Background: People with histories of homelessness and serious mental illness experience profound health disparities. Housing First is an evidenced-based practice that is working to end homelessness for these individuals through a combination of permanent housing and community-based supports.

Methods: The Jefferson Department of Family and Community Medicine and a Housing First agency, Pathways to Housing-PA, has formed a partnership to address multiple levels of health care needs for this group. We present a preliminary program evaluation of this partnership using the framework of the patient-centered medical home and the “10 Essential Public Health Services.”

Results: Preliminary program evaluation results suggest that this partnership is evolving to function as an integrated person-centered health home and an effective local public health monitoring system.

Conclusion: The Pathways to Housing-PA/Jefferson Department of Family and Community Medicine partnership represents a community of solution, and multiple measures provide preliminary evidence that this model is feasible and can address the “grand challenges” of integrated community health services.