Case studies in public-sector leadership: developing collaborative mental health care for homeless persons at a drop-in center.

Introduction by the column editors: This is the second contribution to our column, which is based on the use of an electronic mailing list (e-list) to generate a collaborative problem-solving process. The process is mod-eled on a module of the academic curriculum of the Columbia University Public Psychiatry Fellowship (PPF) (ppf.hs.columbia.edu) in which PPF alumni who encounter a management problem at their work site present the problem to current PPF fellows and faculty and lead a discussion aimed at developing solutions. The column uses an e-list to stimulate discussion of selected problems. Readers are invited to submit management problems to Dr. Ranz at [email protected], who will send them to the PPF e-list and work with Dr. Deakins to help authors summarize discussions in future columns. H omelessness remains a pressing problem across Canada. In Toronto, Canada's largest city, which has a population of approximately 2.5 million, over 5,000 individuals are homeless on any given night (1,2). Physical illness and mental illness are highly prevalent in the homeless population (3,4). Despite high levels of need, homeless people frequently experience difficulty accessing medical care. Many do not have Ontario Health Cards, which are essential to obtain reimbursement from provincial health insurance for medical services received. Most homeless people do not have the means to travel to medical appointments, and many have experienced the negative attitudes of health care professionals (5). Homeless individuals often rely on emergency department visits or inpa-tient hospitalization to meet their health needs (4,5). In 2006 Inner City Health Associates (ICHA) was created. ICHA consists of more than 40 physicians who provide primary care and psychiatric services to the homeless population in Toronto in settings such as shelters, residences, and drop-in centers. They also provide consultation services to outreach teams that provide intensive case management or assertive community treatment. ICHA physicians receive competitive stipends for both clinical and nonclinical time, thereby alleviating the immediate need for their patients to have Ontario Health Cards. In addition to providing clinical services, ICHA works to improve coordination between various providers , educates medical students and residents, and participates in research on homeless health care. Background Collaborative mental health care happens when primary care providers and mental health providers work together to offer complementary services and mutual support, ensuring that individuals with mental health needs receive coordinated care in a timely fashion (6). The complex medical and social needs of the homeless population …