Cross-Training of Medical, Dental, and Psychiatric Fellows Enhances Access to Comprehensive Care for Homeless and Formerly Homeless Older Adults

Problem Addressed

• A growing population: According to the United States Census Bureau, 9.7 percent of the nation’s citizens 65 and older live below the poverty line.¹ Among this population is a growing group of individuals who are homeless or at risk of becoming homeless. In 2007, those aged 62 and older made up four percent of the nation’s sheltered homeless population, with another 20 percent being between the ages of 51 and 61.²
• More health problems: Older homeless persons are at greater risk of developing a variety of health problems, including high blood pressure, chronic diseases, mental illness, and functional disabilities.³ They are also more likely to be victims of crime than are other homeless people; for example, in 2006, 27 percent of homeless victims of violent crimes were between 50 and 59 years of age.⁴
• Sporadic care, leading to early death: Many homeless older adults have health conditions that remain undiagnosed and untreated through years of sporadic care, often leading to early death. A study in seven cities throughout North America and Europe found that homeless persons were 3 to 4 times more likely to die than were members of the general population, with premature death most often resulting from acute and chronic medical conditions aggravated by life without a home.⁵   

Description of the Innovative Activity

• Fellow rotations: Medical, psychiatric, and dental fellows complete 6-week rotations serving formerly homeless older adults living in residences owned by Hearth, a nonprofit organization dedicated to providing housing and health care for older adults. The fellows, all of whom have recently completed their residencies, participate in the rotation as a part of larger fellowship programs: medical fellows come from Beth Israel Deaconess Medical Center’s Geriatric Medical Fellowship Program, while psychiatric fellows are based at the Cambridge Health Alliance (a Harvard-affiliated teaching health system) and dental fellows at the Harvard School of Dental Medicine.
• Weekly onsite health consultations and care: Each week, clinical staff at Hearth identify clients who have the most pressing health concerns. Fellows from all three disciplines, working under the supervision of Harvard faculty, meet with these clients to examine their medical, psychiatric, and oral health status. Fellows also conduct an in-depth analysis of each client’s care plan. When possible, all consultations take place at the onsite clinic located in the Ruggles Affordable Assisted Living Community, a central Hearth site.
• Monthly care conferences to review cases: Fellows from all three disciplines come together with faculty on a monthly basis for an in-depth care conference. At this meeting, fellows and faculty review current cases and collaborate to improve the care management plan for the Hearth clients they serve. 
• Weekly didactic curriculum: In support of the fellowship’s direct service component, all fellows receive weekly training sessions. The training curriculum spans all three disciplines, so as to prepare fellows to provide comprehensive care to underserved older adults. Training topics include: oral health issues, conducting a dental exam, diagnosing depression and dementia in minority populations, health literacy, health care disparities, health care financing for low-income patients; Medicare pharmacy benefits, and medical leadership.

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Results

• More older adults served: Each medical fellow provides care and consultations to approximately 100 older adults per year. Approximately half of these patients receive additional care from dental fellows, while a fourth receive treatment from psychiatric fellows. In the absence of the program, it is unlikely that these individuals would receive comprehensive care across all three disciplines.
• Positive feedback from patients and fellows: Patients express satisfaction with the personal attention they receive from the fellows, as well as the convenience of having medical, dental, and psychiatric care delivered at one central location. In turn, fellows report appreciating the opportunity to experience patient care outside of a hospital setting.
• Ongoing study of impact on health outcomes: An ongoing study is evaluating how the coordination of interdisciplinary fellows improves health outcomes, including whether the program leads to earlier diagnoses of depression in patients with heart disease.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Securing funding: While project leaders had been interested in pursuing a cross-training fellowship for some time, the emergence of HRSA funding specifically earmarked for such a program enabled them to move forward with planning and implementation. Project leaders sought and received the 3-year HRSA grant.
• Forming leadership committee: A committee, including the principal investigator, site directors for the geriatric psychiatry and the geriatric dentistry fellowships, and the coordinator of the overall geriatric fellowship program, formed to steer the development of the cross-training fellowship program.

Resources Used and Skills Needed

• Staffing: Six to seven fellows participate in the interdisciplinary fellowship program each year. A core group of seven faculty created and implemented the cross-training curriculum, with a wide range of faculty members involved as guest lecturers.
• Costs: Annual grant funding of $600,000 and supplemental funds cover most program expenses. (See Funding Sources section below for more details.) Major categories of expenses include salaries and benefits for the fellows and stipends for the core faculty involved in creating and implementing the program.

Funding Sources

Health Resources and Services Administration

Getting Started with This Innovation

• Build on existing model: Rather than start from scratch, utilize the framework of existing programs or fellowships as a launching point for any new initiatives. Harvard developed its cross-training fellowship within the context of its longstanding and reputable geriatric medical fellowship program.
• Seek targeted funding: The Harvard Geriatrics Fellowship Program was able to secure a significant HRSA grant to support cross-training of medical professionals in an interdisciplinary experience.
• Establish key partnerships: Build and maintain partnerships with a small number of clinical sites. Faculty and fellows must emphasize strong communication with partner sites to facilitate quality and continuity of patient care.

Sustaining This Innovation

• Engage a faculty or provider champion: One or more key leaders must advocate for the fellowship program on an ongoing basis, coordinate the didactic curriculum, and facilitate mutually beneficial partnerships with clinical sites.
• Ensure balance between curriculum and clinical work: Direct patient care and didactic education are both important components of the program, and each should receive adequate emphasis.