Interdisciplinary Models of Care

Integrated, interdisciplinary care is essential to address the multiple and complex needs of displaced people. Navigating fragmented systems of care is often impossible for these individuals, particularly those who are ill. HCH providers understand that health care and other basic needs are interrelated, and strive to address each client’s needs holistically through the use of multidisciplinary clinical teams. Integration of primary care with the treatment of mental illness and substance use disorders is a hallmark of HCH practice, and efforts to secure housing, entitlements, and jobs are intrinsic to this approach.

Healing Hands Newsletters

The HCH Model of Care

  • Comprehensive Services to Meet Complex Needs – A brochure produced by the National Health Care for the Homeless Council that briefly describes the connection between homelessness and poor health, and explains how HCH projects are working to alleviate both of these conditions.
  • The Role of Medical Respite in a Patient-Centered Medical Home (2011) – An article by Brian Klauser, MD, former medical director of Boston Health Care for the Homeless Program’s Boston Medical Center clinic and a Health Care for the Homeless Clinicians’ Network member,  written for the December quarterly Council News.

Integrated Care

  • Integrated Care Quick Guide: Integrating Behavioral Health & Primary Care in the HCH Setting (2013) - Individuals who are homeless often have multiple chronic health conditions and face numerous barriers to care. Integrating behavioral health and primary care is one way to help improve health care delivery and access for this population. This quick guide is to assist Health Care for the Homeless (HCH) grantees with their efforts to integrate behavioral health and primary care services. The guide includes promising practices for integrating services that are currently being utilized by three different HCH grantees.
  • Managing Complex Comorbidities in Individuals Experiencing Homelessness (2012) – Managing patients who have multiple chronic conditions presents many challenges to providers and requires a high level of integrated care to be successful. This resource from the HCH Clinicians’ Network provides a brief summary of the literature on the impact of multiple chronic conditions on the U.S. and highlights practices from four HCH grantees to identify and treat patients with complex comorbidities.
  • Key Elements of Integrated Care for Persons Experiencing Homelessness (2011) – This document is presented as A Guide for HCH Providers, but its reach is much broader, with implications for the entire health care system. Claire Goyer, the author, has succinctly conveyed the genius of the multi- faced HCH “model” as it has developed over a quarter-century. She examines the Key Elements in light of the requirements of the Patient Centered Medical Home model that the Congress built into the 2010 national health care reform. As you will read, HCH shines as an exemplar of care integration.
  • Behavioral Health/Primary Care Integration and the Person-Centered Healthcare Home (2009) – The National Council for Community Behavioral Healthcare published a report describing recommendations for reducing health disparities for individuals with mental health disorders. The report presents the case for a patient-centered medical home model that integrates behavioral health and primary care using a team-based approach. The Four Quadrant Clinical Integration Model is described in full detail and the report ends with policy and practice implications of implementing this model.
  • Integration of Primary Care & Behavioral Health: Report on a Roundtable Discussion of Strategies for Private Health Insurance (2005) | Bazelon Center for Mental Health Law