A Primary Care-Public Health Partnership
A Primary Care-Public Health Partnership
The original Pathways support team, based on the Assertive Community Treatment model, includes social workers, a nurse, a psychiatrist, a peer specialist, a vocational specialist, and a drug and alcohol counselor. Experiences of local service providers with the target population both in Philadelphia and New York revealed significant difficulty in connecting individuals to primary care. This is a population that often has a long history of negative experiences in the mental health and primary care systems and comprises those who are either reluctant to seek or avoid seeking medical care. The Thomas Jefferson University DFCM has a 20-year history of providing flexible, on-site health services to homeless and formerly homeless populations. On the basis of this knowledge and experience, a formal partnership was formed between the DFCM and PTH-PA, and a primary care physician was embedded into the PTH-PA Assertive Community Treatment team to provide on-site primary care and population-based health monitoring and services. The partnership draws from general departmental resources, the St. Elizabeth's community satellite clinic, and the main family medicine practice, Jefferson Family Medicine Associates, which is a level-3 medical home recognized by the National Committee for Quality Assurance. Additional clinical, evaluation, and educational partnerships have been formed with the Jefferson's Center for Urban Health, Department of Emergency Medicine, School of Nursing, and School of Public Health (Figure 1).
(Enlarge Image)
Figure 1.
Pathways to Housing-PA/Department of Family and Community Medicine partnership. JFMA, Jefferson Family Medicine Associates; TJU, Thomas Jefferson University.
The topic of the intersection of primary care with public health efforts, including the potential overlap of outcomes, is relatively new. The 2012 Institute of Medicine report makes clear that a universal template for integration is impossible because of the varied settings in which primary care is delivered and the unique population health needs across different settings. We recognized that the DFCM/PTH-PA partnership builds on and extends the recommendations of the key principles of the PCMH and the "10 Essential Public Health Services." As such, we describe below the method used for evaluating the adherence of our program model to these principles.
Intervention
The original Pathways support team, based on the Assertive Community Treatment model, includes social workers, a nurse, a psychiatrist, a peer specialist, a vocational specialist, and a drug and alcohol counselor. Experiences of local service providers with the target population both in Philadelphia and New York revealed significant difficulty in connecting individuals to primary care. This is a population that often has a long history of negative experiences in the mental health and primary care systems and comprises those who are either reluctant to seek or avoid seeking medical care. The Thomas Jefferson University DFCM has a 20-year history of providing flexible, on-site health services to homeless and formerly homeless populations. On the basis of this knowledge and experience, a formal partnership was formed between the DFCM and PTH-PA, and a primary care physician was embedded into the PTH-PA Assertive Community Treatment team to provide on-site primary care and population-based health monitoring and services. The partnership draws from general departmental resources, the St. Elizabeth's community satellite clinic, and the main family medicine practice, Jefferson Family Medicine Associates, which is a level-3 medical home recognized by the National Committee for Quality Assurance. Additional clinical, evaluation, and educational partnerships have been formed with the Jefferson's Center for Urban Health, Department of Emergency Medicine, School of Nursing, and School of Public Health (Figure 1).
(Enlarge Image)
Figure 1.
Pathways to Housing-PA/Department of Family and Community Medicine partnership. JFMA, Jefferson Family Medicine Associates; TJU, Thomas Jefferson University.
The topic of the intersection of primary care with public health efforts, including the potential overlap of outcomes, is relatively new. The 2012 Institute of Medicine report makes clear that a universal template for integration is impossible because of the varied settings in which primary care is delivered and the unique population health needs across different settings. We recognized that the DFCM/PTH-PA partnership builds on and extends the recommendations of the key principles of the PCMH and the "10 Essential Public Health Services." As such, we describe below the method used for evaluating the adherence of our program model to these principles.
