摘要：During the past 25 years, the Boston Health Care for the Homeless Program has evolved into a service model embodying the core functions and essential services of public health. Each year the program provides integrated medical, behavioral, and oral health care, as well as preventive services, to more than 11 000 homeless people. Services are delivered in clinics located in 2 teaching hospitals, 80 shelters and soup kitchens, and an innovative 104-bed medical respite unit. We explain the program's principles of care, describe the public health framework that undergirds the program, and offer lessons for the elimination of health disparities suffered by this vulnerable population. Homelessness remains a bewilderingly complex public health challenge that has long thwarted simple solutions. Homelessness magnifies poor health, exposes those in crowded shelters to communicable diseases, complicates management of chronic illnesses, and uncovers deep fault lines in our health care system. For those who are homeless, the relentless daily struggle for safe shelter and a warm meal overshadows health needs, leaving common illnesses to progress and injuries to fester. A vast array of obstacles exasperates clinicians serving the homeless and confounds delivery systems intended to help this population. As many as 13.5 million Americans are estimated to have been homeless at some point in their lives, 1 and the nation's homeless population on any given night ranges from 250 000 to 3.5 million. 2 , 3 Many studies have found evidence of premature mortality among homeless persons. 4 , 5 In Philadelphia, the mortality rate in a cohort of homeless adults was 3.5 times higher than in the general population. 6 A Boston study found that homeless men aged 18 to 44 years were several times more likely to die than were their housed counterparts. 7 In a bitter urban irony, homeless persons sleep neglected in the long shadows cast by towering academic medical centers that offer sophisticated health care to persons from throughout the country and the world. No study has previously articulated a public health framework designed to capture the dimensions of prevention, treatment, and continuity of care necessary for a patient-centered, multisector service delivery model for homeless populations. We begin to address this deficit by analyzing the country's largest and most comprehensive freestanding health care for the homeless program, the Boston Health Care for the Homeless Program (BHCHP). We analyze BHCHP's history and evolution from a public health perspective by using the 3 core functions and 10 essential services of public health identified by the landmark Institute of Medicine report The Future of Public Health . 8 To do so, we reviewed: (1) BHCHP's original 1984 grant proposal to the Robert Wood Johnson Foundation (RWJF), (2) annual reports to RWJF and then to the Health Resources and Services Administration's (HRSA's) Bureau of Primary Health Care, (3) publications and articles in the BHCHP archives, and (4) interviews with key clinicians and administrators. On the basis of this review, we describe a public health framework for improving the health of homeless persons that is generalizable to other programs working to eliminate health disparities among marginalized populations.
