Homeless persons, especially those with mental illness, constitute a population that attracts little advocacy but that has extreme need. The Western Psychiatric Institute and Clinic (WPIC) recognized this need and over the past decade has been developing an innovative program to provide supportive housing for the seriously mentally ill homeless population in the Pittsburgh area—the WPIC Homeless Continuum. WPIC developed creative strategies to obtain financing, bringing together a variety of government, community, and university funding sources to develop a collaboration along a continuum of needs. Using the community treatment team and assertive community treatment models, the project engages the homeless where they live and tries to get them into treatment and off the streets. It has struck a balance between engaging people who need help and respecting the individual's right to refuse treatment—use of a continuum means that people do not have to fit a template that they are not ready for.

WPIC houses the department of psychiatry of the University of Pittsburgh School of Medicine. Each year WPIC provides clinical services to more than 30,000 individuals and provides training programs to more than 15,000 individuals in recovery and professionals. The WPIC Homeless Continuum has been fully operational since July 1998. It consists of WPIC Community Services, the Neighborhood Living Project, and the Buffalo Street Project. WPIC Community Services has served more than 300 homeless individuals and families through assertive outreach efforts in the streets and homeless shelters of Pittsburgh and throughout Allegheny county. The Neighborhood Living Project is currently serving around 70 homeless individuals who have a diagnosis of serious mental illness, many of whom have families who are also served by the project. More than 80 percent of the clients with mental illness also have a history of substance abuse. These individuals and families receive varying degrees of support, according to their needs. Most of them are living in the community in housing of their choice. Those who are deemed to be in greater need of treatment and support live in apartments owned by the University of Pittsburgh Medical Center Health System and constitute the client base of the Buffalo Street Project.

The expectation is that people will move through the continuum as they become more stable, which requires that their physical and mental health problems, their family and social problems, and their educational and vocational problems all be addressed. In addition to its various supportive housing options, the WPIC Homeless Continuum includes case management as well as medical and psychiatric treatment, including addictions and social and vocational rehabilitation. Both rapid-response and long-term follow-through approaches are used.

Community organization is another feature of the continuum. The continuum works closely with the Mayor's Task Force on Homelessness and holds several workshops on recovery for psychiatric residents, other professionals, and consumers. Staff from WPIC organized the Homeless Outreach Coordinating Committee, which consists of the majority of social service and mental health agencies that work with the homeless population in Allegheny county.

Two psychiatrists share responsibility for the WPIC Homeless Continuum. One of the psychiatrists spends eight hours a week meeting with the community treatment team and seeing clients either in a clinic for homeless persons or in their own homes. The other psychiatrist works for the project three hours a week, providing clinical consultation to the senior psychiatric nurses on the team, and is very active in the homeless community. He also supervises the psychiatric residents, who provide consultation to the community treatment teams, go into the community to monitor clinical treatment, and moonlight at various shelters throughout the county.

Seven psychiatric nurses perform a valuable function in assisting the psychiatrists with monitoring the medications and medical care needs of each client. They provide the bulk of the assertive outreach and spend part of each workday in homeless shelters monitoring the status of shelter residents. They also help clients negotiate the managed care environment and help them obtain access to other resources in the community. The team also includes five intensive case managers, one certified addiction counselor, and a secretary.

The program's current budget comprises a three-year grant of $2.5 million from the Department of Housing and Urban Development to the Neighborhood Living Project, $600,000 from the county, and $300,000 from the Department of Housing and Urban Development to the Buffalo Street Project.

The WPIC Homeless Continuum has pioneered community-based outreach, treatment, and supportive housing in the region. The program's "enhanced case management team model" is the first of its kind in Pennsylvania. Staff from the continuum are frequently called on by regional community support programs, mental health and homeless provider agencies, and regional chapters of the National Alliance for the Mentally Ill and the Mental Health Association to provide consultations on homelessness and mental health. The program also provides consultation to several surrounding counties on the integration of dialectical behavior therapy into a community-based case management model. The program has been awarded a Mental Health Community Block Grant to better serve transitional-age young adults through a community treatment team approach.

One challenge the program faced was in securing funding to move individuals and families between the various stages of the continuum in a timely fashion. For example, if a mother with three children living on the streets needs to get treatment for an addiction and for a psychiatric disorder, the children need to be adequately and appropriately cared for until she is stable. Essentials of daily living, such as food, clothing, and respite shelter, become this family's major priority. Funding for treatment services for the mother, day care for the children, and health care for the entire family all require different funding streams. Traditionally, the mother may have been prevented from receiving services until funding had been finalized. The WPIC Homeless Continuum has addressed some of the gaps in services by establishing contingency funds and partnering with local treatment agencies and grocery stores to provide a voucher system to enable its clients to meet their basic needs.

The project's outcome measures include consumer satisfaction, clinical outcomes, number of days in the hospital, number of days in jail, use of homeless shelters, and staff turnover. The average length of stay in supportive housing is 11.8 months. Around 75 percent of clients move on to more permanent housing, and 96 percent report an improvement in their quality of life. Almost all participants stay in mental health treatment on a voluntary basis. The average level of functioning of the clients, as measured by Global Assessment of Functioning (GAF) scores, has improved by 27 percent. The program has also been associated with significant reductions in the number of days in jail and in psychiatric hospitals, and the use of shelters by the individuals and families served by the continuum has been all but eliminated. The WPIC Homeless Continuum has demonstrated that a high-quality program that serves the homeless mentally ill population can have a tremendous impact on the health status, compliance with treatment, and quality of life of those it serves.

For more information, contact Paul J. Cornely, Ph.D., The WPIC Homeless Continuum, 3811 O'Hara Street, Ross Building, Second Floor, Pittsburgh, Pennsylvania 15213; phone 412-605-1212; fax 412-605-1220; e-mail, cornelypj@msx.upmc.edu.