Primary Care Medical Services for Homeless Veterans
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.
The more challenging questions surround the implementation of the current clinic models to address the needs of these patient cohorts and possible avenues to improve each clinic. High rates of chronic medical illness, mental illness, and ATOD use are well known in the homeless veteran and general populations.2,9 Within these 3 HPACTs, the high rates of medical/mental illness and ATOD use speak favorably about the clinics’ respective recruitment strategies; ie, normative homeless populations with high rates of illness are enrolling in these clinics. However, current service integration practices may be enhanced with the specific knowledge gained from this examination. For example, the very high rates of mood and anxiety disorders at each site suggest a role for an embedded mental health provider with prescribing privileges (the model adopted by BIR) as opposed to mental health referrals used at WLA and PIT. There may also be a role for cognitive behavioral therapy services within these clinics. Similarly, the high rates of ATOD (especially alcohol, tobacco, and cocaine) misuse suggest a role for addiction medicine training among the PCPs (the PIT model) as well as psychosocial rehabilitation for ATOD use within the HPACTs. High rates of chronic medical conditions, such as diabetes, hepatitis C, and hypertension elucidate possible roles for specialty care integration and/or chronic disease management programs tailored to the homeless.
Comparing the housing status of these cohorts can help in the design of future homeless-tailored primary care operations and improve these HPACTs. Most patients across sites lived in VA transitional housing/residential rehabilitation programs. As such, current referral practices at these 3 HPACTs proved sufficient in recruiting this subpopulation of homeless veterans. However, in light of national data showing that the count of unsheltered homeless veterans has not declined as rapidly as the count of homeless veterans overall, the higher numbers of veterans recruited from interim sheltering arrangements suggest a need for enhanced outreach to unsheltered individuals.1 WLA data suggest that linkages to EDs can advance this objective. BIR data show that targeted outreach in shelters can engage this high-risk, transiently sheltered subpopulation in primary care. At the time of this project, PIT just began using a peer support specialist for outreach to unsheltered veterans. It will be important to evaluate the outcomes of this new referral strategy.
Limitations
These exploratory findings—though from a small convenience sample within a nascent, growing program—generated critical and detailed information to guide ongoing policies and service design. However, these findings have limitations. First, though this research contributes to limited existing literature about the operational design of homeless-focused primary care, no outcome data were included. Although a comprehensive evaluation of all HPACT sites is a distinct and useful endeavor, this project instead offers a rapid, detailed illustration of 3 early-stage clinics. Though smaller in scope, this effort informs other facilities developing homeless-focused primary care initiatives and the larger demonstration project.
Second, a convenience sample of 3 urban facilities with strong academic ties and community commitment to providing services for homeless persons was presented. It may be difficult to translate these findings to communities with fewer resources.
Third, EHR review was used to determine patient demographics, diagnoses, and patterns of health care use. Though EHR review offers detailed information that is unavailable from administrative data, EHR is subject to variations in documentation patterns.
Last, differing characteristics of the homeless veteran population in each city may interact with contrasting HPACT structures to influence the characteristics of patients served. For example, though the data suggest that linkages with the ED may facilitate greater recruitment of unsheltered veterans in WLA, Los Angeles is known to have particularly high rates of unsheltered individuals.1
CONCLUSIONS
Clinicians, administrators, and researchers in the safety net may benefit from the experience implementing new clinics to recruit and engage homeless veterans in primary care. In a relatively nascent field with few accepted models of care, this paper offers detailed descriptions of newly developed homeless-focused primary care clinics at 3 VA facilities, which can inform other sites undertaking similar initiatives. This study highlights the wide range of approaches to building such clinics, with important variations in structural characteristics such as clinic location and operating hours, as well as within the intricacies of service integration patterns.
Within primary care clinics for homeless adults, this study suggests a role for embedded mental health (medication management and psychotherapy) and substance abuse services, chronic disease management programs tailored to this vulnerable population, and the role of linkages to the ED or community-based outreach to recruit unsheltered homeless patients. To pave a path toward identifying an evidence-based model of homeless-focused primary care, future studies are needed to study nationwide HPACT outcomes, including health status, patient satisfaction, quality of life, housing, and cost-effectiveness.
