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IAA 07-069 – HSR&D Study

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IAA 07-069
Primary Care Quality and Service Customization for the Homeless
Stefan G Kertesz MD MSc
Birmingham VA Medical Center, Birmingham, AL
Birmingham, AL
Funding Period: September 2008 - August 2012

BACKGROUND/RATIONALE:
While the VA has in many areas surpassed mainstream health systems in improving quality or reducing disparities, some reports from the 1990s suggested VA had not met with similar success in assuring primary care access to homeless veterans. Conversely some studies from organizations that tailor primary care services for the homeless suggest that patient-level outcomes are improved in regard to appointment attendance, reductions in some hospital admissions, and improvements in some diseases. The question of how best to align primary care services for the homeless has drawn attention as the Veterans Health Administration recently initiated a 32-site program in tailored primary care. This team sought to assess whether the patient experience was superior in primary care service settings tailored to homeless primary care (tailoring includes aspects of mission, staffing, service location, training and data systems) compared to settings where such tailoring is less prominent or absent. Although numerous patient-reported measures of care exist, none were developed for the unique concerns of persons who have been homeless. Thus, this study first developed a psychometrically valid measure of the primary care experience appropriate to the population, the Primary Care Quality-Homeless (PCQ-H) survey. We then assessed whether ratings of care were superior in two settings that tailor primary care for the homeless, compared to three where such tailoring was less present or absent.

OBJECTIVE(S):
Objective 1: To develop an understanding of the major aspirations for the primary care of homeless patients, as voiced by the patients themselves and experts in their care.
Objective 2: To develop a psychometrically valid survey to assess primary care quality from the perspective of homeless-experienced patients.
Objective 3. To compare primary care quality across 5 locations differing substantively in regard to the organization and delivery of primary care services for persons who have been homeless. We tested this hypothesis: homeless-experienced patients rate primary care more highly when it is obtained in a setting where services are explicitly tailored to the homeless population.

METHODS:
Qualitative interviews were necessary to properly draft a new, psychometrically valid patient survey, the Primary Care Quality-Homeless (PCQ-H) tool. To narrow interview focus to constructs of greatest relevance, 26 homeless-experienced patients and 12 expert providers were asked to prioritize aspects of quality drawn from 2 major reports from the Institute of Medicine, using a cardsort exercise. The resulting 8 constructs were then explored through interviews with 36 homeless-experienced patients (in Birmingham and Boston) and 22 experts in their care. Based on coding of interviews, the team developed a preliminary 78-item survey (PCQ-H version 0), administered to 601 randomly selected patients across 5 organizational settings. These included three VA facilities that did not tailor primary care for the homeless, one tailored VA program, and a 26-year old non-VA primary care program for homeless individuals recognized as a national exemplar. A random sample of homeless-experienced primary care patients was sought through random selection from medical record systems. The 78-item PCQ-H version 0 was administered as part of a battery including measures of other patient characteristics important either to instrument validation analysis or for purposes of casemix control required for statistical comparison of the 5 sites under study.
Analyses occurred in two phases. Phase 1 applied elements of classical psychometrics, confirmatory factor analysis and Item Response Theory to identify a subset of items having high informational value relative to the scales of interest. Phase 2 involved comparison of mean scale scores across sites to test the hypothesis that patients would rate care more highly when obtained from sites that tailor care for homeless clients. This analysis compared continuous scores and a categorical indicator of an unfavorable experience, defined as falling into the lowest tertile of scores across all sites.

FINDINGS/RESULTS:
Qualitative analyses under Objective 1 yielded a large number of themes of special concern to homeless-experienced primary care patients. As one example, patient participants offered thoughtful reservations concerning the notion promulgated by the Institute of Medicine that patients should have "control" in their care. A voice in care, while sharing control, was a favored motif. Cardinal concerns included trust and respect, and responsiveness of caregivers to certain needs unique to the homeless condition.
Under Objective 2, we arrived at a 33-item instrument with a 4-scale solution comprised of Patient-Clinician Relationship (13 items), Cooperation among clinicians (3 items), Accessibility/Coordination (11 items) and Homeless-Specific Needs (4 items). Collectively these are termed Primary Care Quality-Homeless (PCQ-H) scales. These 4 scales met study criteria for convergent validity, divergent validity and internal reliability.
Site comparisons (Objective 3) are framed in terms of a 4-point scale (higher is better) where the options in response to an item (e.g. "If my doctor and I were to disagree about something related to my care, we could work it out") were Strongly Disagree, Disagree, Agree and Strongly Agree. Across all participants, mean scores fell between 2.5 and 3.5 (generally, participants offered moderate agreement with favorably-worded items), with standard deviations of 0.4-0.5. Scores were lowest for perceptions of cooperation among caregivers. Comparing sites,the highly-tailored non-VA site scored higher than all others, significantly so for Patient-Clinician Relationship (p<0.001), Cooperation (p=0.004), and nearly significantly so for Access/Coordination (p=0.055), but not so for Homeless Specific Needs (0.22). When analyses were restricted to persons reporting Poor or Fair Health (n=256), there was a far greater magnitude in the difference between the highly-tailored non-VA site and the non-tailored VA sites (differences ranged between 1/4 and 1 full standard deviation, all p-values significant <0.05). In general the tailored VA site performed similarly or slightly better than the non-tailored VA sites. When analyses focused on the percentage of individuals with lowest-tertile scores, the differences were large. In absolute terms, at the tailored non-VA site, no more than 1/3 and typically just 20-25% of patients had scores in the lowest tertile. By contrast, at the non-tailored sites, the percentage with lowest-tertile scores was routinely 10%-30% (in absolute terms) higher, a difference that was significant for all 4 measured scales (all p<0.01).
These results support the hypothesis of this study. Homeless-experienced patients rate their primary care more highly in settings that have instituted homeless-tailored primary care through service modifications including outreach/shelter care, specially recruited and trained staff, a homeless-specific identity, and inclusion of formerly homeless persons in governance roles. Additionally, we found that patients were more likely to give unfavorable ratings in regard to cooperation among their caregivers than in regard to other aspects of care, and that the problems with "Cooperation" among caregivers stood out most prominently at all sites we studied.

IMPACT:
The Secretary has declared ending veteran homeless a cardinal priority at this time. VA's recent 18-month, 32-site deployment of homeless-tailored Patient Aligned Care Teams is a potential asset to this effort. The current Homeless PACT initiative will continue only if outcomes appear to suggest it results in superior experiences for patients. Our results support the validity of the PCQ-H instrument developed as part of this study. Because it is deeply grounded in homeless patient experiences we believe it should be advanced for approval for use in clinical settings. Such advancement will likely require collaboration with VA Central Office, and other agencies with authority or stakeholder interest in patient surveys including the Office of Management and Budget and the Bureau of Primary Health Care within the US Department of Health and Human Services. The results of our analysis do highlight that homeless patients' primary care patient experiences are measurable and amenable to enhancement through proper service design.

PUBLICATIONS:

Journal Articles

  1. 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.
  2. Steward J, Holt CL, Pollio DE, Austin EL, Johnson N, Gordon AJ, Kertesz SG. Priorities in the Primary Care of Persons Experiencing Homelessness: Convergence and Divergence in the Views of Patients and Provider/Experts. Patient preference and adherence. 2016 Feb 12; 10(1):153-8.
  3. Chrystal JG, Glover DL, Young AS, Whelan F, Austin EL, Johnson NK, Pollio DE, Holt CL, Stringfellow E, Gordon AJ, Kim TA, Daigle SG, Steward JL, Kertesz SG. Experience of primary care among homeless individuals with mental health conditions. PLoS ONE. 2015 Feb 6; 10(2):e0117395.
  4. Kertesz SG, Pollio DE, Jones RN, Steward J, Stringfellow EJ, Gordon AJ, Johnson NK, Kim TA, Daigle SG, Austin EL, Young AS, Chrystal JG, Davis LL, Roth DL, Holt CL. Development of the Primary Care Quality-Homeless (PCQ-H) instrument: a practical survey of homeless patients' experiences in primary care. Medical care. 2014 Aug 1; 52(8):734-42.
  5. Kertesz SG, Holt CL, Steward JL, Jones RN, Roth DL, Stringfellow E, Gordon AJ, Kim TW, Austin EL, Henry SR, Kay Johnson N, Shanette Granstaff U, O'Connell JJ, Golden JF, Young AS, Davis LL, Pollio DE. Comparing homeless persons' care experiences in tailored versus nontailored primary care programs. American journal of public health. 2013 Dec 1; 103 Suppl 2:S331-9.
  6. Vijayaraghavan M, Kushel MB, Vittinghoff E, Kertesz S, Jacobs D, Lewis CE, Sidney S, Bibbins-Domingo K. Housing instability and incident hypertension in the CARDIA cohort. Journal of urban health : bulletin of the New York Academy of Medicine. 2013 Jun 1; 90(3):427-41.
  7. Ku BS, Scott KC, Kertesz SG, Pitts SR. Factors associated with use of urban emergency departments by the U.S. homeless population. Public health reports (Washington, D.C. : 1974). 2010 May 1; 125(3):398-405.
  8. Milby JB, Schumacher JE, Wallace D, Vuchinich R, Mennemeyer ST, Kertesz SG. Effects of sustained abstinence among treated substance-abusing homeless persons on housing and employment. American journal of public health. 2010 May 1; 100(5):913-8.
  9. Kertesz SG, Hwang SW, Irwin J, Ritchey FJ, Lagory ME. Rising inability to obtain needed health care among homeless persons in Birmingham, Alabama (1995-2005). Journal of general internal medicine. 2009 Jul 1; 24(7):841-7.
  10. Kertesz SG, Crouch K, Milby JB, Cusimano RE, Schumacher JE. Housing first for homeless persons with active addiction: are we overreaching? The Milbank Quarterly. 2009 Jun 1; 87(2):495-534.
  11. Vuchinich R, Wallace D, Milby JB, Schumacher JE, Mennemeyer S, Kertesz S. Relations between in-treatment and follow-up abstinence among cocaine-dependent homeless persons in three clinical trials. Experimental and clinical psychopharmacology. 2009 Jun 1; 17(3):165-72.
  12. Kertesz SG, Weiner SJ. Housing the chronically homeless: high hopes, complex realities. JAMA : the journal of the American Medical Association. 2009 May 6; 301(17):1822-4.
  13. Wang EA, Pletcher M, Lin F, Vittinghoff E, Kertesz SG, Kiefe CI, Bibbins-Domingo K. Incarceration, incident hypertension, and access to health care: findings from the coronary artery risk development in young adults (CARDIA) study. Archives of internal medicine. 2009 Apr 13; 169(7):687-93.
  14. Kertesz SG, Posner MA, O'Connell JJ, Swain S, Mullins AN, Shwartz M, Ash AS. Post-hospital medical respite care and hospital readmission of homeless persons. Journal of Prevention & Intervention in The Community. 2009 Jan 1; 37(2):129-42.
Magazine/Popular Press Articles

  1. Kertesz SG. Treating the homeless can go beyond medical care. American Medical News. 2009 Mar 2; 52(March 2):1.
Conference Presentations

  1. Glover D, Chrystal J, Young A, Whelan F, Austin E, Johnson-Roe N, Pollio D, Holt C, Stringfellow E, Gordon AJ, Kim T, Daigle S, Steward J, Kertesz S. Specialized healthcare for homeless individuals with mental health conditions. Poster session presented at: AcademyHealth Annual Research Meeting; 2015 Jun 15; Minneapolis, MN.
  2. Gabrielian S, Gordon AJ, Gelberg L, Patel B, Manchanda R, Altman L, Campbell RA, Broyles LM, Conley J, Kertesz S. Building medical homes for homeless Veterans: a comparison of organizational processes and patient characteristics at three Veterans Affairs facilities. Poster session presented at: American Public Health Association Annual Meeting and Exposition; 2013 Nov 6; Boston, MA.
  3. Young AS, Austin E, Kim T, Holt C, Pollio D, Johnson K, Steward J, Gordon A, Stringfellow E, Golden J, Kertesz S. Comparison of tailored and mainstream primary care delivery for homeless persons: A new, validated patient assessment. Paper presented at: American Public Health Association Annual Meeting and Exposition; 2013 Oct 31; San Francisco, CA.
  4. Kertesz S, Gordon AJ, Davis L, Kim T, Golden J. Does a homeless-tailored primary care service model enhance the care experience for homeless patients? Poster session presented at: Association for Medical Education and Research in Substance Abuse Annual Meeting; 2012 Nov 1; Bethesda, MD.
  5. Stallworth V, Mason E, Williams J, Kainaroi A, Gordon AJ, Kertesz SG. Interim analysis: outcomes of co-located mental and medical health provision in medical clinics for homeless individuals. Poster session presented at: Substance Abuse and Mental Health Services Administration Centers for Medicare and Medicaid Services on Medicaid and Mental Health Services Annual Conference; 2012 Aug 1; Washington, DC.
  6. Kertesz SG, Johnson-Roe NK, Steward J, Stringfellow E, Austin EL, Holt C, Gordon AJ, Davis L, Kim T, Pollio DE. Systematic methodology for developing a patient-centered primary care measure for homeless Veterans. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD.
  7. Kertesz SG, Pollio DE, Johnson-Roe KN, Holt C, Steward J, Gordon AJ, Kim TW, Stringfellow E, Austin EL, Golden J, Johnson N, Davis LL. Comparison of tailored versus mainstream primary care delivery for homeless persons: a new, validated patient assessment tool. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2012 May 9; Orlando, FL.
  8. Kertesz SG, Steward J, Johnson NK, Pollio DE, Holt C, Austin EL, Gordon AJ, Stringfellow E, Granstaff U. Comparison of customized versus mainstream primary care for homeless individuals: the primary care quality-homeless survey. Poster session presented at: Southern Regional Societies Annual Meeting; 2012 Feb 10; New Orleans, LA.
  9. Kertesz S, Pollio D, Holt C, Johnson-Roe K, Gordon AJ. Implications of substance abuse for primary care quality of homeless patients. Poster session presented at: Association for Medical Education and Research in Substance Abuse Annual Meeting; 2011 Nov 4; Arlington, VA.
  10. Kertesz SG. Veteran Homelessness: The Mental Health Challenge Within. Paper presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA.
  11. Kertesz SG. Crossing Quality Chasm: Primary Care from the Perspective of Homeless Patients and Their Caregivers. Paper presented at: Society of General Internal Medicine Annual Meeting; 2011 May 4; Phoenix, AZ.
  12. Kertesz SG. Crossing the Primary Care Quality Chasm for Homeless Patients: Understanding the Perspectives of Patients and their Providers. Paper presented at: Society of General Internal Medicine Southern Regional Annual Meeting; 2011 Feb 17; New Orleans, LA.
  13. Steward JL, Berry J, Johnson-Roe NK, Holt C, Pollio D, Safford MM, Kertesz SG. Primary care quality from the perspective of homeless patients, their providers, and the Institute of Medicine: A multidimensional problem. Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 27; Boston, MA.
  14. Kertesz SG. Homelessness, Housing and Health. Paper presented at: University of Alabama at Birmingham Department of Internal Medicine Monthly Grand Rounds; 2010 Mar 24; Birmingham, AL.
  15. Steward J, Johnson-Roe NK, Pollio D, Kertesz SG. Quality of care in homeless patients and their providers. Do priorities differ in veteran and gender status? Paper presented at: AcademyHealth Annual Research Meeting; 2009 Aug 12; Chicago, IL.
  16. Steward J, Johnson-Roe NK, Pollio D, Kertesz SG. Quality of care in homeless patients and their providers. Do priorities differ in veteran and gender status? Paper presented at: University of Alabama at Birmingham Minority Health and Research Center Health Disparities Annual Symposium; 2009 Jul 11; Birmingham, AL.
  17. Steward J, Johnson-Roe NK, Pollio D, Kertesz SG. Quality of care in homeless patients and their providers. Do priorities differ in veterans and gender status? Poster session presented at: University of Alabama School of Medicine Trainee Research Annual Symposium; 2009 Feb 16; Birmingham, AL.
  18. Kertesz SK. Homelessness, Addiction and Housing Interventions: What We Don’t Know So Far. Paper presented at: Institute for Homeless Studies at Camillus House Annual Symposium; 2008 Feb 4; Miami, FL.


DRA: Health Systems
DRE: Treatment - Observational, Technology Development and Assessment
Keywords: Homeless, Organizational issues, Primary care, Quality of Care
MeSH Terms: none