Better Experiences among Homeless Patients with Tailored Primary Care
Experts in the field of homelessness have advocated tailoring primary care service design and delivery for homeless patients. Tailored modifications can include outreach workers to develop relationships outside of traditional settings, primary care services in shelters or on the streets, team-based care, and the co-location of homeless-dedicated primary and mental health providers. However, to date there has been no evaluation of whether efforts to "tailor" service delivery for homeless clients have yielded improved patient experiences. This study compared assessments of recently or currently homeless patients across five settings that varied in their degree of homeless-tailored service design – from none (i.e., "mainstream primary care") to intensive tailoring. The five sites included three mainstream VA primary care settings (Veterans = 312), one homeless-tailored VA clinic (Veterans = 94), and one highly-tailored non-VA Health Care for the Homeless program (participants = 195). Investigators developed and validated a new Primary Care Quality-Homeless (PCQ-H) Survey that consists of four scales: 1) patient-clinician relationship, 2) cooperation among clinicians, 3) accessibility/coordination, and 4) homeless-specific needs. The study analysis also controlled for several variables: patient characteristics, history of homelessness (70% of participants met criteria for chronic homelessness in the prior three years), health status, psychiatric symptoms, and substance use.
- Patients rated their primary care experience more highly when their healthcare was obtained in settings that explicitly tailored services for the homeless population through variations in service design.
- Survey scores at the tailored non-VA site were higher (reflecting more positive experiences with care) than at the three mainstream VA sites. The tailored VA site generally had scores that were either similar to the three mainstream VA sites or somewhat higher, depending on the subscale of interest.
- Adjusting for patient characteristics, differences remained significant for scales assessing the patient-clinician relationship and perceptions of cooperation among providers. An unfavorable experience was a 1.5 to 2 times more common in domains of patient-clinician relationship, cooperation, and accessibility/coordination for the mainstream VA sites compared to the tailored non-VA site, with the tailored VA site attaining intermediate results.
- Study participants were not randomly assigned to clinics.
- By studying four VA sites and one Massachusetts health center, few participants in the study lacked finanical coverage for care, thus survey questions on financial access may be less informative.
Although one recent single-center VA study suggested possible improvements in some aspects of care with homeless-tailored approaches, there has been no comparative study of tailored primary care. As VHA initiated 37 homeless-tailored PACTs in 2012, findings from this study will help inform decisions regarding continuation or expansion.
This study was supported by HSR&D (IAA 07-069). Dr. Kertesz is part of the Birmingham VA Medical Center.
Kertesz S, Holt C, Steward J, et al. Comparing Homeless Persons' Care Experiences in Tailored Versus Non-Tailored Primary Care Programs. American Journal of Public Health December 2013;103(Suppl 2):S331-39.