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?
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.
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.
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%).
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.
- 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.