A national evaluation of homeless and nonhomeless veterans’ experiences with primary care.

Abstract

Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons’ avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and non-homeless Veterans with MHSUDs receiving care in the Veterans Health Administration’s medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Healthcare Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth “homeless”) were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 Veterans with MHSUDs (9.2% homeless). Compared to their non-homeless counterparts, homeless Veterans were younger, more likely to be non-Hispanic Black and non-married; had less education; and were more likely to live in urban areas. Homeless Veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless Veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than non-homeless Veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services.

An evolutionary view of patient experience in primary care: A concept analysis

“…Patient experience survey results and narrative data lead to the understanding of the level of patient‐centered care, which informs healthcare organizations where to place their financial and human capital for improvements. Several research teams investigated patient experience from the perspective of persons who lacked consistent housing. The separate research teams tested different service delivery models and used patients’ survey results to evaluate the model’s effectiveness in facilitating patient‐centered care .…”

“…Several research teams investigated patient experience from the perspective of persons who lacked consistent housing. The separate research teams tested different service delivery models and used patients’ survey results to evaluate the model’s effectiveness in facilitating patient‐centered care . Results from one patient experience study of persons with unstable housing and behavioral health diagnoses affirmed an organization’s practice to employ clinicians who valued humanistic care .…”

Health Service Access Among Homeless Veterans: Health Access Challenges Faced by Homeless African American Veterans

“…In a more recent study, homeless veterans reported more negative primary care experiences than housed veterans across seven of eight domains of care. These negative experiences applied not only in interpersonal domains but also in veteran perception of the thoroughness of treatment and their role in medication decision-making [ 76 ]. In some cases, homeless veterans reported delaying entry into primary care services due to a lack of trust in providers and perceived stigma as a result of their homelessness status [ 77 ].…”

Exploring Quality of Primary Care for Patients Who Experience Homelessness and the Clinicians Who Serve Them: What Are Their Aspirations?

“…Individuals experiencing homelessness face unique challenges in obtaining appropriate primary care: perceived stigma, lack of trust, negative experiences with care coordination, as well as logistic barriers such as ability to pay, lack of transportation, and pressure from competing priorities (Gelberg et al, 1997; Gruenewald et al, 2018; Jones et al, 2017; Ramsay et al, 2019; Wen et al, 2007). Over the last four decades, federal and nonfederal programs have sought to deliver primary care that is more responsive to their needs (Gabrielian et al, 2017; Jones et al, 2018; O’Toole et al, 2011).…”

“…Despite these numerous efforts at addressing access to primary care, reports suggest that persons experiencing homelessness continue to have serious problems accessing primary care and that they have inferior experiences even when care is obtained (Baggett et al, 2010; Jones et al, 2017; Kertesz, McNeil, et al, 2014). Efforts to improve the design and delivery of primary care for persons who are homeless could be enhanced by a better understanding of what indicates quality in primary care, from the viewpoints of patients who are homeless and experts who have focused their careers on this population.…”