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J Am Board Fam Med. 2013 May-Jun;26(3):279-87. doi: 10.3122/jabfm.2013.03.120239.

A primary care-public health partnership addressing homelessness, serious mental illness, and health disparities.

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Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA; Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA 19107, USA.



People with histories of homelessness and serious mental illness experience profound health disparities. Housing First is an evidenced-based practice that is working to end homelessness for these individuals through a combination of permanent housing and community-based supports.


The Jefferson Department of Family and Community Medicine and a Housing First agency, Pathways to Housing-PA, has formed a partnership to address multiple levels of health care needs for this group. We present a preliminary program evaluation of this partnership using the framework of the patient-centered medical home and the "10 Essential Public Health Services."


Preliminary program evaluation results suggest that this partnership is evolving to function as an integrated person-centered health home and an effective local public health monitoring system.


The Pathways to Housing-PA/Jefferson Department of Family and Community Medicine partnership represents a community of solution, and multiple measures provide preliminary evidence that this model is feasible and can address the "grand challenges" of integrated community health services.


Community Medicine; Delivery of Health Care; Homeless Persons; Mental Health; Public Health

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