Homeless Population-tailored Patient-Aligned Care Team Can Reduce Acute Care Services and Healthcare Costs

BACKGROUND:
Healthcare for socially disadvantaged, high-risk, or high-need patients, such as homeless persons, is often defined by high rates of acute care service use and poor clinical outcomes. The development of patient-centered medical homes (PCMHs) is one approach to care delivery that has received increased attention recently, and PCMH models of care have been adopted in health systems with generally positive results. VA's model is called the Patient-aligned Care Team (PACT). This multicenter, single-blinded trial compared healthcare service use and cost outcomes among homeless Veterans enrolled in a traditional (not tailored to a homeless population) PACT (n=83) with outcomes among Veterans enrolled in a homeless population–tailored H-PACT (n=183). Veterans in this study included those who were living outdoors, and those staying in an emergency shelter or transitional housing. Using VA data (administrative and manual chart review), investigators examined health services use, cost, and patient satisfaction from June 2012 to January 2014. Investigators also administered questionnaires assessing Veterans' demographics, sheltering status, number of months homeless, cash on hand, as well as self-reported medical and mental health conditions.

FINDINGS:

• Annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036), and most cost savings came from fewer VA and non-VA hospitalizations.
• A significantly greater percentage of Veterans in the PACT arm compared to H-PACT were hospitalized for any cause (35% vs 23%), had a mental health–related ED visit (48% vs 34%), or attended group therapy (54% vs 40%). In addition, there were significant differences in primary care provider–specific visits (H-PACT 5 vs PACT 4 visits), mental healthcare visits (H-PACT 9 vs PACT 13 visits), 30-day prescription drug fills (H-PACT 41 vs PACT 59 fills), and use of group therapy (H-PACT 40% vs PACT 54%).
• Overall, almost 86% of Veterans reported at least one medical condition, and 78% reported at least one mental health condition. The most common medical conditions were: arthritis/chronic pain (43%), hypertension (33%), hepatitis/cirrhosis (25%), and emphysema/ asthma/COPD (24%). The most common mental health conditions were: depression (69%), anxiety (63%), and PTSD (51%).

IMPLICATIONS:

• A population-tailored medical home approach for socially disadvantaged populations can both reduce reliance on acute care service use and generate significant cost savings.

LIMITATIONS:

• Unmeasured differences between Veterans in the PACT versus H-PACT groups might have been controlled for in a randomized controlled study design.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (SDR 11-230). Dr. O'Toole is part of HSR&D's Center of Innovation in Long-term Services and Supports for Vulnerable Veterans, Providence, RI.

O’Toole T, Johnson E, Borgia M, et al. Population-tailored Care for Homeless Veterans and Acute Care Use, Cost, and Satisfaction: A Prospective Quasi-experimental Trial. Preventing Chronic Disease. February 15, 2018;15:E23.