Community-academic partnerships to improve systems of care with the participation of individuals experiencing homelessness, serious mental illness, and chronic physical disease

Americans with serious mental illnesses have poorer health outcomes and die approximately 25 years earlier than the general population with differential morbidity and mortality rates having increased in recent years Moreover, chronic homelessness, which is disproportionately experienced by people with serious mental illnesses, is a significant determinant of poor health. Pathways to Housing ends homelessness for people with psychiatric disability by providing access to permanent, independent housing, along with comprehensive, community-based support and treatment services. Once housed, numerous chronic health conditions are often first recognized and finally able to be addressed. A unique partnership between Pathways to Housing and the Department of Family and Community Medicine at Thomas Jefferson University has facilitated ongoing clinical and research programs to improve the health of the population. This presentation describes ongoing efforts to build the capacity for community-based health services research program with the participation of consumers with experiences of psychiatric disability, chronic homelessness, and chronic physical disease now in the Pathways to Housing program. The research program uses a combined approach of epidemiologic health surveillance, continuous quality improvement, and community based participatory research. This presentation will review: 1) The ongoing development of an on-site integrated medical and behavioral health care clinical and research programs 2) Health status and health needs as collected longitudinally over the first 2 years of population health surveillance 3) Chronic disease screening rates and health service utilization during initial efforts to implement a standard set of health indicators to screen for chronic disease