In 2011, Harborview Medical Center, in partnership with the Downtown Emergency Services Center (DESC), developed a new model for improving access to medical care for the chronically homeless mental health population. The goal was to improve primary care outcomes for people living with serious mental illness, such as schizophrenia or bipolar mood disorders, who have substantially higher rates of all major cardiovascular risk factors compared with the general population.

The hospital established a health care home at Harborview’s Community Mental Health Center and at DESC’s licensed community mental health program. Primary care and wellness services were delivered onsite for clients receiving mental health case management services and who had no regular source of primary care. An RN care manager worked with the primary care provider ARNP and the mental health program case managers to engage and enroll patients and pro-actively track health outcomes.

Nearly 800 patients were served over the four years of the program. Compared to status on baseline entry, 50% of clients with hypertension, 28% with elevated Hemoglobin A1C levels, 8% with tobacco use, and 9% with elevated body mass indices improved to the point that they no longer met criteria for the respective risk factor. The program received the 2015 National Association of Public Health Hospital’s Gage Award as a “Remarkable Program” in the population health category. Harborview Medical Center will continue offering primary care services within the mental health center.