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Integrating Primary Health Care and Behavioral Health Care in New Hampshire
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There are many challenges to the integration of health and outreach, including a lack of resources. This article outlines collaborations among PATH and Health Care for the Homeless programs in New Hampshire from the perspective of Bernie Bluhm, New Hampshire’s State PATH Contact. (Author)
The integration of primary health care and behavioral health care services for people with severe mental illness experiencing chronic homelessness focuses on the development of multilayered systems. The emphasis is on working to diminish separate “silos” strengthening communication between them. At the core of this integration are PATH and Health Care for the Homeless outreach workers who work in tandem to offer welcoming doorways for access to both primary health care and behavioral health care services.

PATH workers in New Hampshire work alongside U.S. Department of Housing and Urban Development (HUD) and Health Resources and Services Administration (HRSA) funded agencies to help connect people with mental health, housing, and medical services. Reporting on seven New Hampshire agencies last year, PATH outreach workers were able to contact more than 1,200 new people and so far enrolled 85 percent of them. As the result of PATH enrollment, relationships formed between PATH workers and people in need of services. As those relationships grew, PATH workers were able to assess when people were experiencing mental illness and mutually engage in a plan with that person to achieve basic supportive services. These services include links to both community mental health and primary health care.

As Bernie Bluhm, Program Planning and Review Specialist for the New Hampshire, Department of Health and Human Services Bureau of Homeless and Housing Services states, “If you are living with a mental illness while living in the woods, behind a church, or under a bridge, it is clearly unlikely that you are accessing treatment, or taking your medications on a regular basis.”  Bernie works to ensure that PATH workers have what they need to provide the basic supportive services necessary to assist people experiencing homelessness and living with persistent mental illness and substance use disorders. He provides opportunities for cross consultation, meetings on a quarterly basis, coordinates trainings on topics such as Motivational Interviewing, and helps PATH workers to troubleshoot. In his view, “Linkage and access -- this is the drum we are all beating. Through our data and site visits, we want to see how PATH workers are demonstrating that they are linking people to all the services they need. This can all begin with providing clean drinking water on a hot day.  The outreach progresses at a pace that works best for the person.  When I ask a person who is living in a tent, ‘How things are going,’ It’s important to hear how the relationship with the PATH worker is helping the person get reconnected to supports and treatment.” Bernie works in the field with the service providers he supports. He finds side-by-side shadowing and experiential collaboration far more valuable than simply reading a file:
When I go out into the field with PATH workers, I have seen that there is almost always a prevailing medical issue. I recall meeting a veteran on outreach who had been experiencing homelessness for over a decade. The first thing the PATH outreach worker did was to provide access to medical care for an ankle injury. The assessment of medical needs can open doors. Once medical conditions are assessed and treated, avenues for understanding additional mental health needs are revealed. Thanks to the creativity and skills of the outreach worker and his local program, the veteran was housed within 6 months, and continues to live in safe housing through this time.
Bernie works in conjunction with Marianne Savarese, Director of Health Care for the Homeless, whom he describes as a person always advocating for disenfranchised and disadvantaged people living in poverty. This administrative teamwork ensures that mental health care and primary health care service providers work together. PATH workers gravitate naturally toward Health Care for the Homeless centers, and are very skilled at involving people with medical expertise. “They are all very dedicated and creative. They know it is much easier to work together than to work in silos,” explains Bernie.

Going out into the field with PATH workers helps facilitate the development of new tools. “It has become harder to access something as basic as food stamps today,” says Bernie. While State human services divisions do the best they can with limited resources, there is an increase in workloads and a decrease in staffing. After watching how PATH workers encountered situations in the field, he worked with the Division of Family Assistance to address access barriers encountered by people who experience homelessness. One result of this collaboration is that every PATH program received training to complete web-based applications for food stamps and other State benefits. New Hampshire has the advantage of being small, which provides opportunities for regular collaboration among complementary service providers. Bernie uses the “small state advantage” to visit every site regularly and ensure that PATH workers get the support they need.

On the surface, Bernie’s ultimate job is simple -- to ensure that all New Hampshire PATH programs receive the funding they need. In order to do so, however, he needs to know that all programs operate as they should and that people living in cars and tents receive vital services to transition out of homelessness. He stresses the need for continued and increased funding for supportive programs like PATH, noting that outreach workers need to be increasingly creative to connect people with mental health treatment and medical care.  He would like to see funding in every New Hampshire county for both PATH and Health Care for the Homeless (currently, 7 out of 10 counties receive funding for PATH; fewer are funded for Health Care for the Homeless). He concludes with the hopeful scenario, “What if we had the funding to provide both of those services in every New Hampshire county?”

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