Date of Publication


Project Team

Mary Val Palumbo DNP, APRN, GNP-BC, Lauren Passalaqua, Team Lead


Background: Individuals with serious mental illness are a high-risk population that need improved access to physical health care. Many have negative experiences with the healthcare system and need support in accessing it. A housing-first organization in Vermont offers wrap-around services to these individuals but does not have a standardized way to assess for client healthcare needs or to communicate with primary care provider offices.

Purpose: The project aimed to: 1. Identify the current processes used to assess client health needs; 2. Change organizational workflow to include comprehensive and standardized health protocols. 3. Instruct staff to increase knowledge to identify and disseminate information about client health concerns.

Methods: A retrospective chart review determined the percentage of clients with primary care providers. Current intake and annual-self assessment protocols were evaluated for completeness of physical health screening. Workflow was standardized based on these findings and staff were educated on how to access and disseminate client medical information. A survey assessed changes in knowledge before and after the intervention.

Results: Forty two percent of clients did not have primary care providers. Medical questions were added to the Electronic Health Record forms. Health information was added to the shared client work board. The intake process was modified to include formal written collaboration between the organization and existing medical providers. Survey results showed that the interventions increased staff knowledge of medications and ability to locate medical information.

Discussion: The Theory of Change links between desired outcomes and interventions. Increasing staff knowledge about client medical needs will improve health outcomes.

Document Type