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Gin JL, Balut MD, Dobalian A. COVID-19 vaccination uptake and receptivity among veterans enrolled in homelessness-tailored primary health care clinics: provider trust vs. misinformation. BMC PRIMARY CARE 2024; 25:24. [PMID: 38216894 PMCID: PMC10785369 DOI: 10.1186/s12875-023-02251-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 12/18/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Compared to the general population, individuals experiencing homelessness are at greater risk of excess morbidity and mortality from COVID-19 but have been vaccinated at lower rates. The U.S. Department of Veterans Affairs (VA)'s Homeless Patient Aligned Care Team (HPACT) program integrates health care and social services for Veterans experiencing homelessness to improve access to and utilization of care. METHODS This study explores the vaccination uptake behavior and attitudes through a qualitative comparative case study of two HPACT clinics, one in California (CA) and one in North Dakota (ND). Semi-structured telephone interviews were conducted with Veterans enrolled in the two VA HPACT clinics from August to December 2021 with 20 Veterans (10 at each clinic). RESULTS Four themes emerged from the interviews: (1) Vaccination uptake and timing- While half of the Veterans interviewed were vaccinated, ND Veterans were more likely to be vaccinated and got vaccinated earlier than CA Veterans; (2) Housing- Unsheltered or precariously housed Veterans were less likely to be vaccinated; (3) Health Care- Veterans reporting positive experiences with VA health care and those who trusted health providers were more likely to vaccinate than those with negative or nuanced satisfaction with health care; (4) Refusers' Conspiracy Theories and Objectivity Claims- Veterans refusing the vaccine frequently mentioned belief in conspiracy theories while simultaneously asserting their search for objective information from unbiased sources. CONCLUSIONS These findings amplify the importance of improving access to population-tailored care for individuals experiencing homelessness by reducing patient loads, expanding housing program enrollment, and increasing the provider workforce to ensure personalized care. Health care providers, and housing providers, social workers, and peers, who offer information without discrediting or criticizing Veterans' beliefs, are also key to effectively delivering vaccine messaging to this population.
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Affiliation(s)
- June L Gin
- Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, 16111 Plummer St. MS-152, North Hills, CA, 91343, USA.
| | - Michelle D Balut
- Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, 16111 Plummer St. MS-152, North Hills, CA, 91343, USA
| | - Aram Dobalian
- Veterans Emergency Management Evaluation Center, Department of Veterans Affairs, 16111 Plummer St. MS-152, North Hills, CA, 91343, USA
- Division of Health Services Management and Policy, The Ohio State University College of Public Health, 202 Cunz Hall, 1841 Neil Ave, Columbus, OH, 43210, USA
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2
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Betancourt CA, Goldberg DG, Hawks BA, Kitsantas P. Perspectives of homeless veterans living with substance use disorders (SUD) and mental illness. Heliyon 2023; 9:e20364. [PMID: 37767504 PMCID: PMC10520805 DOI: 10.1016/j.heliyon.2023.e20364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023] Open
Abstract
Upon returning home from the military, America's veterans face complex challenges such as homelessness and substance use disorders (SUD). Veterans who have experienced SUDs and homelessness are more likely to struggle with depression and suicidal behaviors. This study aims to understand homeless veterans' lived experiences of their everyday life and social interactions. We used semi-structured interviews to conduct a phenomenological study of 14 homeless veterans with known SUDs living in the Baltimore-Washington D.C. Metropolitan area. A Social-Ecological Model (SEM) was used to create themes, a priori, then used open coding analytic methods to identify emerging themes. Two-thirds of veterans used illicit drugs or abused alcohol, and nearly all reported a history of depression or anxiety. Suicidal behaviors were present in a third of all veterans. We found that veteran homelessness and substance use are strongly associated with emotional and physical trauma suffered while on active duty. Consequently, once homeless, a veteran's community may encourage and exacerbate SUDs, thus impeding a path toward sobriety. Homeless veterans who have struggled with SUDs and later experience a death in their family often relapse to substance use. Deeply exploring a veteran's relationships with family, friends, and their immediate community may reveal opportunities to address these issues using healthcare and community interventions.
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Affiliation(s)
- Christian A. Betancourt
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Debora G. Goldberg
- Department of Health Administration and Policy, George Mason University, 4400 University Drive, Fairfax, VA, 22032, USA
| | - Beth A. Hawks
- Department of Preventive Medicine and Biostatistics, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA
| | - Panagiota Kitsantas
- Department of Population Health and Social Medicine, Florida Atlantic University, 777 Glades Rd, Boca Raton, FL, 33431, USA
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3
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Tsai J, Havlik J, Howell BA, Johnson E, Rosenthal D. Primary Care for Veterans Experiencing Homelessness: a Narrative Review of the Homeless Patient Aligned Care Team (HPACT) Model. J Gen Intern Med 2023; 38:765-783. [PMID: 36443628 PMCID: PMC9971390 DOI: 10.1007/s11606-022-07970-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/16/2022] [Indexed: 11/29/2022]
Abstract
In 2011, the U.S. Department of Veterans Health (VA) implemented a homeless-tailored primary care medical home model called the Homeless Patient Aligned Care Teams (HPACTs). The impact of HPACTs on health and healthcare outcomes of veterans experiencing homelessness has not been adequately synthesized. This narrative review summarized peer-reviewed studies published in databases Ovid MEDLINE, Ovid EMBASE, and APA PsycInfo from 1946 to February 2022. Only original research studies that reported outcomes of the HPACT model were included in the review. Of 575 studies that were initially identified and screened, 26 studies met inclusion criteria and were included in this review. Included studies were categorized into studies that described the following: (1) early HPACT pilot implementation; (2) HPACT's association with service quality and utilization; and (3) specialized HPACT programs. Together, studies in this review suggest HPACT is associated with reductions in emergency department utilization and improvements in primary care utilization, engagement, and positive patient experiences; however, the methodological rigor of the included studies was low, and thus, these findings should only be considered preliminary. There is a need for randomized controlled trials assessing the impact of the PACT model on key outcomes of interest, as well as to determine whether the model is a viable way to manage healthcare for persons experiencing homelessness outside of the VA system.
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Affiliation(s)
- Jack Tsai
- Office of Homeless Programs, U.S. Department of Veterans Affairs, Washington D.C., USA.
- University of Texas Health Science Center at Houston, School of Public Health, 1200 Pressler St, Houston, TX, 77030, USA.
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA.
| | - John Havlik
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Benjamin A Howell
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Erin Johnson
- Office of Homeless Programs, U.S. Department of Veterans Affairs, Washington D.C., USA
| | - David Rosenthal
- Section of General Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- 4Catalyzer Inc., CT, Guilford, USA
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4
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Blonigen D, Smelson D, Smith J, Baldwin N, McInnes DK, Raikov I, Weber J, Hyde J. Peer support and whole health coaching to address the healthcare needs of homeless veterans: a pilot study. BMC PRIMARY CARE 2022; 23:331. [PMID: 36529718 PMCID: PMC9760553 DOI: 10.1186/s12875-022-01927-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/25/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Homelessness is a robust social determinant of acute care service utilization among veterans. Although intensive outpatient programs have been developed for homeless veterans who are high utilizers of acute care ("super utilizers"), few scalable programs have been implemented to address their needs. OBJECTIVE Describe the development and pilot testing of a novel intervention that integrates the roles of a peer and whole health coach ("Peer-WHC") in coordination with primary care teams to reduce homeless veterans' frequent use of acute care. DESIGN Single-arm trial in three outpatient primary care clinics at a Veterans Health Administration (VHA) medical center; pre/post design using mixed-methods. PARTICIPANTS Twenty veterans from VHA's homeless registry who were super-utilizers of acute care and enrolled in primary care. INTERVENTION Weekly health coaching sessions with a peer over 12 weeks, including discussions of patients' health care utilization patterns and coordination with primary care. MAIN MEASURES Rates of session attendance and intervention fidelity, patient-reported satisfaction and changes in patient engagement and perceptions of health, pre/post utilization of acute and supportive care services, and qualitative interviews with multiple stakeholders to identify barriers and facilitators to implementation. KEY RESULTS On average, patients attended 6.35 sessions (SD = 3.5, Median = 7). Satisfaction scores (M = 28.75 out of 32; SD = 2.79) exceeded a priori benchmarks. Patients' perceptions of health improved from pre to post [t(df)=-2.26(14), p = 0.04]. In the 3-months pre/post, 45% (n = 9) and 15% (n = 3) of patients, respectively, were hospitalized. Qualitative feedback from patients, providers, and peers and fidelity metrics suggested value in increasing the length of the intervention to facilitate goal-setting with patients and coordination with primary care. CONCLUSION Findings support the feasibility, acceptability, and utility of Peer-WHC to address the healthcare needs of homeless veterans. A future trial is warranted to test the impact of Peer-WHC on reducing these patients' frequent use of acute care.
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Affiliation(s)
- Daniel Blonigen
- grid.280747.e0000 0004 0419 2556Department of Veterans Affairs Palo Alto Health Care System, Health Services Research and Development Center for Innovation to Implementation, 795 Willow Road (152), Menlo Park, CA 94025 USA ,grid.168010.e0000000419368956Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA USA
| | - David Smelson
- HSR&D Center for Health Care Organization and Implementation Research, VA Bedford HealthCare System, Bedford, MA USA ,grid.168645.80000 0001 0742 0364University of Massachusetts Chan Medical School, Worcester, MA USA
| | - Jennifer Smith
- grid.280747.e0000 0004 0419 2556Department of Veterans Affairs Palo Alto Health Care System, Health Services Research and Development Center for Innovation to Implementation, 795 Willow Road (152), Menlo Park, CA 94025 USA
| | - Nicole Baldwin
- grid.261634.40000 0004 0526 6385Clinical Psychology Program, Palo Alto University, Palo Alto, USA
| | - D. Keith McInnes
- HSR&D Center for Health Care Organization and Implementation Research, VA Bedford HealthCare System, Bedford, MA USA ,grid.189504.10000 0004 1936 7558Department of Health Law Policy and Management, Boston University School of Public Health, Boston, MA USA
| | - Ivan Raikov
- grid.168010.e0000000419368956Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA USA
| | - Jillian Weber
- grid.239186.70000 0004 0481 9574Veterans Health Administration, Homeless Program Office, Washington, DC USA
| | - Justeen Hyde
- HSR&D Center for Health Care Organization and Implementation Research, VA Bedford HealthCare System, Bedford, MA USA
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5
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Shepherd-Banigan M, Drake C, Dietch JR, Shapiro A, Tabriz AA, Van Voorhees EE, Uthappa DM, Wang TW, Lusk JB, Rossitch SS, Fulton J, Gordon A, Ear B, Cantrell S, Gierisch JM, Williams JW, Goldstein KM. Primary Care Engagement Among Individuals with Experiences of Homelessness and Serious Mental Illness: an Evidence Map. J Gen Intern Med 2022; 37:1513-1523. [PMID: 35237885 PMCID: PMC9085989 DOI: 10.1007/s11606-021-07244-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 10/20/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Experiences of homelessness and serious mental illness (SMI) negatively impact health and receipt of healthcare. Interventions that promote the use of primary care services for people with both SMI and homelessness may improve health outcomes, but this literature has not been evaluated systematically. This evidence map examines the breadth of literature to describe what intervention strategies have been studied for this population, elements of primary care integration with other services used, and the level of intervention complexity to highlight gaps for future intervention research and program development. METHODS We followed an a priori protocol developed in collaboration with clinical stakeholders. We systematically searched the published literature to identify interventions for adults with homelessness who also had SMI. We excluded case reports, editorials, letters, and conference abstracts. Data abstraction methods followed standard practice. Data were categorized into intervention strategies and primary care integration strategies. Then we applied the Complexity Assessment Tool for Systematic Reviews (iCAT_SR) to characterize intervention complexity. RESULTS Twenty-two articles met our inclusion criteria evaluating 15 unique interventions to promote engagement in primary care for adults with experiences of homelessness and SMI. Study designs varied widely from randomized controlled trials and cohort studies to single-site program evaluations. Intervention strategies varied across studies but primarily targeted patients directly (e.g., health education, evidence-based interactions such as motivational interviewing) with fewer strategies employed at the clinic (e.g., employee training, multidisciplinary teams) or system levels (e.g., data sharing). We identified elements of primary care integration, including referral strategies, co-location, and interdisciplinary care planning. Interventions displayed notable complexity around the number of intervention components, interaction between intervention components, and extent to which interventions were tailored to specific patient populations. DISCUSSION We identified and categorized elements used in various combinations to address the primary care needs of individuals with experiences of homeless and SMI.
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Affiliation(s)
- Megan Shepherd-Banigan
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA.
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, Durham, NC, USA.
- Margolis Center for Health Policy, Duke University, Durham, NC, USA.
| | - Connor Drake
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, Durham, NC, USA
| | - Jessica R Dietch
- School of Psychological Science, Oregon State University, Corvallis, OR, USA
| | - Abigail Shapiro
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA
- Department of Oncological Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Elizabeth E Van Voorhees
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Diya M Uthappa
- Duke University School of Medicine, Durham, NC, USA
- Duke Global Health Institute, Durham, NC, USA
| | - Tsai-Wei Wang
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, Durham, NC, USA
| | - Jay B Lusk
- Duke University School of Medicine, Durham, NC, USA
- Duke University Fuqua School of Business, Durham, NC, USA
| | | | - Jessica Fulton
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Adelaide Gordon
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Belinda Ear
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
| | - Sarah Cantrell
- Duke University School of Medicine, Durham, NC, USA
- Duke University Medical Center Library & Archives, Durham, USA
| | - Jennifer M Gierisch
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Duke University, Durham, NC, USA
- Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC, USA
| | - John W Williams
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC, USA
| | - Karen M Goldstein
- Durham Center of Innovation To Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Medical Center, Durham, NC, USA
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC, USA
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6
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Wray CM, Vali M, Walter LC, Christensen L, Chapman W, Austin PC, Byers AL, Keyhani S. Examining the association of social risk with heart failure readmission in the Veterans Health Administration. BMC Health Serv Res 2021; 21:874. [PMID: 34445974 PMCID: PMC8393433 DOI: 10.1186/s12913-021-06888-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/10/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Previous research has found that social risk factors are associated with an increased risk of 30-day readmission. We aimed to assess the association of 5 social risk factors (living alone, lack of social support, marginal housing, substance abuse, and low income) with 30-day Heart Failure (HF) hospital readmissions within the Veterans Health Affairs (VA) and the impact of their inclusion on hospital readmission model performance. METHODS We performed a retrospective cohort study using chart review and VA and Centers for Medicare and Medicaid Services (CMS) administrative data from a random sample of 1,500 elderly (≥ 65 years) Veterans hospitalized for HF in 2012. Using logistic regression, we examined whether any of the social risk factors were associated with 30-day readmission after adjusting for age alone and clinical variables used by CMS in its 30-day risk stratified readmission model. The impact of these five social risk factors on readmission model performance was assessed by comparing c-statistics, likelihood ratio tests, and the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS The prevalence varied among the 5 risk factors; low income (47 % vs. 47 %), lives alone (18 % vs. 19 %), substance abuse (14 % vs. 16 %), lacks social support (2 % vs. <1 %), and marginal housing (< 1 % vs. 3 %) among readmitted and non-readmitted patients, respectively. Controlling for clinical factors contained in CMS readmission models, a lack of social support was found to be associated with an increased risk of 30-day readmission (OR 4.8, 95 %CI 1.35-17.88), while marginal housing was noted to decrease readmission risk (OR 0.21, 95 %CI 0.03-0.87). Living alone (OR: 0.9, 95 %CI 0.64-1.26), substance abuse (OR 0.91, 95 %CI 0.67-1.22), and having low income (OR 1.01, 95 %CI 0.77-1.31) had no association with HF readmissions. Adding the five social risk factors to a CMS-based model (age and comorbid conditions; c-statistic 0.62) did not improve model performance (c-statistic: 0.62). CONCLUSIONS While a lack of social support was associated with 30-day readmission in the VA, its prevalence was low. Moreover, the inclusion of some social risk factors did not improve readmission model performance. In an integrated healthcare system like the VA, social risk factors may have a limited effect on 30-day readmission outcomes.
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Affiliation(s)
- Charlie M Wray
- Department of Medicine, University of California, San Francisco, USA.
- Division of Hospital Medicine, San Francisco Veterans Affairs Medical Center, University of California San Francisco, 4150 Clement Street, San Francisco, CA, 94121, USA.
| | - Marzieh Vali
- Northern California Institute for Research and Education, San Francisco Veterans Affairs Medical Center, San Francisco, USA
| | - Louise C Walter
- Department of Medicine, University of California, San Francisco, USA
- Division of Geriatrics, San Francisco Veterans Affairs Medical Center, San Francisco, USA
| | - Lee Christensen
- Department of Biomedical Informatics, University of Utah, Salt Lake City, USA
| | - Wendy Chapman
- Centre for Digital Transformation of Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter C Austin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Amy L Byers
- Department of Psychiatry, University of California, San Francisco, USA
- Mental Health Services, San Francisco Veterans Affairs Medical Center, San Francisco, USA
| | - Salomeh Keyhani
- Division of General Internal Medicine, San Francisco Veterans Affairs Medical Center, San Francisco, USA
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7
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Vickery KD, Winkelman TNA, Ford BR, Busch A, Robertshaw D, Pittman B, Gelberg L. Trends in Trimorbidity Among Adults Experiencing Homelessness in Minnesota, 2000-2018. Med Care 2021; 59:S220-S227. [PMID: 33710099 PMCID: PMC7958979 DOI: 10.1097/mlr.0000000000001435] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Earlier and more severe onset of chronic health conditions contributes to the increased risk of premature death among adults experiencing homelessness. Trimorbidity, a subset of multimorbidity representing overlap of physical health, mental health, and substance use conditions, disproportionately impacts adults experiencing homelessness. We know of no longitudinal data comparing trimorbidity trends among adults experiencing homelessness. OBJECTIVE To characterize 19-year trimorbidity trends among adults experiencing homelessness. RESEARCH DESIGN Repeated longitudinal, statewide survey administered every 3 years. SUBJECTS Adults living throughout Minnesota experiencing homelessness. MEASURES Reported diagnoses of chronic health conditions within 3 categories: physical health conditions (hypertension, heart disease, asthma, diabetes); mental health conditions (depression, posttraumatic stress disorder, bipolar disorder, schizophrenia/other paranoid, and delusional disorders); and substance use conditions (alcohol and illicit substances). RESULTS A total of 25,552 surveys were completed by adults at 3-year intervals in a total of 7 waves. Participants reported increasing frequency and duration of homelessness, and more nights slept outside/in a car. 77.3% of adults experiencing homelessness in 2018 had one or more chronic health condition in any domain. From 2000 to 2018, bimorbidity and trimorbidity surpassed morbidity within a single domain. This was driven by increases in mental health conditions. In 2018, 31.7% of participants reported bimorbidity and 16.3% of adults reported trimorbidity. CONCLUSIONS Adults experiencing homelessness bear a substantial and growing burden of bimorbidity and trimorbidity. Ensuring accessible, high quality care that includes robust services that can address all 3 categories of health is critical. Such care is best delivered in combination with affordable supportive housing.
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Affiliation(s)
- Katherine Diaz Vickery
- Division of General Internal Medicine, Hennepin Healthcare, Health,
Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research
Institute, Health Care for the Homeless, Hennepin County Public Health
Department, Minneapolis, MN
| | - Tyler N. A. Winkelman
- Division of General Internal Medicine, Hennepin Healthcare, Health,
Homelessness, and Criminal Justice Lab, Hennepin Healthcare Research
Institute, Minneapolis, MN
| | - Becky R. Ford
- Health, Homelessness, and Criminal Justice Lab, Hennepin Healthcare
Research Institute, Minneapolis, MN
| | - Andrew Busch
- Department of Medicine, Hennepin Healthcare, Department of
Medicine, University of MN, Minneapolis, MN
| | - Danielle Robertshaw
- Division of General Internal Medicine, Hennepin Healthcare, Health
Care for the Homeless, Hennepin County Public Health Department,
Minneapolis, MN
| | - Brian Pittman
- Research Scientist, Wilder Research, Amherst H. Wilder Foundation,
St. Paul, MN
| | - Lillian Gelberg
- Department of Family Medicine, David Geffen School of Medicine at
UCLA, Department of Health Policy and Management, UCLA Fielding School of
Public Health, Los Angeles, CA
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8
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Codell N, Kelley AT, Jones AL, Dungan MT, Valentino N, Holtey AI, Knight TJ, Butz A, Gallop C, Erickson S, Patton J, Hyte-Richins LJ, Rollins BZ, Gordon AJ. Aims, development, and early results of an interdisciplinary primary care initiative to address patient vulnerabilities. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2021; 47:160-169. [PMID: 33301347 DOI: 10.1080/00952990.2020.1832507] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
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.
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Affiliation(s)
- Nodira Codell
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - A Taylor Kelley
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA.,Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Audrey L Jones
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Matthew T Dungan
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Natalie Valentino
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Ana I Holtey
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Tania J Knight
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Amy Butz
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Christina Gallop
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sean Erickson
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Jeremy Patton
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Laura Jane Hyte-Richins
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Benjamin Z Rollins
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA.,Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, USA.,Greater Intermountain Node (GIN) of the NIDA Clinical Trials Network, University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
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9
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Wray CM, Vali M, Walter LC, Christensen L, Abdelrahman S, Chapman W, Keyhani S. Examining the Interfacility Variation of Social Determinants of Health in the Veterans Health Administration. Fed Pract 2021; 38:15-19. [PMID: 33574644 DOI: 10.12788/fp.0080] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Introduction Recently, numerous studies have linked social determinants of health (SDoH) with clinical outcomes. While this association is well known, the interfacility variability of these risk favors within the Veterans Health Administration (VHA) is not known. Such information could be useful to the VHA for resource and funding allocation. The aim of this study is to explore the interfacility variability of 5 SDoH within the VHA. Methods In a cohort of patients (aged ≥ 65 years) hospitalized at VHA acute care facilities with either acute myocardial infarction (AMI), heart failure (HF), or pneumonia in 2012, we assessed (1) the proportion of patients with any of the following five documented SDoH: lives alone, marginal housing, alcohol use disorder, substance use disorder, and use of substance use services, using administrative diagnosis codes and clinic stop codes; and (2) the documented facility-level variability of these SDoH. To examine whether variability was due to regional coding differences, we assessed the variation of living alone using a validated natural language processing (NLP) algorithm. Results The proportion of veterans admitted for AMI, HF, and pneumonia with SDoH was low. Across all 3 conditions, lives alone was the most common SDoH (2.2% [interquartile range (IQR), 0.7-4.7]), followed by substance use disorder (1.3% [IQR, 0.5-2.1]), and use of substance use services (1.2% [IQR, 0.6-1.8]). Using NLP, the proportion of hospitalized veterans with lives alone was higher for HF (14.4% vs 2.0%, P < .01), pneumonia (11% vs 1.9%, P < .01), and AMI (10.2% vs 1.4%, P < .01) compared with International Classification of Diseases, Ninth Edition codes. Interfacility variability was noted with both administrative and NLP extraction methods. Conclusions The presence of SDoH in administrative data among patients hospitalized for common medical issues is low and variable across VHA facilities. Significant facility-level variation of 5 SDoH was present regardless of extraction method.
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Affiliation(s)
- Charlie M Wray
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
| | - Marzieh Vali
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
| | - Louise C Walter
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
| | - Lee Christensen
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
| | - Samir Abdelrahman
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
| | - Wendy Chapman
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
| | - Salomeh Keyhani
- is an Internist in the Division of Hospital Medicine; is a Statistician in the Northern California Institute for Research and Education; is a Geriatrician in the Division of Geriatrics; and is an Internist in the Division of General Internal Medicine; all at the San Francisco Veterans Affairs Medical Center. is a Project Manager and is an Assistant Professor, both in the Department of Biomedical Informatics, University of Utah in Salt Lake City. is the Associate Dean of Digital Health and Informatics in the Centre for Digital Transformation of Health, University of Melbourne, Victoria, Australia. Charlie Wray is an Assistant Professor of Medicine, Louise Walter and Salomeh Keyhani are Professors of Medicine; all in the Department of Medicine, University of California, San Francisco
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10
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Livingston WS, Brignone E, Fargo JD, Gundlapalli AV, Maguen S, Blais RK. VHA-Enrolled Homeless Veterans Are at Increased Risk for Eating Disorder Diagnoses. Mil Med 2019; 184:e71-e75. [PMID: 30085246 DOI: 10.1093/milmed/usy175] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Indexed: 11/14/2022] Open
Abstract
Introduction Veterans are overrepresented in the U.S. homeless population, comprising 8.6% of the general U.S. population, but 14% of the homeless population. Homeless veterans have several risk factors for eating disorder diagnoses, but the association of homelessness and eating disorders in this population is understudied. Given limited access to adequate food given their diminished resources, it is critical to better understand risk for eating disorders as a function of homelessness. Materials and Methods Administrative data on homelessness, eating disorder diagnoses, and related comorbidities occurring within the first 5 years of Veterans Health Administration (VHA) healthcare utilization between 2004 and 2014 in 265,806 Iraq/Afghanistan veterans were extracted from VHA medical records. Logistic regression analysis estimated the risk for eating disorders as a function of homelessness while accounting for demographic, military, and mental health covariates. Results Homelessness was observed in 11,876 veterans (4.5%), and of these, 71 (0.6%) had an eating disorder diagnosis. Odds of having an eating disorder diagnosis were 59% higher (adjusted odds ratio = 1.59, 95% confidence interval [1.21-2.09]) among homeless veterans relative to domiciled veterans. Conclusions A diagnosis of eating disorders in veterans is rare at the VHA, however, the current study found that homelessness may increase risk for eating disorders in this population. Unique strategies to provide evidenced-based care while accounting for inadequate daily resources are needed to reduce the risk of eating disorders in this population.
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Affiliation(s)
- Whitney S Livingston
- Department of Psychology, Utah State University, 2800 Old Main Hill, Logan, UT.,Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Dr., Salt Lake City, UT
| | - Emily Brignone
- Department of Psychology, Utah State University, 2800 Old Main Hill, Logan, UT.,Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Dr., Salt Lake City, UT
| | - Jamison D Fargo
- Department of Psychology, Utah State University, 2800 Old Main Hill, Logan, UT.,Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Dr., Salt Lake City, UT.,National Center for Homelessness Among Veterans, VA Medical Center, 3900 Woodland Ave., Philadelphia, PA
| | - Adi V Gundlapalli
- Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Dr., Salt Lake City, UT.,National Center for Homelessness Among Veterans, VA Medical Center, 3900 Woodland Ave., Philadelphia, PA.,Department of Internal Medicine, University of Utah School of Medicine, 30 N. 1900 E., Salt Lake City, UT.,Department of Biomedical Informatics, University of Utah School of Medicine, 30 N. 1900 E., Salt Lake City, UT
| | - Shira Maguen
- San Francisco VA Medical Center, 4150 Clement St., San Francisco, CA.,University of California, 505 Parnassus Ave., San Francisco, CA
| | - Rebecca K Blais
- Department of Psychology, Utah State University, 2800 Old Main Hill, Logan, UT.,Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, 500 Foothill Dr., Salt Lake City, UT
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11
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Jones AL, Hausmann LRM, Kertesz SG, Suo Y, Cashy JP, Mor MK, Pettey WBP, Schaefer JH, Gordon AJ, Gundlapalli AV. Providing Positive Primary Care Experiences for Homeless Veterans Through Tailored Medical Homes: The Veterans Health Administration's Homeless Patient Aligned Care Teams. Med Care 2019; 57:270-278. [PMID: 30789541 PMCID: PMC7773035 DOI: 10.1097/mlr.0000000000001070] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Audrey L. Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Leslie R. M. Hausmann
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Stefan G. Kertesz
- Birmingham VA Medical Center, Birmingham, AL; and Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Ying Suo
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - John P. Cashy
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Maria K. Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Warren B. P. Pettey
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - James H. Schaefer
- Department of Veterans Affairs Office of Reporting, Analytics, Performance, Improvement and Deployment, Durham, NC
| | - Adam J. Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT
| | - Adi V. Gundlapalli
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
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12
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Differences in Experiences With Care Between Homeless and Nonhomeless Patients in Veterans Affairs Facilities With Tailored and Nontailored Primary Care Teams. Med Care 2019; 56:610-618. [PMID: 29762272 DOI: 10.1097/mlr.0000000000000926] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
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.
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13
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Velezmoro R. The role of the psychologist in the veterans administration's patient aligned care team and huddle: A review, practical recommendations, and a call to action. Health Psychol Res 2018; 6:7393. [PMID: 30542669 PMCID: PMC6240835 DOI: 10.4081/hpr.2018.7393] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/31/2018] [Indexed: 12/04/2022] Open
Abstract
The Veterans Administration (VA)’s Patient Aligned Care Team (PACT) model has been a cornerstone of primary care in the VA healthcare system and has indicated the need for an organizational cultural shift towards interdisciplinary care. Most of the focus in PACT has been on the traditional providers of the medical model, with little attention focused on the role of the psychologist. This paper examines how psychologists can assist in the PACT model and, in particular, within the team VA huddle. Literature on the PACT model, mental health in PACT, and the advantages of the huddle are reviewed. Lessons learned within a large VA clinic are also discussed. Psychologists’ ability to be a clinician, teambuilder, and system specialist is discussed and how it benefits the PACT and the huddling process. Practical recommendations are made for how to best assist during the huddle, and how to advocate for both the huddle, and for a broader cultural shift in care.
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Affiliation(s)
- Rodrigo Velezmoro
- C.W. Bill Young VAMC, Bay Pines VA Healthcare System, Bay Pines, FL, USA
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14
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Pauly JB, Moore TA, Shishko I. Integrating a mental health clinical pharmacy specialist into the Homeless Patient Aligned Care Teams. Ment Health Clin 2018; 8:169-174. [PMID: 30155391 PMCID: PMC6063462 DOI: 10.9740/mhc.2018.07.169] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction To address the complex needs of the homeless veteran population, the US Department of Veterans Affairs created the Homeless Patient Aligned Care Team (H-PACT) model. The South Texas Veterans Health Care System has an established H-PACT model, however it does not include a clinical pharmacy specialist in mental health (MH). Methods An H-PACT MH pharmacy resident clinic was created and managed by a postgraduate year-2 psychiatric pharmacy resident. Improvements in access to MH care, Veterans Health Administration performance metrics, and estimated cost savings associated with resident interventions were reviewed to evaluate clinic utility. Results Over the 6-month clinic time frame, there were a total of 40 patient encounters in which 21 veterans had MH medication evaluation on at least 1 occasion. The average wait time for Veterans previously followed by the H-PACT psychiatrist was approximately 8 weeks. The H-PACT MH pharmacy resident clinic enabled veterans to be evaluated every 4 to 6 weeks. Interventions made by the resident included identification of medication administration errors, medication adjustments, adherence education, reduction in polypharmacy, and referral to other services. Estimated cost savings from clinic interventions totaled $33 613.67. Discussion The H-PACT MH pharmacy resident clinic allowed for an improvement in wait time for psychiatric pharmacotherapy follow-up for homeless veterans, with interventions that were associated with significant estimated cost savings.
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Affiliation(s)
- Julienne B Pauly
- (Corresponding author) Primary Care Mental Health Clinical Pharmacy Specialist, Pharmacy Department, South Texas Veterans Health Care System, San Antonio, Texas; Adjoint Assistant Professor, Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas,
| | - Troy A Moore
- Clinical Pharmacy Specialist - Psychiatry, Pharmacy Department, South Texas Veterans Health Care System, San Antonio, Texas; Director, American Society of Health-System Pharmacists - Accredited Postgraduate Year 2 Psychiatric Pharmacy Residency Program, Pharmacotherapy Division, College of Pharmacy, The University of Texas at Austin, Austin, Texas; Assistant Professor, Division of Community Recovery, Research and Training, Department of Psychiatry, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Ilona Shishko
- Clinical Pharmacy Specialist - Psychiatry, Pharmacy Department, South Texas Veterans Health Care System, San Antonio, Texas
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15
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Jones AL, Thomas R, Hedayati DO, Saba SK, Conley J, Gordon AJ. Patient predictors and utilization of health services within a medical home for homeless persons. Subst Abus 2018; 39:354-360. [PMID: 29412071 DOI: 10.1080/08897077.2018.1437500] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The Veterans Health Administration (VHA) established a patient-centered medical home model of care for veterans experiencing homelessness called a Homeless Patient Aligned Care Team (HPACT) to improve engagement with primary care and reduce utilization of hospital-based services. To evaluate the impact of the HPACT model, this study compares the number and type of health care visits in the 12 months before and after enrollment in HPACT at one VHA facility, and explores patient characteristics associated with increases and decreases in visits. METHODS Chart reviews of VHA medical records were conducted for all patients enrolled in an HPACT in Pittsburgh, Pennsylvania, between May 2012 and December 2013 (N = 179). Multivariable mixed-effect logistic regressions estimated differences in having any visit in the 0-6 months and 7-12 months before and after HPACT enrollment, and multinomial logistic regressions predicted increases or decreases versus no change in number of visits over 12 months. RESULTS Compared with 0-6 months prior to HPACT, patients were more likely to visit primary care in the 0-6 months (adjusted odds ratio [aOR] = 4.91, 95% confidence interval [CI] = 2.94-8.20) and 7-12 months (aOR = 2.30, 95% CI = 1.42-3.72) following HPACT. Patients were less likely to visit the emergency department (ED) or to be hospitalized in the 0-6 months (aOR = 0.57, 95% CI = 0.34-0.94; and aOR = 0.55, 95% CI = 0.25-0.76) and 7-12 months (aOR = 0.43, 95% CI = 0.33-0.91; and aOR = 0.45, 95% CI = 0.26-0.80) following HPACT. Patients were less likely to visit mental health (aOR = 0.35, 95% CI = 0.20-0.60) and addiction specialists (aOR = 0.39, 95% CI = 0.18-0.84) in the 7-12 months following HPACT. Overall, 59% of patients had increases in primary care visits following HPACT. Female patients and those with self-housing were less likely to have increases versus no change in primary care visits (adjusted relative risk ratio [aRRR] = 0.15, 95% CI = 0.03-0.74; and aRRR = 0.35, 95% CI = 0.14-0.90). CONCLUSIONS An integrated HPACT model was successful in engaging homeless veterans in primary care for 1 year, potentially contributing to reductions in ED use. More tailored approaches may be needed for vulnerable populations experiencing homelessness, including homeless women.
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Affiliation(s)
- Audrey L Jones
- a Informatics , Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center of Innovation, VA Salt Lake City Health Care System , Salt Lake City , Utah , USA.,b Department of Internal Medicine , University of Utah School of Medicine , Salt Lake City , Utah , USA
| | - Roxanne Thomas
- c Providence Milwaukie Hospital , Milwaukie , Oregon , USA
| | | | - Shaddy K Saba
- e Center for Health Equity Research and Promotion (CHERP) , VA Pittsburgh Healthcare System , Pittsburgh , Pennsylvania , USA
| | - James Conley
- e Center for Health Equity Research and Promotion (CHERP) , VA Pittsburgh Healthcare System , Pittsburgh , Pennsylvania , USA
| | - Adam J Gordon
- a Informatics , Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center of Innovation, VA Salt Lake City Health Care System , Salt Lake City , Utah , USA.,b Department of Internal Medicine , University of Utah School of Medicine , Salt Lake City , Utah , USA.,f Department of Psychiatry , University of Utah School of Medicine , Salt Lake City , Utah , USA
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16
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New Evidence Reflecting VA's Commitment to Achieve Health and Health Care Equity for All Veterans. Med Care 2017; 55 Suppl 9 Suppl 2:S1-S3. [PMID: 28806358 DOI: 10.1097/mlr.0000000000000782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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