BACKGROUND/RATIONALE:
Despite efforts to develop patient-centered medical homes for homeless persons, little is known about the aspects of service design and delivery that offer the best results for patients. In 2012, VA initiated homeless-tailored primary care in Homeless Patient-Aligned Care Team (HPACTs). This natural experiment invites two questions. First, do VA's homeless-tailored primary care programs offer a superior patient experience? Second, what organizational features matter most?

OBJECTIVE(S):
This proposal prioritizes homeless patients' experience of care as the proximal indicator of successful engagement, and includes other indicators, i.e. health care utilization.

Aim 1: Compare primary care experience and utilization indicators for homeless-experienced patients obtaining primary care in HPACTs to patients receiving primary care in mainstream-PACT clinics operating at the same VA Medical Centers.

Aim 2: Identify features of HPACT service design that are most associated with a superior patient experience.

METHODS:
Aim 1 is a mailed survey (with telephone follow-up) of homeless-experienced Veterans (n = ~15,000) at 29 VAMCs who receive care in either an HPACT or non-HPACT setting to assess patient experience. We anticipate a final sample size of ~6,000 veterans.

Methods for Aim 2 are sequential. First, the team will gather qualitative insights through semi-structured interviews at 5 primary care sites. This will help us to refine an organizational assessment survey focusing on service design features likely to impact patient experience and other utilization indicators.

This optimized survey will be given to the HPACTs lead nurse and/or prescribing provider at the same 29 HPACTS from which our Veteran cohort is drawn. We will then perform analysis to compare satisfaction scores for HPACTs on the presences or absence of each potentially relevant HPACT service feature.

FINDINGS/RESULTS:
Interim/Preliminary analysis of administrative data show that Veterans using HPACTs significantly differ from homeless-experienced mainstream primary care Veterans for indicators of social vulnerability (e.g. income, marital status), addiction diagnoses, and some mental health diagnoses, but not in regard to medical diagnoses or ER/Hospital utilization.

Survey data collection will be completed in September 2018. However, in response to national concerns, we adjusted survey content to capture data on overdoses and conducted an interim incidence analysis. Of 1,386 respondents (as of May 2018), 94 (6.9%) homeless-experienced veterans reported personal experience of substance overdose. Among these, alcohol (57%), cocaine (18%), and opioids (18%) were the most common substances attributed to an overdose event. Further analysis of the survey cohort is pending completion of data collection.

Among 21 surveyed HPACTs (target 29), we find differences in range of services, leadership support, and service access. There are striking contrasts in service accessibility; 42% reported they would not likely attend to a walk-in patient near the end of the day if they had a non-emergent need. We found challenges in capacity to coordinate/integrate service. While 71% of HPACTs reported mental health service onsite, only 19% had addiction treatment within the HPACT (fully 10% reported it was neither within the HPACT nor within brief walking distance). A full 24% reported that major medical specialty services were not available within the HPACT or within brief walking distance, and 24% reported similar inaccessibility of a pharmacy. However, 100% reported social work services within the HPACT (86%) or within brief walking distance (14%).

IMPACT:
The study team has presented qualitative findings and preliminary quantitative results at several regional and national scientific conferences.

Evidence from this study will help to guide the future of primary care delivery for homeless-experienced patients within VA, and in non-VA Federally Qualified Health Centers.

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External Links for this Project

NIH Reporter

Grant Number: I01HX001900-01A1
Link: https://reporter.nih.gov/project-details/9086772

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PUBLICATIONS:

Journal Articles

1. Kertesz SG, DeRussy AJ, Riggs KR, Hoge AE, Varley AL, Montgomery AE, Austin EL, Blosnich JR, Jones AL, Gabrielian SE, Gelberg L, Gordon AJ, Richman JS. Characteristics Associated With Unsheltered Status Among Veterans. American journal of preventive medicine. 2021 Sep 1; 61(3):357-368. [view]
2. Kertesz SG, deRussy AJ, Kim YI, Hoge AE, Austin EL, Gordon AJ, Gelberg L, Gabrielian SE, Riggs KR, Blosnich JR, Montgomery AE, Holmes SK, Varley AL, Pollio DE, Gundlapalli AV, Jones AL. Comparison of Patient Experience Between Primary Care Settings Tailored for Homeless Clientele and Mainstream Care Settings. Medical care. 2021 Jun 1; 59(6):495-503. [view]
3. Gabrielian S, Jones AL, Hoge AE, deRussy AJ, Kim YI, Montgomery AE, Blosnich JR, Gordon AJ, Gelberg L, Austin EL, Pollio D, Holmes SK, Varley AL, Kertesz SG. Enhancing Primary Care Experiences for Homeless Patients with Serious Mental Illness: Results from a National Survey. Journal of primary care & community health. 2021 Jan 1; 12:2150132721993654. [view]
4. Varley AL, Montgomery AE, Steward J, Stringfellow E, Austin EL, Gordon AJ, Pollio D, deRussy A, Hoge A, Gelberg L, Riggs K, Kim TW, Rubens SL, Kertesz SG. Exploring Quality of Primary Care for Patients Who Experience Homelessness and the Clinicians Who Serve Them: What Are Their Aspirations?. Qualitative Health Research. 2020 May 1; 30(6):865-879. [view]
5. Owens T, Ewing D, Devera M, Shrestha S, Capone-Newton P, Kopelson K, Altman L, Gelberg L. Housing For Health in the Veterans Affairs Greater Los Angeles Tent Community. Annals of Family Medicine. 2022 May 1; 20(3):281. [view]
6. deRussy AJ, Jones AL, Austin EL, Gordon AJ, Gelberg L, Gabrielian SE, Riggs KR, Blosnich JR, Montgomery AE, Holmes SK, Varley AL, Hoge AE, Kertesz SG. Insights for Conducting Large-Scale Surveys with Veterans Who Have Experienced Homelessness. Journal of social distress and the homeless. 2021 Dec 28; 32(1):123-134. [view]
7. Jones AL, Gelberg L, deRussy AJ, Varley AL, Riggs KR, Gordon AJ, Kertesz SG. Low Uptake of Secure Messaging Among Veterans With Experiences of Homelessness and Substance Use Disorders. Journal of addiction medicine. 2021 Nov 1; 15(6):508-511. [view]
8. Jones AL, Gordon AJ, Gabrielian SE, Montgomery AE, Blosnich JR, Varley AL, deRussy AJ, Austin EL, Hoge AE, Kim YI, Gelberg L, Kertesz SG. Perceptions of Care Coordination Among Homeless Veterans Receiving Medical Care in the Veterans Health Administration and Community Care Settings: Results From a National Survey. Medical care. 2021 Jun 1; 59(6):504-512. [view]
9. Riggs KR, Hoge AE, DeRussy AJ, Montgomery AE, Holmes SK, Austin EL, Pollio DE, Kim YI, Varley AL, Gelberg L, Gabrielian SE, Blosnich JR, Merlin J, Gundlapalli AV, Jones AL, Gordon AJ, Kertesz SG. Prevalence of and Risk Factors Associated With Nonfatal Overdose Among Veterans Who Have Experienced Homelessness. JAMA Network Open. 2020 Mar 2; 3(3):e201190. [view]
10. Riggs KR, Hoge AE, DeRussy AJ, Montgomery AR, Holmes SK, Austin EL, Pollio DE, Kim Y, Varley AL, Gelberg L, Gabrielian SE, Blosnich JR, Merlin J, Gundlapalli AV, Jones AL, Gordon AJ, Kertesz SG. Prevalence of Non-Fatal Overdose Among Homeless-Experienced Veterans. JAMA Network Open. 2020 Mar 17; 3(3):e201190. [view]
11. Holliday R, Liu S, Brenner LA, Monteith LL, Cappelletti MM, Blosnich JR, Brostow DP, Gelberg L, Hooshyar D, Koget J, McInnes DK, Montgomery AE, O'Brien R, Rosenheck RA, Strickland S, Workman GM, Tsai J. Preventing Suicide Among Homeless Veterans: A Consensus Statement by the Veterans Affairs Suicide Prevention Among Veterans Experiencing Homelessness Workgroup. Medical care. 2021 Apr 1; 59(Suppl 2):S103-S105. [view]
12. Jones AL, Kertesz SG, Hausmann LRM, Mor MK, Suo Y, Pettey WBP, Schaefer JH, Gundlapalli AV, Gordon AJ. Primary care experiences of veterans with opioid use disorder in the Veterans Health Administration. Journal of substance abuse treatment. 2020 Jun 1; 113:107996. [view]
13. Jones AL, Hausmann LRM, Kertesz SG, Suo Y, Cashy JP, Mor MK, Pettey WBP, Schaefer JH, Gordon AJ, Gundlapalli AV. Providing Positive Primary Care Experiences for Homeless Veterans Through Tailored Medical Homes: The Veterans Health Administration's Homeless Patient Aligned Care Teams. Medical care. 2019 Apr 1; 57(4):270-278. [view]
14. Riggs KR, DeRussy AJ, Leisch L, Shover CL, Bohnert ASB, Hoge AE, Montgomery AE, Varley AL, Jones AL, Gordon AJ, Kertesz SG. Sensitivity of health records for self-reported nonfatal drug and alcohol overdose. The American journal on addictions. 2022 Nov 1; 31(6):517-522. [view]
15. Stringfellow EJ, Kim TW, Gordon AJ, Pollio DE, Grucza RA, Austin EL, Johnson NK, Kertesz SG. Substance use among persons with homeless experience in primary care. Substance Abuse. 2016 Oct 1; 37(4):534-541. [view]
16. Nelson RE, Montgomery AE, Suo Y, Cook J, Pettey W, Gundlapalli A, Greene T, Evans W, Gelberg L, Kertesz SG, Tsai J, Byrne TH. Temporary Financial Assistance Decreased Health Care Costs For Veterans Experiencing Housing Instability. Health affairs (Project Hope). 2021 May 1; 40(5):820-828. [view]
17. Varley AL, Hoge A, Riggs KR, deRussy A, Jones AL, Austin EL, Gabrielian S, Gelberg L, Gordon AJ, Blosnich JR, Montgomery AE, Kertesz SG. What do Veterans with homeless experience want us to know that we are not asking? A qualitative content analysis of comments from a national survey of healthcare experience. Health & Social Care in The Community. 2022 Nov 1; 30(6):e5027-e5037. [view]

DRA: Health Systems
DRE: Treatment - Comparative Effectiveness
Keywords: Homeless, Organizational Structure, Utilization
MeSH Terms: none