frontline staff (staff that provide direct medical and behavioral health care for homeless persons) from different agencies also participated in several joint trainings to encourage integrated education among medical and behavioral healthcare providers.
On the system level, a full-time county liaison was hired to facilitate communication between stakeholders, service providers, and Allegheny County administration. A full-time integration ombudsman was hired to assist the coordination of services among the partner agencies. AIM-HIGH established a homeless integrated delivery system workgroup to identify and confront facilitators and barriers to integration, an education core led by an education consultant to present conferences and trainings, and an evaluation core led by an evaluation consultant (Figure 1 ▶).
FIGURE 1—
Administrative Structure of AIM-HIGH.
Note. Arrows indicate group-to-group interactions and communications.
AIM-HIGH received monetary resources ($200000 per year) from the funding agencies, as well as in-kind resources from partner agencies. New positions dedicated to AIM-HIGH included county liaison ($25000 per year), integration ombudsman ($52000 per year), educational consultant ($10000 per year for educational activities), and evaluation consultant ($10000 per year for evaluation activities). Provision of behavioral health services was contracted to the Western Psychiatric Institute and Clinic’s Neighborhood Living Project (WPIC/NLP; $80000 per year). In this capacity, WPIC/NLP provided several part-time mental health nurses, case managers, substance abuse counselors, and 1 volunteer psychiatrist, in various combinations, to the 5 AIM-HIGH clinics. The remaining annual funds were spent to provide for the administrative project director, data entry, travel to grantee conferences, equipment, and supplies.
RESULTS
Client Level
The 5 integrated clinics provided medical or behavioral health care to at least 1986 unique individuals through 4084 encounters over 3 years. Of these encounters, 2777 (68%) were provided by medical personnel, 679 (17%) by mental health personnel, 311 (8%) by case management personnel, and 315 (8%) by drug and alcohol treatment providers. Clients in the GPRA subsample were generally middle-aged, of ethnic/racial minority, and had various domicile arrangements (Table 2 ▶). Over 1917 new referrals from medical, mental health, substance abuse, and case management staff to various outside and on-site services were documented (Table 3 ▶). The main referrals for clinic patients to internal or external health services were for pharmacy assistance (n=763; 40%), behavioral health care (n=443; 23%), and medical or surgical care (n=252; 13%). Dental (5%), medical assistance or insurance (5%), other social (5%), housing (4%), and substance treatment (3%) service referrals were more infrequent at the colocated clinics.
TABLE 2—
Characteristics of Subsample of AIM-HIGH Clients
| No. (%)a,b | |
| Gender : Men | 124 (77.0) |
| Race | |
| African American | 90 (55.9) |
| White | 67 (41.6) |
| Other | 4 (2.5) |
| Housing statusc | |
| Transitional | 36 (22.6) |
| Doubled-up/shared domicile | 30 (18.9) |
| Shelter | 17 (10.7) |
| Institution | 12 (7.5) |
| Unsheltered | 5 (3.1) |
| Other | 59 (37.1) |
| Employment | |
| Unemployed or other | 123 (76.9) |
| Employed full-time | 23 (14.4) |
| Employed part-time | 14 (8.8) |
| Illnessesd | |
| Any mental illness | 89 (54.9) |
| Current alcohol use | 52 (30.4) |
| Current substance use | 36 (21.1) |
Note. AIM-HIGH = Allegheny Initiative for Mental Health Integration for the Homeless. aCharacteristics of 162 clinic patients assessed at baseline. Not all participants in the sample answered all questions.
bPercentages do not necessarily add to 100% because of rounding.
c With regard to housing status, it is likely that some of the “other” subjects were temporarily housed in some capacity.
dCurrent alcohol and substance use are on the basis of any consumption in the last month.
TABLE 3—
Reasons for Referrals to Care (Both Internal and External) for AIM-HIGH Clinic Patients
| Reason for Referral | No. (%) |
| Pharmacy assistance | 763 (39.7) |
| Mental health and dual diagnosis care | 443 (23.2) |
| Medical or surgical care | 252 (13.1) |
| Dental and vision services | 100 (5.2) |
| Medical assistance or insurance referrals | 98 (5.1) |
| Other social services | 94 (5.0) |
| Housing services | 72 (3.7) |
| Substance abuse care | 54 (2.8) |
| Laboratory and radiology | 33 (1.7) |
| Unspecified reasons | 10 (0.5) |
Note. AIM-HIGH = Allegheny Initiative for Mental Health Integration for the Homeless.
Provider Level
Over 637 homeless health care professionals participated in the AIM-HIGH county-wide conferences (mean attendance=127), representing 72 unique agencies (mean = 40 per conference). Attendees were primarily employed as case managers or social service workers (28%), clinical staff (17%), and support staff (16%). Many attendees (35%) indicated that the conferences would immediately impact their performance, and 50% indicated that they would be more receptive to further collaboration and integration opportunities. The cross-trainings represented additional opportunities for clinic staff to compare philosophical approaches in service delivery, strengthen integration and coordination activities, and discuss important health care issues facing homeless persons.
System Level
AIM-HIGH established a formal network of integrated homeless service providers, though not without some difficulties. The homeless integrated delivery system workgroup, which included the county liaison and integration ombudsman, encountered many facilitators and barriers to integration and coordination of services for homeless persons (Table 4 ▶). For example, to confront funding issues, the AIM-HIGH team explored opportunities for additional and continuation funding from external agencies, the county, and Medicaid insurers. Eventually, Health Care for the Homeless successfully competed for Section 330 Bureau of Primary Health Care for the Health Care for the Homeless mental health expansion funding for the colocated clinic sites. Other major barriers included Health Insurance Portability and Accountability Act requirements, mistrust between large health care systems, and coordination of electronic medical record systems.
TABLE 4—
Barriers and Facilitators to Integration of Medical and Behavioral Health Services in Allegheny County
| Barriers | Facilitators |
| Need for education and support of community stakeholders and homeless service providers about Project AIM-HIGH |
|
| Impact of budget cuts and limitations on resources |
|
| Need for education of homeless providers (both internally and externally to the HIDS) about availability and appropriate use of homeless resources |
|
| Need for greater information sharing and formal agreements between agencies |
|
| Lack of a clear, defined mission statement for Project AIM-HIGH |
|
| Communication and attendance problems of key participants |
|
| Problems of working with and integrating agencies with different missions and viewpoints of treatment delivery |
|
| Lack of education and need for support from general community about homeless issues |
|
| Need for sustained funding for integrated services initiated with Project AIM-HIGH |
|
Note. AIM-HIGH = Allegheny Initiative for Mental Health Integration for the Homeless; HIDS = homeless integrated delivery system.
DISCUSSION
The lack of integrated and coordinated medical and behavioral health services for homeless persons has been postulated as a significant barrier to the efficient provision of homeless health care.11–13 Using client-, provider-, and system-level interventions, AIM-HIGH provided needed, integrated, and coordinated health care services in homeless clinics to homeless populations of Allegheny County. For a modest investment, over 1986 homeless or indigent patients received free medical and behavioral health care and 1917 referrals for care in over 4084 encounters over 3 years.
AIM-HIGH confronted several key barriers to integration, and facilitated coordination of activities among disparate providers. AIM-HIGH leaders identified several of the barriers that they considered to be the most challenging, including the need for greater information sharing and formal agreements between agencies, and reconciling different missions and, at times, viewpoints of treatment delivery. Although solutions to all these challenges cannot reasonably be expected in 3 years, AIM-HIGH successfully initiated contractual arrangements between agencies, colocated behavioral health services within medical clinics, and implemented electronic medical records in most clinics.
Some limitations of AIM-HIGH should be noted. First, AIM-HIGH’s service and system integrations were slow to develop. Once clinics were established, the integrated providers were successful in engaging clients and providing sustainable services. Second, AIM-HIGH was unable to successfully integrate external homeless health care agencies into its collaborative effort. In part, this lack of external integration was attributable to the complexity of coordinating stakeholders and providers within AIM-HIGH, as well as to budget constraints. Third, AIM-HIGH had initial difficulty with integration efforts on the provider level. Joint trainings for providers and regular stakeholder meetings assisted in this regard. Finally, issues such as integration and sharing of computerized medical records and difficulties in transporting clients from one service provider to another were not fully solved during the course of AIM-HIGH. These barriers likely needed additional resources beyond the scope of AIM-HIGH. Despite these limitations, AIM-HIGH’s strongest attribute was the ability to address integration of homeless health care through comprehensive approaches.
The process evaluation for AIM-HIGH has helped shape several recommendations for future initiatives. First, because integration projects are often challenging to sustain, and require time and resource commitment, homeless integration projects should be viewed and undertaken as long-term efforts. Second, consistent with work from another community program,14 AIM-HIGH found that the leaders of integration projects should seek early investment and support from funding agencies, community leaders, and public policy leaders. Finally, hiring a dedicated staff member (i.e., county liaison or integration ombudsman) can facilitate communication among partner agencies. It was the experience of the AIM-HIGH team that such facilitation was most effective when the facilitator was (1) previously entrenched in the homeless system, (2) viewed by all partners as an unbiased party, and (3) in a position to build relationships with agencies and policymakers of diverse perspectives.
AIM-HIGH’s experience demonstrated that homeless service agencies can originate and sustain medical and behavioral health integration initiatives. Although health care integration is a challenging undertaking, lessons can be learned and built upon.
Acknowledgments
Financial support was provided to AIM-HIGH by a 3-year grant from the US Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, and Health Resources and Services Administration, Bureau of Primary Health Care to the Health Care for the Homeless–Primary Care Services program of Pittsburgh, Pa (grant 3 H80 CS 00714–01–01).
The AIM-HIGH Team also included Natalie J. Hatcher, Chris Laemmle, Theda Sanders, and Rich Venezia.
Human Participant Protection The University of Pittsburgh institutional review board approved this project.
Peer Reviewed
Contributors All of the authors contributed to implementing the study, revising the article, discussing the research at all phases, and interpreting the results. A. J. Gordon originated the study and collaborated with M. L. Montlack on the original conceptualization and structure of the article. J. Williams, T. Bui, and A. Gordon collaborated on implementing the study. D. Johnson and P. Freyder further contributed to implementation and interpretation of the results.
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