Tailoring the primary care medical home model improves the care experience for US Department of Veterans Affairs (VA) patients with homelessness experience, according to a recent study by Dr. Audrey Jones and colleagues in the journal Medical Care. Researchers from the VA’s Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center and Center for Health Equity Research and Promotion showed that patient care experience was improved in several domains through the VA’s innovative program addressing their unique social determinants of health.
Veteran Homelessness
Estimates of veteran status in homelessness have risen as high as 1 in 4 of all homeless individuals in the past, but that number has come down dramatically in recent years. This is largely due to a concerted effort by the VA and the US Dept of Housing and Urban Development (HUD) to provide subsidized housing services – most often housing choice vouchers – and supportive services from the VA (HUD-VASH). At this point, the National Coalition for Homeless Veterans (NCHV) says homeless vets make up about 11% of the total population experiencing homelessness.
HUD’s 2018 Point-in-Time Count (which is a standardized, but certainly conservative, census of individuals experiencing homelessness) estimates that there are just 37,878 veterans experiencing homelessness [pdf] on a given night last winter. Yet the VA treats nearly 150,000 homeless veterans every year, and the NCHV also estimates that there are another 1.4 million veterans are at imminent risk of homelessness “due to poverty, lack of support networks, and dismal living conditions in overcrowded or substandard housing”. The sample for the current study in Medical Care came from surveys collected in 2014 and 2015, during the middle of the most recent decline in homelessness.
Homeless Patient Aligned Care Teams
In concert with the VA’s plan to end veteran homelessness by 2015, they rolled out a number of programmatic innovations to go alongside the HUD-VASH housing funds. The Homeless Patient Aligned Care Teams (H-PACT) were launched in 2012, designed to coordinate treatment of primary healthcare needs with housing program access. H-PACT provides a coordinated “medical home” specifically tailored to the needs of homeless veterans, to provide the care necessary to keep veterans in housing.
The program is intended to combine two successful models: the Health Care for the Homeless clinics and Patient-Centered Medical Homes. Functionally speaking, H-PACT is comprised of interdisciplinary teams of doctors, nurses, and case managers who respond to the ongoing and evolving medical, mental health, and substance abuse needs of homeless veterans entering the VA system. They incorporate a housing and social service hub placed within the primary care facilities allowing patients access to those services in integrated visits through a “no wrong door” policy. This method of tailoring the primary care visit to meet the unique needs of veterans experiencing homelessness can actually reverse the typical trend observed, that homeless individuals have more negative experiences [pdf] with their healthcare interactions. Housing improves the health outcomes of veterans experiencing homelessness and the H-PACT model has been shown to improve housing outcomes [pdf]. Research from the National Center on Homelessness Among Veterans also showed that H-PACT reduced acute care utilization rates and overall costs of care [pdf] for homeless veterans.
Latest Results on Patient Care Experiences
Using an annual survey conducted by the VA called the Patient-Centered Medical Home Survey of Healthcare Experiences of Patients (PCMH-SHEP) they found that 5 of the 8 patient care experience domains were rated significantly higher by patients who were enrolled in H-PACT compared to patients in standard primary care at those same sites. In order of effect size these were access, communication, office staff helpfulness/courtesy, overall provider rating, and comprehensiveness. There was no effect seen in 3 domains: care coordination, self-management support, and shared decision-making.
In order to test for bias from a sample of sites who chose to launch H-PACT, the researchers added a unique step. Homeless veterans enrolled in standard primary care at sites with H-PACT available were compared to patients at sites with no H-PACT at all. Sites that had implemented H-PACT performed better in 2 domains: communication and self-management support, even for patients who weren’t receiving H-PACT’s tailored services. This shows that sites implementing the H-PACT innovation may provide better care experiences than the rest of the system.
All research is necessarily bracketed by the context of previous findings and in this case, the evidence is split. The authors highlighted two previous attempts to characterize the primary care experience of veterans in homelessness. The first identified a preference for care [pdf] tailored to the experience of homelessness but took place before H-PACT was implemented. The second found no difference in care experience measures [pdf] between H-PACT and non-HPACT participants, although the authors point to concerns about an under-powered sample and selection bias toward positive care experiences in a prospective cohort study. To improve on those efforts, the current study used a more conservative method for establishing cut-offs between positive and negative ratings. They also used a second control group comprised of administrative data and surveys from sites that never implemented H-PACT at all.
The evidence has been building that tailoring primary care services to address the social determinants of health seems to improve the patients’ experience. Now we see that this holds true, even in a population that is notoriously difficult to reach and engage with…and that typically views their healthcare experiences more negatively.
Ben King