Population-Tailored Care for Homeless Veterans and Acute Care Use, Cost, and Satisfaction: A Prospective Quasi-Experimental Trial

Abstract

IntroductionAlthough traditional patient-centered medical homes (PCMHs) are effective for patients with complex needs, it is unclear whether homeless-tailored PCMHs work better for homeless veterans. We examined the impact of enrollment in a Veterans Health Administration (VHA) homeless-tailored PCMH on health services use, cost, and satisfaction compared with enrollment in a traditional, nontailored PCMH.MethodsWe conducted a prospective, multicenter, quasi-experimental, single-blinded study at 2 VHA medical centers to assess health services use, cost, and satisfaction during 12 months among 2 groups of homeless veterans: 1) veterans receiving VHA homeless-tailored primary care (Homeless-Patient Aligned Care Team [H-PACT]) and 2) veterans receiving traditional primary care services (PACT). A cohort of 266 homeless veterans enrolled from June 2012 through January 2014.ResultsCompared with PACT patients, H-PACT patients had more social work visits (4.6 vs 2.7 visits) and fewer emergency department (ED) visits for ambulatory care-sensitive conditions (0 vs 0.2 visits); a significantly smaller percentage of veterans in H-PACT were hospitalized (23.1% vs 35.4%) or had mental health–related ED visits (34.1% vs 47.6%). We found significant differences in primary care provider–specific visits (H-PACT, 5.1 vs PACT, 3.6 visits), mental health care visits (H-PACT, 8.8 vs PACT, 13.4 visits), 30-day prescription drug fills (H-PACT, 40.5 vs PACT, 58.8 fills), and use of group therapy (H-PACT, 40.1% vs PACT, 53.7%). Annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036). In logistic regression model of acute care use, assignment to the H-PACT model was protective as was rating health “good” or better.ConclusionHomeless veterans enrolled in the population-tailored primary care approach used less acute care and costs were lower. Tailored-care models have implications for care coordination in the US Department of Veterans Affairs VA and community health systems.

Primary Care for Homeless Veterans: A Systematic Review of the Homeless Patient Aligned Care Team (HPACT)

“…Between 2012 and 2014, O’Toole and colleagues studied 2 VHA medical centers to assess health services use, cost, and satisfaction over 12 months for a cohort of 266 homeless Veterans. (22) They found that compared with PACT patients, HPACT patients had more social work visits (4.6 vs 2.7 visits) and fewer emergency department (ED) visits for ambulatory care-sensitive conditions (0 vs 0.2 visits); a significantly smaller percentage of Veterans in HPACT were hospitalized (23.1% vs 35.4%) or had mental health–related ED visits (34.1% vs 47.6%). They also found significant differences in primary care provider–specific visits (HPACT, 5.1 vs PACT, 3.6 visits), mental health care visits (HPACT, 8.8 vs PACT, 13.4 visits), 30-day prescription drug fills (HPACT, 40.5 vs PACT, 58.8 fills), and use of group therapy (HPACT, 40.1% vs PACT, 53.7%).…”

Trends in Health Service Utilization After Enrollment in an Interdisciplinary Primary Care Clinic for Veterans with Addiction, Social Determinants of Health, or Other Vulnerabilities

“…Integrated primary care (IPC) models that address addiction and SDOH could promote primary care engagement and mitigate problematic patterns of acute care utilization. 8 – 10 IPC models utilize interdisciplinary teams to provide longitudinal, patient-centered care; reduce care fragmentation; and avert preventable hospitalizations via enhanced primary care access and disease management. 9 Such approaches have increased primary care utilization (especially preventive services) and reduced ED visits and hospitalizations for patients with chronic health conditions, serious mental illness, and experience of homelessness.…”

Characteristics Associated With Unsheltered Status Among Veterans

“…This paper used responses from a survey of veterans (N=5,766) who experienced homelessness and were receiving primary care at 26 Department of Veterans Affairs, Veterans Administration (VA) Medical Centers in 2018. The parent study compared primary care experiences among those who used a new kind of VA clinic designed for homeless-experienced veterans (Homeless Patient−Aligned Care Teams) 14 and those receiving non−Homeless Patient−Aligned Care at the same VA Medical Centers.…”