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SDR 11-230 – HSR&D Study

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SDR 11-230
Aligning Resources to Care for Homeless Veterans (ARCH)
Thomas P O'Toole MD
Providence VA Medical Center, Providence, RI
Providence, RI
Funding Period: November 2011 - October 2015

BACKGROUND/RATIONALE:
A high priority goal for VA is to prevent and end Veteran homelessness. To accomplish this goal, VHA will need to have access to permanent supportive housing, treatment models that promote the use of integrated health care services and increase access to benefits and employment opportunities so Veterans can rapidly exit homelessness and integrate back into their families and the community. This also needs to include well designed primary care, mental health care, and specifically primary care tailored to the needs of homeless Veterans. Another priority of VA is to redesign healthcare delivery within VHA with the implementation of the Patient Aligned Care Team (PACT). This transformative initiative is intended to provide patient-centered care that is team-based, comprehensive and with enhanced access and improved coordination. PACT allows patients to have a more active role in their health care and is associated with increased quality improvement, patient satisfaction, and a decrease in costs due to fewer hospital visits and readmissions.

Primary care, specifically primary care directed to homeless Veterans, represents an opportunity to engage individuals in care, address unmet health needs, and facilitate receipt of services necessary to exit homelessness. However, it is unclear what the best and most cost-efficient approach is to providing this care. Past research suggests two alternative approaches to organizing and delivering primary care to homeless Veterans: 1) structurally realigned and organized care and 2) embedded peer mentoring.


OBJECTIVE(S):
The overall purpose of our research is to compare and contrast outcomes from 4 different adaptations and combinations of primary care delivery to homeless Veterans within the construct of the Patient Aligned Care Team (PACT) model for primary care. Utilization patterns of Veterans enrolled in VA PACT teams were compared to utilization patterns among Veterans enrolled in homeless-tailored PACT teams (H-PACT).

METHODS:
We employed Patient Aligned Care Teams located in 4 different settings at 3 different medical facilities in this study. The sites selected provided us the opportunity to assess the intervention across a spectrum of urban, medical center- and CBOC-based settings in the Northeast and on the West Coast.

This was a mixed methods study design comprised of four interrelated substudies:

Substudy #1- Two multi-center Randomized Controlled Trials: The first compared PACT to PACT+Peer Support (PACT+P); and the second compared Homeless-oriented PACT (H-PACT) to H-PACT+Peer Support (H-PACT+P). Selection into the PACT-based trial or the H-PACT-based trial was conditional on the site from which the participant was recruited, reflecting the established care processes already developed at the study sites. Within each sites we conducted a 1:1 RCT of embedded peer support.

Substudy #2- Qualitative Study: We conducted a qualitative study using focus groups of study participants from each of the intervention arms to assess perceptions of care, treatment engagement, and satisfaction within each approach. These findings were triangulated with survey data and conditional logistic regression modeling to address the question of how each model is perceived by those receiving care within it and what outcomes can be ascribed to each care approach.

Substudy #3- Cost-Utilization Analysis Study: We conducted a cost-utilization analysis assessing cost offsets using CPRS, DSS, and PCMM labor mapping data to develop cost models for each care approach. Findings from this inform policy makers as to the implementation and management costs associated with observed outcomes noted in Substudy #1.

Substudy #4 - Comparison of homeless Veterans' utilization rates at VA medical facilities that had an H-PACT to those facilities that did not have an H-PACT. The primary outcome was emergency department utilization by homeless veterans in the different care models using Corporate Data Warehouse files to inform the secondary data analysis.

Study outcomes include: clinical services utilization (primary care, specialty care, emergency department, mental health, substance abuse, and inpatient care, including missed appointments); chronic disease management performance measures; patient satisfaction and therapeutic alliance; and participation in VA-sponsored homeless services. The qualitative focus group study and cost-utilization analysis will complement findings from the RCT, providing in-depth data on patient perspectives and further context to explain the quantitative results and inform policy decisions related to optimal implementation strategies to end Veteran homelessness.




FINDINGS/RESULTS:
When comparing PACT to H-PACT enrolled Veterans, over the 12 month study period, patients in the H-PACT arm had significantly more primary care visits (5.1 (SD 4.1) vs. 3.6 (SD 2.8); p<0.01) and social work visits (4.6 (SD 3.7) vs. 2.7 (SD 2.1); p<0.01) than patients enrolled in a PACT care model. Homeless Veterans in H-PACTs were hospitalized less often than those in PACTs (23.1% vs. 35.4%; p=0.04).

In addressing which Veterans may benefit from a peer mentor (RCT), using qualitative data, 15 of the 23 (65%) focus group participants were classified as having perceived a benefit from having a peer mentor.

Economic and cost data also examine PACT v. H-PACT-enrolled Veterans. Data comparing total average costs 6 months after randomization (including non-VA costs) indicate (mean/SD) $37,415 ($36,872) per PACT Veteran v. $28,036 ($27,207) per H-PACT-enrolled Veteran (p=0.04). This was mainly driven by fewer hospitalizations in VA and the community. Mental health costs between the groups was also significantly lower (p=0.03) with PACT costs (mean/SD) totaling $4,770 ($5,084) v. H-PACT costs per patient totaling $3,378 ($4,759). The costs associated with peer mentors was also explored to see whether patients assigned to peer mentors had lower health care costs and utilization compared to patients in usual care in 6-months prior to and 6-months after randomization. The total 6-month cost of treating peer mentor patients was $17,764, while the total cost for usual care was $16,852 per patient. These data were presented at AcademyHealth by Dr. Yoon in 2015.





IMPACT:
Finding from this study have directly informed national policy and implementation of the VA Homeless PACT program, now at over 60 VAs across the country. Results continue to inform clinical operations and VACO.

PUBLICATIONS:

Journal Articles

  1. Yoon J, Lo J, Gehlert E, Johnson EE, O'Toole TP. Homeless Veterans' Use of Peer Mentors and Effects on Costs and Utilization in VA Clinics. Psychiatric services (Washington, D.C.). 2017 Jun 1; 68(6):628-631.
  2. Resnik L, Ekerholm S, Johnson EE, Ellison ML, O'Toole TP. Which Homeless Veterans Benefit From a Peer Mentor and How?. Journal of Clinical Psychology. 2017 Sep 1; 73(9):1027-1047.
Conference Presentations

  1. O'Toole TP, Yoon J, Lo J, Cowgill E. Homeless Patient Use of Peer Mentors in VA Clinics. Paper presented at: AcademyHealth Annual Research Meeting; 2015 Jun 15; Minneapolis, MN.


DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Homeless, Social Support
MeSH Terms: none