Health Care for the Homeless
Program Name: Health Care for the Homeless Primary Care Medical Home
Grant Amount: $750,000/3 years
Health Care for the Homeless (HCH) provides health-related services, education, and advocacy to reduce the incidence and burdens of homelessness. This program will bring the concepts, strategies, and technologies of the PCMH model to this extremely ill, multiple-diagnosed, impoverished, and vulnerable population. Specifically, the program will empanel those with multiple chronic conditions, hire another full-time physician to serve the complex needs of these patients who have three or more chronic conditions as well as behavioral health challenges and, due to the complexity of their conditions, require significant physician engagement, and establish cross-disciplinary teams with a care coordinator (under physician's directives) acting as team conductor. The team will include addiction counselors, therapist case managers, psychiatrist, RN with psychiatric expertise, vocational specialist, patient navigator, and peer counselor. Meeting daily, the care team will complete care plans (in concert with the client), provide prescribed medical and behavioral health services, track appointment and care plan adherence, conduct outreach to clients for whom such compliance has been difficult, and provide same day appointments as necessary.