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.

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The objective of this study was to describe health services utilization by homeless and housed poor adults stratified by six-month primary sheltering arrangements. The primary method used in this study was a cross-sectional survey of 373 homeless adults. Interviews at twenty-four community-based sites (in Allegheny County, Pennsylvania) assessed demographic and clinical characteristics, reasons for homelessness, functional status and social support networks, and health services utilization during the previous six months. Multivariate logistic regression analysis identified factors independently associated with health services utilization. Subjects were classified as unsheltered, emergency-sheltered, bridge-housed, doubled-up, and housed-poor. The median age of the subjects was 38.4 years; 78.6 percent were African American and 69.9 percent had health insurance. Overall, 62.7 percent reported health services use in the past six months, with significantly more use among emergency-sheltered and bridge-housed subjects than among unsheltered subjects. The study concludes that health services use among the homeless is substantial and is independently associated with sheltering arrangement, comorbid illness, race, health insurance, and social support.

Tailoring primary care to homeless veterans can decrease unnecessary ED use and medical admissions and improve chronic disease management.

Older homeless adults have a greater disease burden than their younger counterparts. However, it is unclear whether these needs are being appropriately identified and met. There is a need for specific and targeted outreach to connect them to appropriate services.