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2019 HSR&D/QUERI National Conference Abstract

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1041 — Homeless Veterans Rate Primary Care More Favorably in Homeless-Tailored Compared to Mainstream Primary Care Clinics: A National Survey

Lead/Presenter: Stefan Kertesz,  Birmingham VA Medical Center
All Authors: Kertesz SG (Birmingham VA Medical Center; University of Alabama at Birmingham School of Medicine, Birmingham, AL), deRussy AJ (Birmingham VA Medical Center, Birmingham, AL), Jones AL (VA Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, UT) Gordon AJ (VA Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, UT) Gelberg L (VA Greater Los Angeles; David Geffen School of Medicine at UCLA, Los Angeles, CA) Austin EL (Birmingham VA Medical Center; University of Alabama at Birmingham School of Public Health, Birmingham, AL) Montgomery AE (Birmingham VA Medical Center; University of Alabama at Birmingham School of Public Health, Birmingham, AL) Hoge AE (Birmingham VA Medical Center, Birmingham, AL) Gabrielian SE (VA Greater Los Angeles; David Geffen School of Medicine at UCLA, Los Angeles, CA) Holmes SK (Birmingham VA Medical Center, Birmingham, AL) Blosnich JR (Pittsburgh VA Medical Center, Pittsburgh, PA) Varley AL (Birmingham VA Medical Center; University of Alabama at Birmingham School of Medicine, Birmingham, AL) Riggs KR (Birmingham VA Medical Center; University of Alabama at Birmingham School of Medicine, Birmingham, AL) Pollio DE (Birmingham VA Medical Center; University of Alabama at Birmingham College of Arts and Sciences, Birmingham, AL) Kim YI (Birmingham VA Medical Center; University of Alabama at Birmingham School of Medicine, Birmingham, AL) Gundlapalli AV (VA Salt Lake City Health Care System; University of Utah School of Medicine, Salt Lake City, UT)

Objectives:
People experiencing homelessness face challenges accessing primary care (PC) and difficulties related to coordination and stigma. In 2012, the Veterans Health Administration (VHA) implemented a patient-centered medical home model for Homeless Experienced Veterans (HEVs): Homeless-Patient Aligned Care Teams (H-PACTs). H-PACTs tailor services with smaller panels, outreach, and support for tangible needs, along with linkage to social services. Some HEVs use H-PACTs and some use Mainstream PC. We compared patient experience in these two service models using a validated patient experience instrument, in the largest survey of HEVs to date.

Methods:
We surveyed a stratified, random sample of HEVs in H-PACTs and Mainstream PC at 26 VA facilities nationally. The 33-item Primary Care Quality-Homeless (PCQ-H) instrument measured Patient-Clinician Relationship, Perceived Cooperation among Caregivers, Accessibility/Coordination, and Homeless-Specific Needs (on a 1-4 scale). We used mixed effect linear regressions to estimate mean differences (H-PACT vs Mainstream) in PCQ-H scores, controlling for demographics, unsheltered status, chronic homelessness, medical condition count, alcohol/drug problems, psychiatric medication, mental distress, social support and chronic pain, adjusting for facility as a random effect.

Results:
Of 14,340 HEVs, 40.2% responded to the survey (comparable to response observed for housed Veterans in other national mailed surveys). Compared to HEVs in Mainstream PC, those in H-PACTs were younger; more often male; had more drug/alcohol problems, lower social support, worse emotional distress, lower income; unsheltered, and chronically homeless. Mean scores for H-PACT were superior to Mainstream PC on all scales (p < 0.001): Patient-Clinician Relationship (3.19 vs 3.08), Cooperation (2.79 vs 2.65), Access/Coordination (3.07 vs 2.95) and Homeless-Specific Needs (3.02 vs 2.84). These differences persisted when controlling for covariates.

Implications:
HEVs in H-PACTs reported better care experiences than HEVs in Mainstream PC despite personal characteristics conveying more vulnerability.

Impacts:
Given VA's commitment to customer service and the prominence of support for at-risk Veterans in VA's 2018-2024 Strategic Plan, this study signals a role for population-tailored PC service design. The survey, the largest among homeless Veterans to date, suggests benefits from tailoring PC through H-PACTs in particular. Identifying which resources, programs, and practices account for this benefit will require careful correlation between program design variation and patient experience. [Funding: IIR15-095]