Abstract
IntroductionAlthough the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a “homeless medical home” initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites. Methods We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services.ResultsMore than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies.ConclusionIntegrating social determinants of health into clinical care can be effective for high-risk homeless veterans.
Highlights
The clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless
Integrating social determinants of health into clinical care can be effective for high-risk homeless veterans
Their diagnostic cost group (DCG)-Index complexity score was 0.96. These findings contrast with those for the overall population enrolled in primary care at Veterans Health Administration (VHA) at the time: average age was 63 years and average DCG-Index complexity score was 0.66
Summary
The clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. One survey of homeless adults found that more than 40% used an emergency department (ED) at least once in the previous year [8]; another study showed that only 7.9% of patients using EDs were homeless, those homeless persons accounted for 54.5% of all ED visits [9]. In this same survey of the homeless, 1 in 4 had been hospitalized in the previous year (1996) [10]. The more unstable the sheltering arrangement (eg, unsheltered street homeless, emergency sheltered homeless), the more likely a homeless person was to use an ED for health care [12]
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