Best Practices

Primary Care Medical Services for Homeless Veterans

Fed Pract. 2014 October;31(10):10-19

Author(s):

Sonya Gabrielian, MD, MPH

Adam J. Gordon, MD, MPH

Lillian Gelberg, MD, MSPH

Beena Patel, DrPH

Rishi Manchanda, MD, MPH

Lisa Altman, MD

Ronald M. Andersen, PhD

Robert Andrew Campbell, MD

Lauren M. Broyles, PhD, RN

James Conley, BA

Stefan Kertesz, MD, MSc

Researchers compare Homeless Patient-Aligned Care Team clinics at 3 VA medical centers across the U.S. and the role each plays in homeless-focused primary care.

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References

1. Cortes A, Henry M, de la Cruz RJ, Brown S. The 2012 Point-in-Time Estimates of Homelessness: Volume I of the 2012 Annual Homeless Assessment Report. Washington, DC: The U.S. Department of Housing and Urban Development, Office of Community Planning and Development; 2012.

2. Balshem H, Christensen V, Tuepker A, Kansagara D. A Critical Review of the Literature Regarding Homelessness Among Veterans. U.S. Department of Veterans Affairs, Veterans Health Administration, Health Services Research & Development Service; 2011. VA-ESP Project #05-225.

3. O’Toole TP, Pirraglia PA, Dosa D, et al; Primary Care-Special Populations Treatment Team. Building care systems to improve access for high-risk and vulnerable veteran populations. J Gen Intern Med. 2011;26(suppl 2):683-688.

4. Opening Doors: Federal Strategic Plan to Prevent and End Homelessness. Washington, DC: The United States Interagency Council on Homelessness; 2010.

5. Nakashima J, McGuire J, Berman S, Daniels W. Developing programs for homeless veterans: Understanding driving forces in implementation. Soc Work Health Care. 2004;40(2):1-12.

6. O’Toole TP, Buckel L, Bourgault C, et al. Applying the chronic care model to homeless veterans: Effect of a population approach to primary care on utilization and clinical outcomes. Am J Public Health. 2010;100(12):2493-2499.

7. Desai MM, Rosenheck RA, Kasprow WJ. Determinants of receipt of ambulatory medical care in a national sample of mentally ill homeless veterans. Med Care. 2003;41(2):275-287.

8. Irene Wong YL, Stanhope V. Conceptualizing community: A comparison of neighborhood characteristics of supportive housing for persons with psychiatric and developmental disabilities. Soc Sci Med. 2009;68(8):1376-1387.

9. Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in Los Angeles. Am J Public Health. 1997;87(2):217-220.

10. Hamilton AB, Poza I, Washington DL. “Homelessness and trauma go hand-in-hand”: Pathways to homelessness among women veterans. Womens Health Issues. 2011;21(suppl 4):S203-S209.

11. McGuire J, Gelberg L, Blue-Howells J, Rosenheck RA. Access to primary care for homeless veterans with serious mental illness or substance abuse: A follow-up evaluation of co-located primary care and homeless social services. Adm Policy Ment Health. 2009;36(4):255-264.

12. VHA Operations Activities That May Constitute Research. Washington, DC: U.S. Department of Veterans Affairs, Veterans Health Administration; 2011. VHA Handbook 1058.05.

13. Resnick SG, Armstrong M, Sperrazza M, Harkness L, Rosenheck RA. A model of consumer-provider partnership: Vet-to-Vet. Psychiatr Rehabil J. 2004;28(2):185-187.

14. Hogan TP, Wakefield B, Nazi KM, Houston TK, Weaver FM. Promoting access through complementary eHealth technologies: Recommendations for VA’s Home Telehealth and personal health record programs. J Gen Intern Med. 2011;26(suppl 2):628-635.

15. Rosland AM, Nelson K, Sun H, et al. The patient-centered medical home in the Veterans Health Administration. Am J Manag Care. 2013;19(7):e263-e272.

16. Hsiao CJ, Cherry DK, Beatty PC, Rechtsteiner EA. National Ambulatory Medical Care Survey: 2007 summary. Natl Health Stat Report. 2010;3(27):1-32.

17. Hwang SW, Orav EJ, O’Connell JJ, Lebow JM, Brennan TA. Causes of death in homeless adults in Boston. Ann Intern Med. 1997;126(8):625-628.

18. Hwang SW, Tolomiczenko G, Kouyoumdjian FG, Garner RE. Interventions to improve the health of the homeless: A systematic review. Am J Prev Med. 2005;29(4):311-319.

On a single night in 2012, 62,619 veterans experienced homelessness.¹ With high rates of illness, as well as alcohol, tobacco, and other drug (ATOD) use among homeless adults, ending veteran homelessness is a signature initiative of the VA.^2-4 However, despite increasing efforts to improve health care for homeless individuals, little is known about best practices in homeless-focused primary care.^2,5

With an age-adjusted mortality that is 2 to 10 times higher than that of their housed counterparts, homeless veterans pose a formidable challenge for primary care providers (PCPs).^6,7 The complexity of homeless persons’ primary care needs is compounded by poor social support and the need to navigate priorities (eg, shelter) that compete with medical care.^6,8,9 Moreover, veterans may face unique vulnerabilities conferred by military-specific experiences.^2,10

As of 2012, only 2 VA facilities had primary care clinics tailored to the needs of homeless veterans. McGuire and colleagues built a system of colocated primary care, mental health, and homeless services for mentally ill veterans in Los Angeles, California.¹¹ Over 18 months, this clinic facilitated greater primary and preventive care delivery, though the population’s physical health status did not improve.¹¹More recently, O’Toole and colleagues implemented a homeless-focused primary care clinic in Providence, Rhode Island.⁶ Compared with a historical sample of homeless veterans in traditional VA primary care, veterans in this homeless-tailored clinic had greater improvements in some chronic disease outcomes.⁶ This clinic also decreased nonacute emergency department (ED) use and hospitalizations for general medical conditions.⁶

Despite these promising outcomes, the VA lacked a nationwide homeless-focused primary care initiative. In 2012 the VA Office of Homeless Programs and the Office of Primary Care Operations funded a national demonstration project to create Homeless Patient-Aligned Care Teams (HPACTs)—primary care medical clinics for homeless veterans—at 32 facilities. This demonstration project guided HPACTs to tailor clinical and social services to homeless veterans’ needs, establish processes to identify and refer appropriate veterans, and integrate distinct services.

There were no explicit instructions that detailed HPACT structure. Because new VA programs must fit local contextual factors, including infrastructure, space, personnel, and institutional/community resources, different models of homeless-focused primary care have evolved.

This article is a case study of HPACTs at 3 of the 32 participating VA facilities, each reflecting a distinct community and organizational context. In light of projected HPACT expansion and concerns that current services are better tailored to sheltered homeless veterans than to their unsheltered peers, there is particular importance to detailed clinic descriptions that vividly portray the intricate relationships between service design and populations served.¹

METHODS

VA HPACTs established in May 2012 at 3 facilities were examined: Birmingham VAMC in Alabama (BIR), West Los Angeles VAMC in California (WLA), and VA Pittsburgh Healthcare System in Pennsylvania (PIT). Prior to this demonstration project, each facility offered a range of housing/social services and traditional primary care for veterans. These sites are a geographically diverse convenience sample that emerged from existing homeless-focused collaborations among the authors and represent geographically diverse HPACTs.

The national director of VA Homeless Programs formally determined that this comparison constitutes a VA operations activity that is not research.¹² This activity was exempt from Institutional Review Board review.

Study Design

Timed at an early stage of HPACT implementation, this project had 3 aims: (1) To identify noteworthy similarities and/or differences among the initial HPACT clinic structures; (2) To compare and contrast the patient characteristics of veterans enrolled in each of these clinics; and (3) To use these data to inform ongoing HPACT service design.

HPACT program evaluation data are not presented. Rather, a nascent system of care is illustrated that contributes to the limited literature concerning the design and implementation of homeless-focused primary care. Such organizational profiles inform novel program delivery and hold particular utility for heterogeneous populations who are difficult to engage in care.^13,14

Authors at each site independently developed lists of variables that fell within the 3 guiding principles of this demonstration project. These variables were compiled and iteratively reduced to a consolidated table that assessed each clinic, including location, operating hours, methods of patient identification and referral, and linkages to distinct services (eg, primary care, mental health, addiction, and social services).

This table also became a guide for HPACT directors to generate narrative clinic descriptions. Characteristics of VA medical homes that are embraced regardless of patients’ housing status (eg, patient-centered, team-based care) were also incorporated into these descriptions.¹⁵

Patient Characteristics

The VA electronic health record (EHR) was used to identify all patients enrolled in HPACTs at BIR, WLA, and PIT from May 1, 2012 (clinic inception), through September 30, 2012. Authors developed a standardized template for EHR review and coined the first HPACT record as the patient’s index visit. This record was used to code initial housing status, demographics, and acute medical conditions diagnosed/treated. If housing status was not recorded at the index visit, the first preceding informative record was used.