A national evaluation of homeless and nonhomeless veterans' experiences with primary care

Small Observational Study of Battlefield Acupuncture for Homeless-Experienced Veterans

Background: Homeless-experienced veterans (HEVs) are an important but challenging group to care for in the U.S. Department of Veterans Affairs health care system, and there are opportunities to examine the potential of integrative and complementary medicine approaches. Methods: This observational study enrolled 33 HEVs in a one-group observational, prospective study of Battlefield Acupuncture (BFA) with a monthly follow-up for 3 months after initiating BFA. Results: Linear growth curve analyses revealed a significant improvement in overall pain scores and scores on the effects of pain on activity level, mood, and stress. Conclusions: These preliminary findings suggest the potential of BFA to improve pain among HEVs as an area for further research.

Implementing evidence-based practices to improve primary care for high-risk patients: study protocol for the VA high-RIsk VETerans (RIVET) type III effectiveness-implementation trial

BACKGROUND

Patients with significant multimorbidity and other factors that make healthcare challenging to access and coordinate are at high risk for poor health outcomes. Although most (93%) of Veterans' Health Administration (VHA) patients at high risk for hospitalization or death ("high-risk Veterans") are primarily managed by primary care teams, few of these teams have implemented evidence-based practices (EBPs) known to improve outcomes for the high-risk patient population's complex healthcare issues. Effective implementation strategies could increase adoption of these EBPs in primary care; however, the most effective implementation strategies to increase evidence-based care for high-risk patients are unknown. The high-RIsk VETerans (RIVET) Quality Enhancement Research Initiative (QUERI) will compare two variants of Evidence-Based Quality Improvement (EBQI) strategies to implement two distinct EBPs for high-risk Veterans: individual coaching (EBQI-IC; tailored training with individual implementation sites to meet site-specific needs) versus learning collaborative (EBQI-LC; implementation sites trained in groups to encourage collaboration among sites). One EBP, Comprehensive Assessment and Care Planning (CACP), guides teams in addressing patients' cognitive, functional, and social needs through a comprehensive care plan. The other EBP, Medication Adherence Assessment (MAA), addresses common challenges to medication adherence using a patient-centered approach.

METHODS

We will recruit and randomize 16 sites to either EBQI-IC or EBQI-LC to implement one of the EBPs, chosen by the site. Each site will have a site champion (front-line staff) who will participate in 18 months of EBQI facilitation.

ANALYSIS

We will use a mixed-methods type 3 hybrid Effectiveness-Implementation trial to test EBQI-IC versus EBQI-LC versus usual care using a Concurrent Stepped Wedge design. We will use the Practical, Robust Implementation and Sustainability Model (PRISM) framework to compare and evaluate Reach, Effectiveness, Adoption, Implementation, and costs. We will then assess the maintenance/sustainment and spread of both EBPs in primary care after the 18-month implementation period. Our primary outcome will be Reach, measured by the percentage of eligible high-risk patients who received the EBP.

DISCUSSION

Our study will identify which implementation strategy is most effective overall, and under various contexts, accounting for unique barriers, facilitators, EBP characteristics, and adaptations. Ultimately this study will identify ways for primary care clinics and teams to choose implementation strategies that can improve care and outcomes for patients with complex healthcare needs.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05050643. Registered September 9th, 2021, https://clinicaltrials.gov/study/NCT05050643 PROTOCOL VERSION: This protocol is Version 1.0 which was created on 6/3/2020.

A scoping review examining patient experience and what matters to people experiencing homelessness when seeking healthcare

BACKGROUND

Homelessness is associated with significant health disparities. Conventional health services often fail to address the unique needs and lived experience of homeless individuals and fail to include participatory design when planning health services. This scoping review aimed to examine areas of patient experience that are most frequently reported by people experiencing homelessness when seeking and receiving healthcare, and to identify existing surveys used to measure patient experience for this cohort.

METHODS

A scoping review was undertaken reported according to the PRISMA-ScR 2020 Statement. Databases were searched on 1 December 2022: MEDLINE, EMBASE, APA PsychINFO and CINAHL. Included studies focused on people experiencing homelessness, healthcare services and patient experience, primary research, published in English from 2010. Qualitative papers and findings were extracted and synthesized against a modified framework based on the National Institute for Health and Care Excellence guidelines for care for people experiencing homelessness, the Institute of Medicine Framework and Lachman's multidimensional quality model. People with lived experience of homelessness were employed as part of the research team.

RESULTS

Thirty-two studies were included. Of these, 22 were qualitative, seven quantitative and three mixed methods, from the United States of America (n = 17), United Kingdom (n = 5), Australia (n = 5) and Canada (n = 4). Health services ranged from primary healthcare to outpatient management, acute care, emergency care and hospital based healthcare. In qualitative papers, the domains of 'accessible and timely', 'person-centred', and values of 'dignity and respect' and 'kindness with compassion' were most prevalent. Among the three patient experience surveys identified, 'accessible and timely' and 'person-centred' were the most frequent domains. The least frequently highlighted domains and values were 'equitable' and 'holistic'. No questions addressed the 'safety' domain.

CONCLUSIONS

The Primary Care Quality-Homeless questionnaire best reflected the priorities for healthcare provision that were highlighted in the qualitative studies of people experiencing homelessness. The most frequently cited domains and values that people experiencing homelessness expressed as important when seeking healthcare were reflected in each of the three survey tools to varying degrees. Findings suggest that the principles of 'Kindness and compassion' require further emphasis when seeking feedback on healthcare experiences and the domains of 'safety', 'equitable', and 'efficiency' are not adequately represented in existing patient experience surveys.

Community-Based Wound Care Programs for Unhoused Individuals

Wound care management for unhoused individuals is challenging due to the lack of healthcare infrastructure to handle the unique needs of this population. Therefore, we aimed to obtain insights for best practices and to establish a care clinic that is low threshold, community-based and meets the needs of unhoused people. We employed two approaches: (1) conduct a targeted narrative review of the literature of existing or proposed community-based program models that can address the wound care needs of unhoused individuals, and (2) assess cost-effectiveness and describe the results of a survey administered to unhoused clients and their health care providers at a community-based wound care program in Honolulu, Hawai'i. The literature search and screening yielded 11 articles relevant to the topic. Per the literature, existing community-based healthcare programs were successful when: (1) wound care services were incorporated into a broader social/health program, (2) cost-effective, and (3) comprehensive services were provided. Survey results in Honolulu found that the wound care program matched the needs of the targeted population and was cost-effective. Difficulty in following clients until wound closure and the sustainability of the program, particularly the lack of insurance reimbursement for street-based services, were perceived challenges. Additionally, the lack of insurance reimbursement for street-based wound care services continues to impact sustainability. Community-based programs can be successful in addressing the wound care needs of unhoused individuals if they address complex fundamental issues. This paper highlights existing gaps in logistics and policies that must be addressed to meet the specific medical needs of these vulnerable individuals.

Bringing Lived Experience to Research on Health and Homelessness: Perspectives of Researchers and Lived Experience Partners

Improving health and healthcare for people experiencing homelessness (PEH) has become a national research priority. It is critical for research related to homelessness to be guided by input from PEH themselves. We are a group of researchers and individuals who have personally experienced homelessness collaborating on a study focused on homelessness and housing. In this Fresh Focus, we describe our partnership, lessons learned from our work together, what we have gained from our collaboration, and considerations for future homelessness research-lived experience partnerships.

Trends in Health Service Utilization After Enrollment in an Interdisciplinary Primary Care Clinic for Veterans with Addiction, Social Determinants of Health, or Other Vulnerabilities

BACKGROUND

Models of interdisciplinary primary care (IPC) may improve upon traditional primary care approaches in addressing addiction and social determinants of health.

OBJECTIVE

To compare the trends in health care utilization in the year before and after enrollment in an IPC clinic model, and explore the variations in temporal patterns for patients with histories of high emergency department (ED) use, homelessness, and/or substance use disorders (SUDs).

DESIGN AND PARTICIPANTS

Interrupted time series study of utilization among IPC patients.

MAIN MEASURES

Quarterly ED, inpatient, primary care, and behavioral health visits were abstracted from administrative data before and after IPC enrollment. Negative binomial segmented regressions estimated changes in health care utilization over time. We used interactions to test for statistical differences in temporal patterns for IPC subgroups.

RESULTS

Among IPC patients (n=994), enrollment was associated with overall reductions in ED, inpatient, and behavioral health visits (p's<0.001) and increases in primary care (p's<0.001). Temporal patterns of ED visits, hospitalizations, and behavioral health differed across IPC subgroups (interaction p's<0.001). For those with histories of high ED use (n=265), ED, inpatient, and behavioral health visits decreased after enrollment (level change incidence rate ratios [IRRs]=0.57-0.69) and continued to decline over time (post-enrollment IRRs=0.80-0.88). Among other patients with homeless experiences (n=123), there were initial declines in hospitalizations (IRR=0.33) and overall declines in behavioral health visits (level change and post-enrollment IRRs=0.46-0.94). Other patients with SUDs had initial declines in hospitalizations (IRR=0.46), and post-enrollment declines in rates of specialty SUD visits (IRR=0.92). For all patients, primary care visits initially increased (level change IIRs=2.47-1.34) then gradually declined (post-enrollment IRRs=0.92-0.92).

CONCLUSIONS

An IPC model of care reduces acute care and behavioral health service use, particularly for patients with historically high ED use. IPC models may improve patient and system outcomes of vulnerable patient populations with social, clinical, and addiction morbidities.

Service use and barriers to care among homeless veterans: Results from the National Veteran Homeless and Other Poverty Experiences (NV-HOPE) study

The objective of this study was to examine type of services U.S. veterans seek when they experience homelessness, characteristics associated with service use, and reasons for not using services. Data from a 2021 nationally representative survey of 1004 low-income U.S. veterans were analyzed with descriptive and multivariable analyses. One-quarter of low-income U.S. veterans with experiences of homelessness reported using homeless services while they were homeless and about 27% reported using U.S. Department of Veterans Affairs (VA) healthcare or benefits while homeless. Black and Hispanic veterans were more likely to use both homeless services and VA services while homeless than veterans of other race/ethnic groups. The most common barriers to services were: veterans felt they did not need help, they did not have information about services, there was stigma and shame, and transportation barriers were encountered. These findings suggest veterans use various VA and community-based homeless and healthcare services, but they do experience barriers that may be improved with better public information and care coordination to improve service uptake among homeless veterans.

Developing an operational definition of housing instability and homelessness in Veterans Health Administration's medical records

The main objective of this study was to examine how homelessness and housing instability is captured across data sources in the Veterans Health Administration (VHA). Data from 2021 were extracted from three data repositories, including the Corporate Data Warehouse (CDW), the Homeless Operations Management System (HOMES), and the Homeless Management Information System (HMIS). Using these three data sources, we identified the number of homeless and unstably housed veterans across a variety of indicators. The results showed that the use of diagnostic codes and clinic stop codes identified a large number of homeless and unstably housed veterans, but the use of HOMES and HMIS data identified additional homeless and unstably housed veterans to provide a complete count. A total of 290,431 unique veterans were identified as experiencing homelessness or housing instability in 2021 and there was regional variability in how homelessness and housing stability were captured across data sources, supporting the need for more uniform ways to operationalize these conditions. Together, these findings highlight the and encourage use of all available indicators and data sources to identify homelessness and housing instability in VHA. These methodologies applied to the largest healthcare system in the U.S. demonstrate their utility and possibilities for other healthcare systems. Transparent practices about data sources and indicators used to capture homelessness and housing instability should be shared to increase uniform use.

The impact of patient-centred care on the relationship between access to care and subjective health outcomes amongst people experiencing homelessness: A mediation analysis

People experiencing homelessness (PEH) have stated that impersonal care and feelings of discrimination are barriers to accessing healthcare which is associated with poor health outcomes amongst PEH. This study examined whether patient-centred care (PCC) mediates the relationship between access to care and subjective health outcomes. Using the 2014-15 Healthcare Center Patient Survey, we identified 1873 homeless and vulnerably housed adults. Items related to the delay or inability to receive primary or mental healthcare, PCC provided by healthcare providers, general health status, and the Kessler-6 psychological distress scale were selected. Ordinary least squares analyses were used to perform mediation analysis. We found that both access to primary care and access to mental healthcare were positively associated with physical health status (β = 0.492, p < 0.001; β = 0.311, p < 0.001) and negatively associated with psychological distress (β = -2.53, p < 0.001; β = -1.85, p < 0.001). PCC partially mediated all associations, but the mediation was stronger in the relationships between access to primary care and health outcomes (ab = 0.25, 95% CI [0.002, 0.052]; ab = -0.21, 95% CI [-0.37, -0.07]) compared to mental healthcare (ab = 0.02, 95% CI [0.01, 0.04]; ab = -0.14, 95% CI [-0.25, -0.06]). The results of this study indicated access to primary and mental healthcare is important in the patient-centred health outcomes of PEH. Additionally, the partial mediation of PCC in these relationships indicated that participants' perception of collaborative, trustworthy, respectful care from healthcare providers impacted the relationship between access to healthcare and health outcomes.

What do Veterans with homeless experience want us to know that we are not asking? A qualitative content analysis of comments from a national survey of healthcare experience

Surveys of people who experience homelessness can portray their life and healthcare experiences with a level of statistical precision; however, few have explored how the very same surveys can deliver qualitative insights as well. In responding to surveys, people experiencing homelessness can use the margins to highlight health and social concerns that investigators failed to anticipate that standard question batteries miss. This study describes the unprompted comments of a large national survey of Veterans with homeless experiences. The Primary Care Quality-Homeless Services Tailoring (PCQ-HOST) survey presented 85 close-ended items to solicit social and psychological experiences, health conditions, and patient ratings of primary care. Amongst 5377 Veterans responding to the paper survey, 657 (12%) offered 1933 unprompted comments across nearly all domains queried. Using a team-based content analysis approach, we coded and organised survey comments by survey domain, and identified emergent themes. Respondents used comments for many purposes. They noted when questions called for more nuanced responses than those allowed, especially 'sometimes' or 'not applicable' on sensitive questions, such as substance use, where recovery status was not queried. On such matters, the options of 'no' and 'yes' failed to capture important contextual and historical information that mattered to respondents, such as being in recovery. Respondents also elaborated on negative and positive care experiences, often naming specific clinics or clinicians. This study highlights the degree to which members of vulnerable populations, who participate in survey research, want researchers to know the reasons behind their responses and topics (like chronic pain and substance use disorders) that could benefit from open-ended response options. Understanding patient perspectives can help improve care. Quantitative data from surveys can provide statistical precision but may miss key patient perspectives. The content that patients write into survey margins can highlight shortfalls of a survey and point towards future areas of inquiry. Veterans with homeless experience want to provide additional detail about their lives and care experiences in ways that transcend the boundaries of close-ended survey questions. Questions on substance use proved especially likely to draw comments that went beyond the permitted response options, often to declare that the respondent was in recovery. Respondents frequently clarified aspects of their care experiences related to pain, pain care, transportation and experiences of homelessness.

Assessing equity and quality indicators for older people – Adaptation and validation of the Assessing Care of Vulnerable Elders (ACOVE) checklist for the Portuguese care context

Background

Development has promoted longer and healthier lives, but the rise in the proportion of older adults poses new challenges to health systems. Susceptibilities of older persons resulting from lower knowledge about services availability, health illiteracy, lower income, higher mental decline, or physical limitations need to be identified and monitored to assure the equity and quality of health care. The aim of this study was to develop equity indicators for the Assessing Care of Vulnerable Elders (ACOVE)-3 checklist and perform the first cross-cultural adaptation and validation of this checklist into Portuguese.

Methods

A scoping literature review of determinants or indicators of health (in)equity in the care of older people was performed. A total of 5 language experts and 18 health professionals were involved in the development and validation of the equity and quality indicators through expert opinion and focus groups. Data collected from focus groups was analyzed through directed or conventional content analysis. The usefulness of the indicators was assessed by analyzing the clinical records of 30 patients.

Results

The literature review revealed that there was a worldwide gap concerning equity indicators for older people primary health care. A structured and complete checklist composed of equity and quality indicators was obtained, validated and assessed. A significant number of non-screened quality or equity related potential occurrences that could have been avoided if the proposed indicators were implemented were detected. The percentage of non-registered indicators was 76.6% for quality and 96.7% for equity.

Conclusions

Applying the proposed checklist will contribute to improve the monitoring of the clinical situation of vulnerable older people and the planning of medical and social actions directed at this group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03104-5.

Predictors of COVID-19 Vaccination among Veterans Experiencing Homelessness

Sufficient uptake of the COVID-19 vaccine is key to slowing the spread of the coronavirus among the most vulnerable in society, including individuals experiencing homelessness. However, COVID-19 vaccination rates among the Veteran homeless population are currently unknown. This study examines the COVID-19 vaccination rate among homeless Veterans who receive care at the U.S. Department of Veterans Affairs (VA), and the factors that are associated with vaccine uptake. Using VA administrative and clinical data, bivariate and multivariate analyses were conducted to identify the sociodemographic, health-related, and healthcare and housing services utilization factors that influenced COVID-19 vaccine uptake during the first eight months of the vaccine rollout (December 2020-August 2021). Of the 83,528 Veterans experiencing homelessness included in the study, 45.8% were vaccinated for COVID-19. Non-white, older Veterans (65+), females, those who received the seasonal flu vaccine, and Veterans with multiple comorbidities and mental health conditions were more likely to be vaccinated. There was a strong association between COVID-19 vaccination and Veterans who utilized VA healthcare and housing services. VA healthcare and homeless service providers are particularly well-positioned to provide trusted information and overcome access barriers for homeless Veterans to receive the COVID-19 vaccine.

Characteristics Associated With Unsheltered Status Among Veterans

INTRODUCTION

Unsheltered homelessness is a strongly debated public issue. The study objective is to identify personal and community characteristics associated with unsheltered homelessness in veterans and to test for interactions between these characteristics.

METHODS

In a 2018 national survey of U.S. veterans with homeless experiences; investigators assessed unsheltered time; psychosocial characteristics; and community measures of shelter access, weather, and rental affordability. Associations between these characteristics and unsheltered status were tested in July-August 2020. This study also tested whether the count of personal risk factors interacted with community characteristics in predicting unsheltered status.

RESULTS

Among 5,406 veterans, 481 (8.9%) reported ≥7 nights unsheltered over 6 months. This group was more likely to report criminal justice history, poor social support, medical and drug problems, financial hardship, and being unmarried. Their communities had poorer shelter access and warmer temperatures. The likelihood of unsheltered experience rose with risk factor count from 2.0% (0-1) to 8.4% (2-3) and to 24.2% (4-11). Interaction tests showed that the increase was greater for communities with warmer weather and higher rents (p<0.05).

CONCLUSIONS

Among veterans experiencing homelessness, unsheltered experiences correlate with individual and community risk factors. Communities wishing to address unsheltered homelessness will need to consider action at both levels.

Health Service Access Among Homeless Veterans: Health Access Challenges Faced by Homeless African American Veterans

Veteran homelessness is a public health crisis, especially among the disproportionate number of minority veterans in the homeless veteran population. African American homeless veterans in particular face unique challenges accessing appropriate health care services to meet their medical needs. Their needs are often underrepresented in the literature on veteran homelessness. Drawing together over 80 studies and government reports from the last two decades, this review provides a timely synopsis of homeless veterans' health care access, with a particular focus on the barriers faced by African American veterans. This review employs Penchansky and Thomas' Access Model to frame health access barriers faced by homeless veterans, dialing in on what is known about the experience of African American veterans, within the five dimensions of access: Availability, Accessibility, Accommodation, Affordability, and Acceptability. Actionable guidance and targeted interventions to address health access barriers for all veterans are delineated with a focus on the need to gather further data for African American homeless veterans and to consider tailoring interventions for this important and underserved group.

Perceptions of Care Coordination Among Homeless Veterans Receiving Medical Care in the Veterans Health Administration and Community Care Settings: Results From a National Survey

BACKGROUND

Initiatives to expand Veterans' access to purchased health care outside Veterans Health Administration (VHA) facilities ("community care") present care coordination challenges for Veterans experiencing homelessness.

OBJECTIVE

Among Veterans with homeless experiences, to evaluate community care use and satisfaction, and compare perceptions of care coordination among Veterans using VHA services and community care to those using VHA services without community care.

RESEARCH DESIGN

Cross-sectional analysis of responses to a 2018 mailed survey.

SUBJECTS

VHA outpatients with homeless experiences.

MEASURES

Self-reported use of community care, Likert-style ratings of satisfaction with that care, and Access/Coordination experiences from the Primary Care Quality-Homeless (PCQ-H) survey.

RESULTS

Of 4777 respondents, 1325 (26.7%) reported using community care; most of this subsample affirmed satisfaction with the community care they received (83%) and its timeliness (75%). After covariate adjustment, Veteran characteristics associated with greater community care use included female sex, being of retirement age and nonmarried, and having higher education, more financial hardship, ≥3 chronic conditions, psychological distress, depression, and posttraumatic stress disorder. Satisfaction with community care was lower among patients with travel barriers, psychological distress, and less social support. Compared with those using the VHA without community care, Veterans using VHA services and community care were more likely to report unfavorable access/coordination experiences [odds ratio (OR)=1.34, confidence interval (CI)=1.15-1.57]. This included hassles following referral (OR=1.37, CI=1.14-1.65) and perceived delays in receiving health care (OR=1.38, CI=1.19-1.61).

CONCLUSIONS

Veterans with homeless experiences value community care options. Potential access benefits are balanced with risks of unfavorable coordination experiences for vulnerable Veterans with limited resources.

Aims, development, and early results of an interdisciplinary primary care initiative to address patient vulnerabilities

Addressing substance use disorders and social determinants of poor health at a population level is a major national healthcare priority. One promising model to improve healthcare outcomes for patients with these conditions is the Vulnerable Veteran Innovative Patient-Aligned Care Team (PACT) Initiative, or VIP - an interdisciplinary, team-based primary care delivery model designed to address the needs of vulnerable patients in the Veterans Health Administration. VIP establishes a single, integrated primary care environment for the management of substance use disorders, mental illness, social determinants of poor health, and complexities in care resulting from the co-occurrence of these conditions. We describe the origination, goals, and evolution of VIP to provide an example of how clinics and health systems can address vulnerable patient populations within a primary care clinic framework. While ongoing evaluation will be essential to understand its impact on patient outcomes and its sustainability and scalability in the future, VIP holds promise as a novel model to improve care for patients with addiction and other vulnerabilities.

Dual use of Department of Veterans Affairs and community healthcare: Homeless veterans' experiences, perspectives, and perceptions

BACKGROUND

Veteran homelessness is a pervasive problem and a high-priority, mission-oriented area of investigation in the United States (US). Most veterans enrolled in healthcare with the Department of Veterans Affairs (VA) carry additional health coverage, which may increase their access to care. For veterans, dual use of VA and non-VA healthcare has potentially positive and negative consequences.

PURPOSE

To explore homeless veterans' experiences seeking and obtaining healthcare within and outside the VA.

METHODOLOGY

US homeless veterans were recruited from a large, urban Northeast Healthcare for the Homeless program from two sites. This was a descriptive phenomenological study. Three semistructured focus group interviews were conducted (total n = 21 distinct participants). We used inductive content analysis procedures to identify main themes in the data.

RESULTS

We found four main themes: dual use decision making, access to care, preferences and perceptions of care, and suggestions for improving VA care. Although veterans in our sample had mixed positive and negative experiences with both systems, positive responses were more common regarding community care than VA. Veterans provided more verbose responses when describing negative VA experiences and more succinct responses for positive experiences.

CONCLUSIONS

We found mixed positive and negative experiences for both healthcare systems, although reports were more positive for non-VA care than VA.

IMPLICATIONS

Veterans' healthcare concerns and needs appeared difficult to meet. Future research is warranted to improve veteran-centered care access and care experiences.

Veterans' Experiences With Outpatient Care: Comparing The Veterans Affairs System With Community-Based Care

Timely access to outpatient care was a primary driver behind the Department of Veterans Affairs' (VA's) increased purchase of community-based care under the Veterans Access, Choice, and Accountability Act of 2014, known as the Choice Act. To compare veterans' experiences in VA-delivered and community-based outpatient care after implementation of the act, we assessed veterans' scores on four dimensions of experience-access, communication, coordination, and provider rating-for outpatient specialty, primary, and mental health care received during 2016-17. Patient experiences were better for VA than for community care in all respects except access. For specialty care, access scores were better in the community; for primary and mental health care, access scores were similar in the two settings. Although all specialty care scores and the primary care coordination score improved over time, the gaps between settings did not shrink. As purchased care further expands under the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks Act of 2018, which replaced the Choice Act in 2019, monitoring of meaningful differences between settings should continue, with the results used to inform both VA purchasing decisions and patients' care choices.

Primary care experiences of veterans with opioid use disorder in the Veterans Health Administration

BACKGROUND

While patients with substance use disorders (SUDs) are thought to encounter poor primary care experiences, the perspectives of patients with opioid use disorder (OUD), specifically, are unknown. This study compares the primary care experiences of patients with OUD, other SUDs and no SUD in the Veterans Health Administration.

METHODS

The sample included Veterans who responded to the national Patient-Centered Medical Home Survey of Healthcare Experiences of Patients, 2013-2015. Respondents included 3554 patients with OUD, 36,175 with other SUDs, and 756,386 with no SUD; 742 OUD-diagnosed patients received buprenorphine. Multivariable multinomial logistic regressions estimated differences in the probability of reporting positive and negative experiences (0-100 scale) for patients with OUD, compared to patients with other SUDs and no SUD, and for OUD-diagnosed patients treated versus not treated with buprenorphine.

RESULTS

Of all domains, patients with OUD reported the least positive experiences with access (31%) and medication decision-making (35%), and the most negative experiences with self-management support (35%) and provider communication (23%). Compared to the other groups, patients diagnosed with OUD reported fewer positive and/or more negative experiences with access, communication, office staff, provider ratings, comprehensiveness, care coordination, and self-management support (adjusted risk differences[aRDs] range from |2.9| to |7.0|). Among OUD-diagnosed patients, buprenorphine was associated with more positive experiences with comprehensiveness (aRD = 8.3) and self-management support (aRD = 7.1), and less negative experiences with care coordination (aRD = -4.9) and medication shared decision-making (aRD = -5.4).

CONCLUSIONS

In a national sample, patients diagnosed with OUD encounter less positive and more negative experiences than other primary care patients, including those with other SUDs. Buprenorphine treatment relates positively to experiences with care comprehensiveness, medication decisions, and care coordination. As stakeholders encourage more primary care providers to manage OUD, it will be important for healthcare systems to attend to patient access and experiences with care in these settings.

Exploring Quality of Primary Care for Patients Who Experience Homelessness and the Clinicians Who Serve Them: What Are Their Aspirations?

To develop and evaluate an effective model of patient-centered, high-quality, homeless-focused primary care, our team explored key domains of primary care that may be important to patients. We anchored our conceptual framework in two reports from the Institute of Medicine (IOM) that defined components of primary care and quality of care. Using questions developed from this framework, we conducted semistructured interviews with 36 homeless-experienced individuals with past-year primary care engagement and 24 health care professionals (clinicians and researchers) who serve homeless-experienced patients in the primary care setting. Template analysis revealed factors important to this population. These included stigma, respect, and perspectives on patient control of medical decision-making in regard to both pain and addiction. For patients experiencing homelessness, the results suggest that quality primary care may have different meanings for patients and professionals, and that services should be tailored to meet homeless-specific needs.

Stigma, discrimination, and substance use among an urban sample men who have sex with men in Massachusetts

Men who have sex with men (MSM) who have intersecting stigmatized identities or characteristics are differentially at risk for acquiring HIV. However, the relationships between specific identities, discrimination and stigma, and HIV risk behaviors require investigation to develop more effective interventions. Data from Boston's 2014 National HIV Behavioral Surveillance MSM cycle were used to assess associations between socio-demographics, structural factors, substance use, discrimination, HIV-stigma, and condomless anal sex. Of the total sample (n = 382), 17.6% reported verbal abuse, 8.3% work-place discrimination, 2.6% health discrimination, and 3.8% physical assault. HIV-stigma beliefs differed by race, sexual-orientation, and income. Those with histories of drug treatment were 9.47 (OR 95%CI: 2.09, 42.79) and 8.29 (OR 95%CI: 2.27, 30.21) times more likely to report health discrimination and physical assault, respectively. Healthcare discrimination and physical assault moderated relationships between substance use and number of condomless anal sex partners such that those who experienced discrimination and substance use reported more partners. Even in Massachusetts, MSM with identities or characteristics marginalized in society disproportionately experienced discrimination and stigma and healthcare discrimination or physical assault were associated with increased sexual risk behavior among MSM who use substances. Decreasing HIV transmission requires reducing discrimination and stigma among those most vulnerable, particularly those using substances.

Providing Positive Primary Care Experiences for Homeless Veterans Through Tailored Medical Homes: The Veterans Health Administration's Homeless Patient Aligned Care Teams

BACKGROUND

In 2012, select Veterans Health Administration (VHA) facilities implemented a homeless-tailored medical home model, called Homeless Patient Aligned Care Teams (H-PACT), to improve care processes and outcomes for homeless Veterans.

OBJECTIVE

The main aim of this study was to determine whether H-PACT offers a better patient experience than standard VHA primary care.

RESEARCH DESIGN

We used multivariable logistic regressions to estimate differences in the probability of reporting positive primary care experiences on a national survey.

SUBJECTS

Homeless-experienced survey respondents enrolled in H-PACT (n=251) or standard primary care in facilities with H-PACT available (n=1527) and facilities without H-PACT (n=10,079).

MEASURES

Patient experiences in 8 domains from the Consumer Assessment of Healthcare Provider and Systems surveys. Domain scores were categorized as positive versus nonpositive.

RESULTS

H-PACT patients were less likely than standard primary care patients to be female, have 4-year college degrees, or to have served in recent military conflicts; they received more primary care visits and social services. H-PACT patients were more likely than standard primary care patients in the same facilities to report positive experiences with access [adjusted risk difference (RD)=17.4], communication (RD=13.9), office staff (RD=13.1), provider ratings (RD=11.0), and comprehensiveness (RD=9.3). Standard primary care patients in facilities with H-PACT available were more likely than those from facilities without H-PACT to report positive experiences with communication (RD=4.7) and self-management support (RD=4.6).

CONCLUSIONS

Patient-centered medical homes designed to address the social determinants of health offer a better care experience for homeless patients, when compared with standard primary care approaches. The lessons learned from H-PACT can be applied throughout VHA and to other health care settings.

Differences in Experiences With Care Between Homeless and Nonhomeless Patients in Veterans Affairs Facilities With Tailored and Nontailored Primary Care Teams

BACKGROUND

Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients.

OBJECTIVE

To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities).

RESEARCH DESIGN

We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities.

SUBJECTS

Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941).

MEASURES

Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support.

RESULTS

In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0).

CONCLUSIONS

VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.

An evolutionary view of patient experience in primary care: A concept analysis

AIM

This concept analysis explores "patient experience" in the context of primary care.

BACKGROUND

In the 21st century, person-centered care became the manner to address the healthcare quality needs of the United States. This study led to using measures of patient experience as an evaluation of patient-centered care.

DESIGN

Concept analysis.

DATA SOURCES

CINAHL, Cochrane Review, PUBMED Central, PsycINFO, Web of Science, and Scopus were queried using "patient experience" and "primary care." All peer-reviewed US-based articles were included from January 2000 to October 2017 (n = 59).

REVIEW METHODS

Rodgers' evolutionary view of concept analysis guided this inquiry.

RESULTS

Patient experience is any process discernible by patients, including subjective experiences, objective experiences, and observations of provider or staff behavior. Patient experience reports are mediated and moderated by many variables and reflect care experiences that directly measure patient-centeredness from the patient's viewpoint. Consequences of patient experience may lead to adherence to shared plans of care, patient engagement, and appropriate use of healthcare services.

CONCLUSION

Conceptual clarity of patient experience adds to the understanding of how patients experience healthcare quality. If healthcare aspires to deliver patient-centered care, understanding quality from the viewpoint of the patient is essential.