Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans Health Administration’s “Homeless Patient Aligned Care Team” Program

Abstract

IntroductionAlthough the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a “homeless medical home” initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites. Methods We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services.ResultsMore than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies.ConclusionIntegrating social determinants of health into clinical care can be effective for high-risk homeless veterans.

Long-acting Reversible Contraception Among Homeless Women Veterans With Chronic Health Conditions

“…Homeless healthcare is a VHA priority with development of the Homeless Patient Aligned Care Teams (H-PACT) that have successfully increased primary care engagement and decreased costly emergency services. 34,35 Addressing homelessness and housing instability will help to mitigate many of the distal risk factors in the IPHF. (Figure 1) Currently, housing and mental health engagement are first line priorities of H-PACT and reproductive health needs are not addressed until the patient is established in primary care and then may need consultant referrals to gynecology, if the primary care provider is not comfortable with gender-specific needs.…”

Screening for Food Insecurity in Six Veterans Administration Clinics for the Homeless, June–December 2015

“…From June through December 2015, we screened new patients who enrolled in care at one of 6 VA Homeless Patient Aligned Care Teams (H-PACTs) (12). The screening instrument was adapted from a one-question query (“In the past month, were there times when the food for you just did not last and there was no money to buy more” [14]) that was validated in a neighborhood health center serving a low-income urban community.…”

“…Integrating public health practice into clinic settings by incorporating social determinants of health in screening and interventions related to broad needs, such as housing insecurity and food insecurity, is an important opportunity that can improve health (12,13). In this article, we describe a clinic-based food insecurity screening program that we pilot-tested in 6 geographically and demographically distinct (East Coast, West Coast, Midwest, urban, rural) Veterans Affairs (VA) clinics caring for veterans who were homeless, at-risk for homelessness, or recently homeless living in transitional or supportive housing.…”

A Hybrid III stepped wedge cluster randomized trial testing an implementation strategy to facilitate the use of an evidence-based practice in VA Homeless Primary Care Treatment Programs

“…To address these needs, the Department of Veterans Affairs (VA) developed specialized Homeless Patient Aligned Care Teams (HPACT). The goal of HPACT is to offer an integrated “one-stop program” that takes into account social determinants of health to address medical and mental health, substance use disorder (SUD), and psychosocial needs (e.g., housing, benefits) of homeless veterans [3]. This is consistent with the patient-centered medical home model that is commonly delivered within and outside of the VA system [4, 5] but different in that HPACT is specifically tailored to address complex needs of homeless veterans.…”