AUSTIN, Texas — Of the more than 7,000 people who experience homelessness in Travis County each year, many have complex health problems as diverse as heart disease and asthma. To help address these persistent challenges, Dell Medical School at The University of Texas at Austin, CommUnityCare Health Centers and Integral Care, Travis County’s mental health authority, are joining forces to launch an innovative, federally-funded mobile care team that serves homeless individuals where they are.
The collaboration, which is funded by a five-year, $2.3 million grant from the Substance Abuse and Mental Health Services Administration (SAMHSA), will support homeless men and women who have a chronic medical condition along with serious mental illness and/or substance use disorder. The mobile, multidisciplinary team will be staffed by qualified health care providers who integrate comprehensive primary care, mental health care, substance use treatment, intensive case management, and wraparound services such as housing assistance and social programs enrollment into a continuum of care with one single team.
“Homeless Austinites living with multiple complex medical problems are among the most vulnerable and difficult to reach members of our community, but we believe that our innovative approach can work,” said Dell Med’s Tim Mercer, M.D., MPH, assistant professor in the departments of Population Health and Internal Medicine, who is the project director for this grant. Efforts to effectively treat this population require careful coordination among advocates and organizations working in Austin’s health ecosystem, he said.
“Our goal is to fill gaps in care by leveraging the existing strengths and infrastructure of the three collaborating organizations in a whole new way,” Mercer said. It’s also essential to coordinate efforts with other local organizations, such as the Ending Community Homelessness Coalition (ECHO), he added.
A 2017 Point-in-Time Count performed by ECHO found that 2,036 Austin residents experience homelessness on any given night, of whom 553 are chronically homeless, 345 have a substance use disorder and 519 experience serious mental illness. It also found that 61 percent of people experiencing homelessness access health care through an emergency room or not at all.
Meeting People Where They Are
One key design feature of the mobile model is that it allows the team to bring care to patients where they live, unlike the traditional model of requiring patients to seek services in clinics or hospitals to address their health needs.
“Normally the burden is entirely on the patient — they have to make appointments, figure out how to get a ride, go to the pharmacy, get their labs processed — they are constantly forced to jump through hoops,” said Audrey Kuang, M.D., clinical director of the homeless health care program at CommUnityCare and assistant professor in the departments of Internal Medicine and Population Health at Dell Med. “It’s tough enough for the average person, but for someone struggling with mental illness or chronically sick or worrying about their next meal, those hoops can be insurmountable obstacles,” she says.
Equipped with mobile medical supplies, laptops to access medical records on site, and well-honed “street medicine” engagement tactics, the team remains unfettered by the need for a building or an exam room to care for patients.
“We can meet with clients on the street, a park bench, under a bridge — wherever we need to be to serve them best,” says Kuang.
When more complex care is needed, the mobile team can also see patients in one of CommUnityCare’s 24 clinics or Integral Care’s four integrated mental and primary care clinics in Travis County.
The community-based mobile care team will consist of at least six health professionals, including:
- A primary care physician or nurse practitioner
- A mental health care psychiatrist or nurse practitioner
- A licensed chemical dependency counselor
- A nurse case manager
- A qualified mental health professional case manager
- A peer navigator
An important part of this community-based program is that it relies on the complementary strengths of the organizations involved. Integral Care has been providing outreach and recovery services to people experiencing co-occurring homelessness, mental illness and substance use disorder for over 20 years. Integral Care also partners with the Austin Police Department and Austin-Travis County EMS to connect individuals living on the street to housing, mental and primary health care and alcohol and drug treatment as part of the Homelessness Outreach Street Team. CommUnityCare, part of Central Health’s enterprise, provides primary care and standard case management services to the homeless as well. Dell Med’s population health experts will augment these existing resources through direct care, coordination among the partners, and research and evaluation efforts.
“We are excited to expand our partnership with Dell Med and CommUnityCare to further support our city’s homeless community,” said Darilynn Cardona-Beiler, director of adult behavioral health systems at Integral Care. “This grant allows us to bring our expertise together and innovate in a unique and effective way. Together, we’re meeting people where they are in the community — providing integrated primary care, mental health care and much needed substance use treatment on the streets of Austin.”
In addition to serving as orchestrator of the project, researchers from Dell Med’s Department of Population Health will work to measure the success of the effort. Its data integration division will coordinate information from Integral Care’s and CommUnityCare’s electronic health systems and directly from patients to evaluate effectiveness and identify opportunities for improving and expanding this care model.
“By incorporating research into this project, we will be able to understand if this approach to caring for our city’s homeless works and can pay for itself, by reducing hospital and ER visits, for example, and if it can be scaled and replicated to improve the health of communities across the nation,” said William Tierney, M.D., professor and chair of Dell Med’s Department of Population Health.