Applying the chronic care model to homeless veterans: effect of a population approach to primary care on utilization and clinical outcomes

How do health system factors (funding and performance) impact on access to healthcare for populations experiencing homelessness: a realist evaluation

BACKGROUND

People experiencing long-term homelessness face significant difficulties accessing appropriate healthcare at the right time and place. This study explores how and why healthcare performance management and funding arrangements contribute to healthcare accessibility or the lack thereof using long-term homeless adults as an example of a population experiencing social exclusion.

METHODS

A realist evaluation was undertaken. Thirteen realist interviews were conducted after which data were transcribed, coded, and analysed.

RESULTS

Fourteen CMOCs were created based on analysis of the data collected. These were then consolidated into four higher-level CMOCs. They show that health systems characterised by fragmentation are designed to meet their own needs above the needs of patients, and they rely on practitioners with a special interest and specialised services to fill the gaps in the system. Key contexts identified in the study include: health system fragmentation; health service fragmentation; bio-medical, one problem at a time model; responsive specialised services; unresponsive mainstream services; national strategy; short health system funding cycles; and short-term goals.

CONCLUSION

When health services are fragmented and complex, the needs of socially excluded populations such as those experiencing homelessness are not met. Health systems focus on their own metrics and rely on separate actors such as independent NGOs to fill gaps when certain people are not accommodated in the mainstream health system. As a result, health systems lack a comprehensive understanding of the needs of all population groups and fail to plan adequately, which maintains fragmentation. Policy makers must set policy and plan health services based on a full understanding of needs of all population groups.

Integration, effectiveness and costs of different models of primary health care provision for people who are homeless: an evaluation study

Background

There is a high prevalence of health problems among single people who are homeless. Specialist primary health care services for this population have been developed in several locations across England; however, there have been very few evaluations of these services.

Objectives

This study evaluated the work of different models of primary health care provision in England to determine their effectiveness in engaging people who are homeless in health care and in providing continuity of care for long-term conditions. It concerned single people (not families or couples with dependent children) staying in hostels, other temporary accommodation or on the streets. The influence on outcomes of contextual factors and mechanisms (service delivery factors), including integration with other services, were examined. Data from medical records were collated on participants' use of health care and social care services over 12 months, and costs were calculated.

Design and setting

The evaluation involved four existing Health Service Models: (1) health centres primarily for people who are homeless (Dedicated Centres), (2) Mobile Teams providing health care in hostels and day centres, (3) Specialist GPs providing some services exclusively for patients who are homeless and (4) Usual Care GPs providing no special services for people who are homeless (as a comparison). Two Case Study Sites were recruited for each of the specialist models, and four for the Usual Care GP model.

Participants

People who had been homeless during the previous 12 months were recruited as 'case study participants'; they were interviewed at baseline and at 4 and 8 months, and information was collected about their circumstances and their health and service use in the preceding 4 months. Overall, 363 participants were recruited; medical records were obtained for 349 participants. Interviews were conducted with 65 Case Study Site staff and sessional workers, and 81 service providers and stakeholders.

Results

The primary outcome was the extent of health screening for body mass index, mental health, alcohol use, tuberculosis, smoking and hepatitis A among participants, and evidence of an intervention if a problem was identified. There were no overall differences in screening between the models apart from Mobile Teams, which scored considerably lower. Dedicated Centres and Specialist GPs were more successful in providing continuity of care for participants with depression and alcohol and drug problems. Service use and costs were significantly higher for Dedicated Centre participants and lower for Usual Care GP participants. Participants and staff welcomed flexible and tailored approaches to care, and related services being available in the same building. Across all models, dental needs were unaddressed and staff reported poor availability of mental health services.

Limitations

There were difficulties recruiting mainstream general practices for the Usual Care GP model. Medical records could not be accessed for 14 participants of this model.

Conclusions

Participant characteristics, contextual factors and mechanisms were influential in determining outcomes. Overall, outcomes for Dedicated Centres and for one of the Specialist GP sites were relatively favourable. They had dedicated staff for patients who were homeless, 'drop-in' services, on-site mental health and substance misuse services, and worked closely with hospitals and homelessness sector services.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (HSDR 13/156/03) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 16. See the NIHR Journals Library website for further project information.

Co-occurring Medical Multimorbidity, Mental Illness, and Substance Use Disorders Among Older Criminal Legal System-Involved Veterans

BACKGROUND

Older veterans involved in the criminal legal system (CLS) may have patterns of multimorbidity that place them at risk for poor health outcomes.

OBJECTIVES

To estimate the prevalence of medical multimorbidity (≥2 chronic medical diseases), substance use disorders (SUDs), and mental illness among CLS-involved veterans aged 50 and older.

RESEARCH DESIGN

Using Veterans Health Administration health records, we estimated the prevalence of mental illness, SUD, medical multimorbidity, and the co-occurrence of these conditions among veterans by CLS involvement as indicated by Veterans Justice Programs encounters. Multivariable logistic regression models assessed the association between CLS involvement, the odds for each condition, and the co-occurrence of conditions.

SUBJECTS

Veterans aged 50 and older who received services at Veterans Health Administration facilities in 2019 (n=4,669,447).

METHODS

Mental illness, SUD, medical multimorbidity.

RESULTS

An estimated 0.5% (n=24,973) of veterans aged 50 and older had CLS involvement. For individual conditions, veterans with CLS involvement had a lower prevalence of medical multimorbidity compared with veterans without but had a higher prevalence of all mental illnesses and SUDs. After adjusting for demographic factors, CLS involvement remained associated with concurrent mental illness and SUD (adjusted odds ratio [aOR] 5.52, 95% CI=5.35-5.69), SUD and medical multimorbidity (aOR=2.09, 95% CI=2.04-2.15), mental illness and medical multimorbidity (aOR=1.04, 95% CI=1.01-1.06), and having all 3 simultaneously (aOR=2.42, 95% CI=2.35-2.49).

CONCLUSIONS

Older veterans involved in the CLS are at high risk for co-occurring mental illness, SUDs, and medical multimorbidity, all of which require appropriate care and treatment. Integrated care rather than disease-specific care is imperative for this population.

A Sanctioned Encampment as a Strategy for Increasing Homeless Veterans' Access to Housing and Healthcare During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic intersected with a housing crisis for unsheltered Veterans experiencing homelessness (VEHs); congregate settings became high risk for viral spread. The VA Greater Los Angeles responded by creating the Care, Treatment, and Rehabilitation Service (CTRS), an outdoor, low-barrier-to-entry transitional housing program on VA grounds. This novel emergency initiative offered a protected outdoor environment ("sanctioned encampment") where VEHs lived in tents and had access to three meals a day, hygiene resources, and health and social services.

OBJECTIVE

To identify contextual factors that supported and impeded CTRS participants' access to healthcare and housing services.

DESIGN

Multi-method, ethnographic data collection.

PARTICIPANTS

VEHs residing at CTRS, CTRS staff.

APPROACH

Over 150 hours of participant observation were conducted at CTRS and at eight town hall meetings; semi-structured interviews were conducted with 21 VEHs and 11 staff. Rapid turn-around qualitative analysis was used to synthesize data, engaging stakeholders in iterative participant validation. Content analysis techniques were used to identify key factors that impacted access to housing and health services among VEHs residing in CTRS.

KEY RESULTS

Staff varied in their interpretation of CTRS' mission. Some conceptualized access to health services as a central tenet, while others viewed CTRS as an emergency shelter only. Regardless, staff burnout was prevalent, which lead to low morale, high turnover, and worsened access to and quality of care. VEHs endorsed trusting, long-term relationships with CTRS staff as paramount for facilitating access to services. Though CTRS addressed basic priorities (food, shelter, etc.) that traditionally compete with access to healthcare, some VEHs needed on-site healthcare services, at their tents, to access care.

CONCLUSIONS

CTRS provided VEHs access to basic needs and health and housing services. To improve access to healthcare services within encampments, our data suggest the value of longitudinal trusting relationships, adequate staff support, and on-site health services.

Purity, Danger, and Patriotism: The Struggle for a Veteran Home during the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic rendered congregate shelter settings high risk, creating vulnerability for people experiencing homelessness (PEH). This study employed participant observation and interviews over 16 months in two Veteran encampments, one located on the grounds of the West Los Angeles Veteran Affairs Medical Center (WLAVA) serving as an emergency COVID-19 mitigation measure, and the other outside the WLAVA gates protesting the lack of onsite VA housing. Study participants included Veterans and VA personnel. Data were analyzed using grounded theory, accompanied by social theories of syndemics, purity, danger, and home. The study reveals that Veterans conceptualized home not merely as physical shelter but as encompassing a sense of inclusion and belonging. They sought a Veteran-run collective with a harm reduction approach to substance use, onsite healthcare, and inclusive terms (e.g., no sobriety requirements, curfews, mandatory treatment, or limited lengths of stay). The twin encampments created distinct forms of community and care that protected Veterans from COVID-19 infection and bolstered collective survival. The study concludes that PEH constitute and belong to communities that provide substantial benefits even while amplifying certain harms. Housing interventions must consider how unhoused individuals become, or fail to become, integrate into various communities, and foster therapeutic community connections.

Primary Care for Veterans Experiencing Homelessness: a Narrative Review of the Homeless Patient Aligned Care Team (HPACT) Model

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.

Navigator programme for hospitalised adults experiencing homelessness: protocol for a pragmatic randomised controlled trial

INTRODUCTION

People experiencing homelessness suffer from poor outcomes after hospitalisation due to systemic barriers to care, suboptimal transitions of care, and intersecting health and social burdens. Case management programmes have been shown to improve housing stability, but their effects on broad posthospital outcomes in this population have not been rigorously evaluated. The Navigator Programme is a Critical Time Intervention case management programme that was developed to help homeless patients with their postdischarge needs and to link them with community-based health and social services. This randomised controlled trial examines the impact of the Navigator Programme on posthospital outcomes among adults experiencing homelessness.

METHODS AND ANALYSIS

This is a pragmatic randomised controlled trial testing the effectiveness of the Navigator Programme at an urban academic teaching hospital and an urban community teaching hospital in Toronto, Canada. Six hundred and forty adults experiencing homelessness who are admitted to the hospital will be randomised to receive support from a Homeless Outreach Counsellor for 90 days after hospital discharge or to usual care. The primary outcome is follow-up with a primary care provider (physician or nurse practitioner) within 14 days of hospital discharge. Secondary outcomes include postdischarge mortality or readmission, number of days in hospital, number of emergency department visits, self-reported care transition quality, and difficulties meeting subsistence needs. Quantitative outcomes are being collected over a 180-day period through linked patient-reported and administrative health data. A parallel mixed-methods process evaluation will be conducted to explore intervention context, implementation and mechanisms of impact.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Unity Health Toronto Research Ethics Board. Participants will be required to provide written informed consent. Results of the main trial and process evaluation will be reported in peer-reviewed journals and shared with hospital leadership, community partners and policy makers.

TRIAL REGISTRATION NUMBER

NCT04961762.

Homelessness and Race are Mortality Predictors in US Veterans Undergoing CABG

Coronary artery disease requiring surgical revascularization is prevalent in United States Veterans. We aimed to investigate preoperative predictors of 30-day mortality following coronary artery bypass grafting (CABG) in the Veteran population. The Veterans Affairs Surgical Quality Improvement (VASQIP) national database was queried for isolated CABG cases between 2008 and 2018. The primary outcome was 30-day mortality. A multivariable logistic regression was performed to assess for independent predictors of the primary outcome. A P-value of <0.05 was considered statistically significant. A total of 32,711 patients were included. The 30-day mortality rate was 1.37%. Multivariable analysis identified the following predictors of 30-day mortality: African-American race (OR 1.46, 95% CI 1.09-1.96); homelessness (OR 6.49, 95% CI 3.39-12.45); female sex (OR 2.15, 95% CI 1.08-4.30); preoperative myocardial infarction within 7 days (OR 1.49, 95% CI 1.06-2.10) or more than 7 days before CABG (OR 1.34, 95% CI 1.04-1.72); partially/fully dependent functional status (OR 1.44, 95% CI 1.07-1.93); chronic obstructive pulmonary disease (OR 1.54, 95% CI 1.24-1.92); mild (OR 1.48, 95% CI 1.04-2.11) and severe aortic stenosis (OR 2.06, 95% CI 1.37-3.09); moderate (OR 1.88, 95% CI 1.31-2.72), or severe (OR 2.99, 95% CI 1.71-5.22) mitral regurgitation; cardiomegaly (OR 1.73, 95% CI 1.35-2.22); NYHA Class III/IV heart failure (OR 2.05, 95% CI 1.10-3.83); and urgent/emergent operation (OR 1.42, 95% CI 1.08-1.87). The 30-day mortality rate in US Veterans undergoing isolated CABG between 2008 and 2018 was 1.37%. In addition to established clinical factors, African-American race and homelessness were independent demographic predictors of 30-day mortality.

Primary Care Engagement Among Individuals with Experiences of Homelessness and Serious Mental Illness: an Evidence Map

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.

Systematic Review of Care Coordination Interventions Linking Health and Social Services for High-Utilizing Patient Populations

Recognizing that social factors influence patient health outcomes and utilization, health systems have developed interventions to address patients' social needs. Care coordination across the health care and social service sectors is a distinct and important strategy to address social determinants of health, but limited information exists about how care coordination operates in this context. To address this gap, the authors conducted a systematic review of peer-reviewed publications that document the coordination of health care and social services in the United States. After a structured elimination process, 25 publications of 19 programs were synthesized to identify patterns in care coordination implementation. Results indicate that patient needs assessment, in-person patient contact, and standardized care coordination protocols are common across programs that bridge health care and social services. Publications discussing these programs often provide limited detail on other key elements of care coordination, especially the nature of referrals and care coordinator caseload. Additional research is needed to document critical elements of program implementation and to evaluate program impacts.

Out of the trenches; prevalence of Australian veterans among the homeless population and the implications for public health

OBJECTIVES

To examine the prevalence of Australian Defence Force veterans among people sleeping rough and explore their health and social needs relative to non-veteran rough sleepers.

METHOD

Analysis of responses to the Vulnerability Index - Service Prioritisation Decision Assistance Tool (VI-SPDAT) collected from 8,027 rough sleepers across five Australian States from 2010-2017.

RESULTS

Veterans were found to comprise 5.6% of people sleeping rough in Australia, with veterans reporting having spent an average of 6.3 years on the street or in emergency accommodation (compared with an average of five years for their non-veterans counterparts). Veterans had a higher prevalence of self-reported physical health, mental health and social issues compared with non-veteran rough sleepers.

CONCLUSIONS

This is the first study of its kind to elucidate the presence of Australian veterans among people sleeping rough. That they are likely to have spent more years on the street, and have a higher prevalence of health and social issues, highlights the imperative for earlier intervention and prevention of veteran homelessness itself, and its health impacts. Implications for public health: Veteran homelessness has been comparatively hidden in Australia compared to other countries, and consequently the myriad of health, psychosocial and adjustment issues faced by homeless veterans has also been hidden. With heightened attention on veteran suicide and self-harm, earlier intervention to prevent veterans becoming homeless constitutes sound public health prevention and mental health policy.

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.

Comparison of Patient Experience Between Primary Care Settings Tailored for Homeless Clientele and Mainstream Care Settings

BACKGROUND

More than 1 million Americans receive primary care from federal homeless health care programs yearly. Vulnerabilities that can make care challenging include pain, addiction, psychological distress, and a lack of shelter. Research on the effectiveness of tailoring services for this population is limited.

OBJECTIVE

The aim was to examine whether homeless-tailored primary care programs offer a superior patient experience compared with nontailored ("mainstream") programs overall, and for highly vulnerable patients.

RESEARCH DESIGN

National patient survey comparing 26 US Department of Veterans Affairs (VA) Medical Centers' homeless-tailored primary care ("H-PACT"s) to mainstream primary care ("mainstream PACT"s) at the same locations.

PARTICIPANTS

A total of 5766 homeless-experienced veterans.

MEASURES

Primary care experience on 4 scales: Patient-Clinician Relationship, Cooperation, Accessibility/Coordination, and Homeless-Specific Needs. Mean scores (range: 1-4) were calculated and dichotomized as unfavorable versus not. We counted key vulnerabilities (chronic pain, unsheltered homelessness, severe psychological distress, and history of overdose, 0-4), and categorized homeless-experienced veterans as having fewer (≤1) and more (≥2) vulnerabilities.

RESULTS

H-PACTs outscored mainstream PACTs on all scales (all P<0.001). Unfavorable care experiences were more common in mainstream PACTs compared with H-PACTs, with adjusted risk differences of 11.9% (95% CI=6.3-17.4), 12.6% (6.2-19.1), 11.7% (6.0-17.3), and 12.6% (6.2-19.1) for Relationship, Cooperation, Access/Coordination, and Homeless-Specific Needs, respectively. For the Relationship and Cooperation scales, H-PACTs were associated with a greater reduction in unfavorable experience for patients with ≥2 vulnerabilities versus ≤1 (interaction P<0.0001).

CONCLUSIONS

Organizations that offer primary care for persons experiencing homelessness can improve the primary care experience by tailoring the design and delivery of services.

Contexts and mechanisms that promote access to healthcare for populations experiencing homelessness: a realist review

Objective

The objective of this study was to identify and understand the health system contexts and mechanisms that allow for homeless populations to access appropriate healthcare when needed.

Design

A realist review.

Data sources

Ovid MEDLINE, embase.com, CINAHL, ASSIA and grey literature until April 2019.

Eligibility criteria for selecting studies

The purpose of the review was to identify health system patterns which enable access to healthcare for people who experience homelessness. Peer-reviewed articles were identified through a systematic search, grey literature search, citation tracking and expert recommendations. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded to identify data relating to contexts, mechanisms and/or outcomes.

Analysis

Inductive and deductive coding was used to generate context–mechanism–outcome configurations, which were refined and then used to build several iterations of the overarching programme theory.

Results

Systematic searching identified 330 review articles, of which 24 were included. An additional 11 grey literature and primary sources were identified through citation tracking and expert recommendation. Additional purposive searching of grey literature yielded 50 records, of which 12 were included, for a total of 47 included sources. The analysis found that healthcare access for populations experiencing homelessness is improved when services are coordinated and delivered in a way that is organised around the person with a high degree of flexibility and a culture that rejects stigma, generating trusting relationships between patients and staff/practitioners. Health systems should provide long-term, dependable funding for services to ensure sustainability and staff retention.

Conclusions

With homelessness on the rise internationally, healthcare systems should focus on high-level factors such as funding stability, building inclusive cultures and setting goals which encourage and support staff to provide flexible, timely and connected services to improve access.

Pharmacist led homeless outreach engagement and non-medical independent prescribing (Rx) (PHOENIx) intervention for people experiencing homelessness: a non- randomised feasibility study

BACKGROUND

Homelessness and associated mortality and multimorbidity rates are increasing. Systematic reviews have demonstrated a lack of complex interventions that decrease unscheduled emergency health services utilisation or increase scheduled care. Better evidence is needed to inform policy responses. We examined the feasibility of a complex intervention (PHOENIx: Pharmacist led Homeless Outreach Engagement Nonmedical Independent prescribing (Rx)) to inform a subsequent pilot randomised controlled trial (RCT).

METHODS

Non-randomised trial with Usual Care (UC) comparator group set in Greater Glasgow and Clyde Health Board, Scotland. Participants were adult inpatients experiencing homelessness in a city centre Glasgow hospital, referred to the PHOENIx team at the point of hospital discharge, from 19th March 2018 until 6th April 2019. The follow up period for each patient started on the day the patient was first seen (Intervention group) or first referred (UC), until 24th August 2019, the censor date for all patients. All patients were offered and agreed to receive serial consultations with the PHOENIx team (NHS Pharmacist prescriber working with Simon Community Scotland (third sector homeless charity worker)). Patients who could not be reached by the PHOENIx team were allocated to the UC group. The PHOENIx intervention included assessment of physical/mental health, addictions, housing, benefits and social activities followed by pharmacist prescribing with referral to other health service specialities as necessary. All participants received primary (including specialist homelessness health service based general practitioner care, mental health and addictions services) and secondary care. Main outcome measures were rates of: recruitment; retention; uptake of the intervention; and completeness of collected data, from recruitment to censor date.

RESULTS

Twenty four patients were offered and agreed to participate; 12 were reached and received the intervention as planned with a median 7.5 consultations (IQR3.0-14.2) per patient. The pharmacist prescribed a median of 2 new (IQR0.3-3.8) and 2 repeat (1.3-7.0) prescriptions per patient; 10(83%) received support for benefits, housing or advocacy. Twelve patients were not subsequently contactable after leaving hospital, despite agreeing to participate, and were assigned to UC. Two patients in the UC group died of drug/alcohol overdose during follow up; no patients in the Intervention group died. All 24 patients were retained in the intervention or UC group until death or censor date and all patient records were accessible at follow up: 11(92%) visited ED in both groups, with 11(92%) hospitalisations in intervention group, 9(75%) UC. Eight (67%) intervention group patients and 3(25%) UC patients attended scheduled out patient appointments.

CONCLUSIONS

Feasibility testing of the PHOENIx intervention suggests merit in a subsequent pilot RCT.

Health Status and Chronic Disease Burden of the Homeless Population: An Analysis of Two Decades of Multi-Institutional Electronic Medical Records

Using a multi-institutional EMR registry, we extracted housing status and evaluated the presence of several important comorbidities in order to describe the demographics and comorbidity burden of persons experiencing homelessness in northeast Ohio and compare this to non-homeless individuals of varying socioeconomic position. Of 1,974,766 patients in the EMR registry, we identified 15,920 (0.8%) as homeless, 351,279 (17.8%) as non-homeless and in the top quintile of area deprivation index (ADI), and 1,607,567 (81.4%) as non-homeless and in the lower four quintiles of area deprivation. The comorbidity burden was highest in the homeless population with depression (48.1%), anxiety (45.8%), hypertension (44.2%), cardiovascular disease (18.4%), and hepatitis (18.1%) among the most prevalent conditions. We conclude that it is possible to identify homeless individuals and document their comorbidity burden using a multi-institutional EMR registry, in order to guide future interventions to address the health of the homeless at the health-system and community level.

Diabetes management interventions for homeless adults: a systematic review

OBJECTIVES

Recent studies investigating diabetes show that inequalities to access appropriate care still persists. Whilst most of the general population are able to access a suitable quality of care, there are a number of groups who fail to receive the same standard. The objective of this review was to identify existing diabetes management interventions for homeless adults.

METHODS

A literature search was conducted in February 2017, and repeated in September 2020.

RESULTS

Of the 223 potentially relevant articles identified, only 26 were retrieved for detailed evaluation, and 6 met the inclusion criteria. Papers focusing on the management of diabetes in homeless people were included. The studies used interventions including diabetes education; medication support and supplies for blood monitoring; improvements in self-care behaviours; improvements in diabetes control; patient empowerment/engagement; and community engagement/partnerships.

CONCLUSIONS

Effective strategies for addressing the challenges and obstacles that the homeless population face, requires innovative, multi-sectored, flexible and well-coordinated models of care. Without appropriate support, these groups of people are prone to experience poor control of their diabetes; resulting in an increased risk of developing major health complications.

Impact of Healthcare Delivery System Type on Clinical, Utilization, and Cost Outcomes of Patient-Centered Medical Homes: a Systematic Review

BACKGROUND

As healthcare reimbursement shifts from being volume to value-focused, new delivery models aim to coordinate care and improve quality. The patient-centered medical home (PCMH) model is one such model that aims to deliver coordinated, accessible healthcare to improve outcomes and decrease costs. It is unclear how the types of delivery systems in which PCMHs operate differentially impact outcomes. We aim to describe economic, utilization, quality, clinical, and patient satisfaction outcomes resulting from PCMH interventions operating within integrated delivery and finance systems (IDFS), government systems including Veterans Administration, and non-integrated delivery systems.

METHODS

We searched PubMed, the Cochrane Library, and Embase from 2004 to 2017. Observational studies and clinical trials occurring within the USA that met PCMH criteria (as defined by the Agency for Healthcare Research and Quality), addressed ambulatory adults, and reported utilization, economic, clinical, processes and quality of care, or patient satisfaction outcomes.

RESULTS

Sixty-four studies were included. Twenty-four percent were within IDFS, 29% were within government systems, and 47% were within non-IDFS. IDFS studies reported decreased emergency department use, primary care use, and cost relative to other systems after PCMH implementation. Government systems reported increased primary care use relative to other systems after PCMH implementation. Clinical outcomes, processes and quality of care, and patient satisfaction were assessed heterogeneously or infrequently.

DISCUSSION

Published articles assessing PCMH interventions generally report improved outcomes related to utilization and cost. IDFS and government systems exhibit different outcomes relative to non-integrated systems, demonstrating that different health systems and populations may be particularly sensitive to PCMH interventions. Both the definition of PCMH interventions and outcomes measured are heterogeneous, limiting the ability to perform direct comparisons or meta-analysis.

Non-communicable Disease among Homeless Men in Nagoya, Japan: Relationship between Metabolic Abnormalities and Sociodemographic Backgrounds

Objective To examine the degree of metabolic abnormalities and their association with the sociodemographic background or mental illness/cognitive disability among homeless men in Nagoya, Japan. Methods We interviewed 106 homeless men (aged 54.2±12.7 years) and measured their metabolic parameters. Mental illness and cognitive disability were diagnosed using the Mini-International Neuropsychiatric Interview and Wechsler Adult Intelligence Scale-III test, respectively. Associations between metabolic abnormalities and the sociodemographic background or mental illness/cognitive disability were analyzed. Results There were significant correlations of liver dysfunction (AST≥35 IU, ALT≥35 IU, γ-GTP≥75 IU), hypertension [systolic/diastolic blood pressure (BP) ≥140/90 mmHg], and dyslipidemia (HDL <40 mg/dL) with the history/duration of homelessness (over 2 times/year) and residence status (living on the streets). Although the mean body mass index (BMI), BP, HbA1c, and LDL in participants living in temporary residences were similar to those obtained from the general population data from National Health Nutrition Survey (NHNS) 2016, the systolic/diastolic BP in those living on the street was significantly higher than in the general population, and the HDL in those living in temporary residences was significantly lower than in those reported in the NHNS 2016 data. In the group with cognitive disability, the ALT, TG, and BMI values were significantly higher and the HDL level significantly lower in those living in temporary residences than in those living on the streets. Conclusion Stressful conditions while living on the streets may exacerbate hypertension and liver dysfunction, and unhealthy food habits when living in a temporary residence may exacerbate low HDL levels. In addition, an inability to self-manage due to cognitive disability may increase the ALT, TG, and BMI values. The provision of homeless people with the skills to sustain independent living conditions and ensure a healthy diet is required.

The effects of the introduction of a chronic care model-based program on utilization of healthcare resources: the results of the Puglia care program

Background

Ageing is continuously increasing the prevalence of patients with chronic conditions, putting pressure on the sustainability of Healthcare Systems. Chronic Care Models (CCM) have been used to address the needs of frail people in the continuum of care, testifying to an improvement in health outcomes and more efficient access to healthcare services. The impact of CCM deployment has already been experienced in a selected cohort of patients affected by specific chronic illnesses. We have investigated its effects in a heterogeneous frail cohort included in a regional CCM-based program.

Methods

a retrospective population-based cohort study was carried out involving a non-oncological cohort of adult subjects with chronic diseases included in the CCM-oriented program (Puglia Care). Individuals in usual care with comparable demographic and clinical characteristics were selected for matched pair analysis. Study cohorts were defined by using a record linkage analysis of administrative databases and electronic medical records, including data on the adult population in the 6 local area health authorities of Puglia in Italy (approximately 2 million people). The effects of Puglia Care on the utilizations of healthcare resources were evaluated both in a before-after and in a case-control analysis.

Results

There were 1074 subjects included in Puglia Care and 2126 matched controls. In before-after analysis of the Puglia Care cohort, 240 unplanned hospitalizations occurred in the pre-inclusion period, while 239 were registered during follow-up. The incidence of unplanned hospitalization was 10.3 per 100 person/year (95% CI, 9.1–11.7) during follow-up and 12.1 per 100 person/year (95% CI, 10.7–13.8) in the pre-inclusion period (IRR, 0.84; 95% CI, 0.80–0.99). During follow-up a significant reduction in costs related to unplanned hospitalizations (IRR, 0.92; 95% CI, 0.91–0.92) was registered, while costs related to drugs (IRR, 1.14; p < 0.01), out-patient specialist visits (IRR, 1.19; p < 0.01), and planned hospitalization (IRR 1.03; p < 0.01) increased significantly. These modifications can be related to the aging of the population and modifications to healthcare delivery; for this reason, a case-control analysis was performed. The results testify to a significantly lower number (IRR, 0.79; 95% CI, 0.68–0.91), length of hospital stay (IRR, 0.80; 95% CI, 0.76–0.84), and costs related to unplanned hospitalizations (IRR, 0.80; 95% CI, 0.80–0.80) during follow-up in the intervention group. However, there was a higher increase in costs of hospitalizations, drugs and out-patients specialist visits during follow-up in Puglia Care when compared with patients in usual care.

Conclusion

In a population-based cohort, inclusion of chronic patients in a CCM-based program was significantly associated with a lower recourse to unplanned hospital admissions when compared with patients in usual care with comparable clinical and demographic characteristics.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3075-0) contains supplementary material, which is available to authorized users.

Population-Tailored Care for Homeless Veterans and Acute Care Use, Cost, and Satisfaction: A Prospective Quasi-Experimental Trial

Introduction

Although traditional patient-centered medical homes (PCMHs) are effective for patients with complex needs, it is unclear whether homeless-tailored PCMHs work better for homeless veterans. We examined the impact of enrollment in a Veterans Health Administration (VHA) homeless-tailored PCMH on health services use, cost, and satisfaction compared with enrollment in a traditional, nontailored PCMH.

Methods

We conducted a prospective, multicenter, quasi-experimental, single-blinded study at 2 VHA medical centers to assess health services use, cost, and satisfaction during 12 months among 2 groups of homeless veterans: 1) veterans receiving VHA homeless-tailored primary care (Homeless-Patient Aligned Care Team [H-PACT]) and 2) veterans receiving traditional primary care services (PACT). A cohort of 266 homeless veterans enrolled from June 2012 through January 2014.

Results

Compared with PACT patients, H-PACT patients had more social work visits (4.6 vs 2.7 visits) and fewer emergency department (ED) visits for ambulatory care-sensitive conditions (0 vs 0.2 visits); a significantly smaller percentage of veterans in H-PACT were hospitalized (23.1% vs 35.4%) or had mental health–related ED visits (34.1% vs 47.6%). We found significant differences in primary care provider–specific visits (H-PACT, 5.1 vs PACT, 3.6 visits), mental health care visits (H-PACT, 8.8 vs PACT, 13.4 visits), 30-day prescription drug fills (H-PACT, 40.5 vs PACT, 58.8 fills), and use of group therapy (H-PACT, 40.1% vs PACT, 53.7%). Annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036). In logistic regression model of acute care use, assignment to the H-PACT model was protective as was rating health “good” or better.

Conclusion

Homeless veterans enrolled in the population-tailored primary care approach used less acute care and costs were lower. Tailored-care models have implications for care coordination in the US Department of Veterans Affairs VA and community health systems.

Improving Health Care Management in Primary Care for Homeless People: A Literature Review

BACKGROUND

Homeless people have poorer health status than the general population. They need complex care management, because of associated medical troubles (somatic and psychiatric) and social difficulties. We aimed to describe the main characteristics of the primary care programs that take care of homeless people, and to identify which could be most relevant.

METHODS

We performed a literature review that included articles which described and evaluated primary care programs for homeless people.

RESULTS

Most of the programs presented a team-based approach, multidisciplinary and/or integrated care. They often proposed co-located services between somatic health services, mental health services and social support services. They also tried to answer to the specific needs of homeless people. Some characteristics of these programs were associated with significant positive outcomes: tailored primary care organizations, clinic orientation, multidisciplinary team-based models which included primary care physicians and clinic nurses, integration of social support, and engagement in the community's health.

CONCLUSIONS

Primary health care programs that aimed at taking care of the homeless people should emphasize a multidisciplinary approach and should consider an integrated (mental, somatic and social) care model.

What are the key elements for implementing intensive primary care? A multisite Veterans Health Administration case study

Many integrated health systems and accountable care organizations have turned to intensive primary care programs to improve quality of care and reduce costs for high-need high-cost patients. How best to implement such programs remains an active area of discussion. In 2014, the Veterans Health Administration (VHA) implemented five distinct intensive primary care programs as part of a demonstration project that targeted Veterans at the highest risk for hospitalization. We found that programs evolved over time, eventually converging on the implementation of the following elements: 1) an interdisciplinary care team, 2) chronic disease management, 3) comprehensive patient assessment and evaluation, 4) care and case management, 5) transitional care support, 6) preventive home visits, 7) pharmaceutical services, 8) chronic disease self-management, 9) caregiver support services, 10) health coaching, and 11) advanced care planning. The teams also found that including social workers and mental health providers on the interdisciplinary teams was critical to effectively address psychosocial needs of these complex patients. Having a central implementation coordinator facilitated the convergence of these program features across diverse demonstration sites. In future iterations of these programs, VHA intends to standardize staffing and key features to develop a scalable program that can be disseminated throughout the system.

Homeless veterans' experiences with substance use, recovery, and treatment through photo elicitation

BACKGROUND

Homeless veterans often have addictions and comorbidities that complicate utilization of longitudinal health care services, such as primary care. An understanding of experiences of veterans enrolled in a Homeless Patient Aligned Care Team (H-PACT) may improve addiction treatment engagement in these settings. The authors aimed to describe H-PACT veterans' experiences with substance use (SU), substance use recovery (SUR), and substance use treatment (SUT).

METHODS

Homeless veterans were recruited from a veteran primary care medical home clinic between September 2014 and March 2015. Twenty veterans were given digital cameras and prompts for taking photographs about their health and health care and participated in 2 photo elicitation interviews. For this secondary analysis, transcripts from the audio-recorded interviews were analyzed by 2 coders using qualitative content analysis.

RESULTS

The majority of participants (75%, n = 15) discussed SU, SUR, and/or SUT in regards to their health and health care utilization. SU themes centered on disclosure of addiction or dependency; substances used; repercussions of SU; SU as a coping mechanism; and association of SU with military service. SUR themes included disclosure of length of sobriety; perceived facilitators of SUR in health, beliefs, social, environmental, financial, and creative pursuit domains; and perceived barriers to SUR in beliefs, social, and environmental domains. SUT themes focused on perceived facilitators of SUT in access to Department of Veterans Affairs (VA) and non-VA services and social domains and perceived barriers to SUT in the social domain.

CONCLUSIONS

Providers seeking to elicit addiction-related clinical history and facilitate SUR and SUT might look to the current findings for guidance. Provider training in motivational interviewing may be warranted, which allows for an exploration of health-related consequences of SU and supports patients' self-efficacy.

Understanding the health of veterans who are homeless: A review of the literature

The United States Department of Housing and Urban Development estimates that almost 50,000 veterans are homeless on any given night. Homeless veterans are at greater risk of health disparities than their housed counterparts due to the multifactorial nature of their health and social needs. The Department of Veterans Affairs, in collaboration with more than a dozen other federal agencies, has concentrated efforts to improve the health of this vulnerable population while enacting a plan to eliminate veteran homelessness within the near future. Understanding the unique health needs of veterans who are homeless allows the profession of nursing to better support these efforts. The purpose of this literature review was to provide comprehensive knowledge to nurses about the health of homeless veterans for their use in clinical practice, research, and in contributing to the positive health outcomes for this vulnerable population.

Identifying Homeless Medicaid Enrollees Using Enrollment Addresses

OBJECTIVE

To design and test the validity of a method to identify homelessness among Medicaid enrollees using mailing address data.

DATA SOURCES/STUDY SETTING

Enrollment and claims data on Medicaid expansion enrollees in Hennepin and Ramsey counties who also provided self-reported information on their current housing situation in a psychosocial needs assessment.

STUDY DESIGN

Construction of address-based indicators and comparison with self-report data.

PRINCIPAL FINDINGS

Among 1,677 enrollees, 427 (25 percent) self-reported homelessness, of whom 328 (77 percent) had at least one positive address indicator. Depending on the type of addresses included in the indicator, sensitivity to detect self-reported homelessness ranged from 30 to 76 percent and specificity from 79 to 97 percent.

CONCLUSIONS

An address-based indicator can identify a large proportion of Medicaid enrollees who are experiencing homelessness. This approach may be of interest to researchers, states, and health systems attempting to identify homeless populations.

Mental disorders and the use of primary health care services among homeless shelter users in the Helsinki metropolitan area, Finland

Background

Homelessness is associated with increased morbidity, mortality and health care use. The aim of this study was to examine the role of mental disorders in relation to the use of 1) daytime primary health care services and 2) after hours primary health care emergency room (PHER) services among homeless shelter users in the Helsinki Metropolitan Area, Finland.

Methods

The study cohort consists of all 158 homeless persons using the four shelters operating in the study area during two selected nights. The health records were analyzed over a period of 3 years prior to the sample nights and data on morbidity and primary health care visits were gathered. We used negative binomial regression to estimate the association between mental disorders and daytime visits to primary health care and after hours visits to PHERs.

Results

During the 3 years the 158 homeless persons in the cohort made 1410 visits to a physician in primary health care. The cohort exhibited high rates of mental disorders, including substance use disorders (SUDs); i.e. 141 persons (89%) had a mental disorder. We found dual diagnosis, defined as SUD concurring with other mental disorder, to be strongly associated with daytime primary health care utilization (IRR 11.0, 95% CI 5.9–20.6) when compared with those without any mental disorder diagnosis. The association was somewhat weaker for those with only SUDs (IRR 4.9, 95% CI 2.5–9.9) or with only other mental disorders (IRR 5.0, 95% CI 2.4–10.8). When focusing upon the after hours visits to PHERs we observed that both dual diagnosis (IRR 14.1, 95% CI 6.3–31.2) and SUDs (11.5, 95% CI 5.7–23.3) were strongly associated with utilization of PHERs compared to those without any mental disorder. In spite of a high numbers of visits, we found undertreatment of chronic conditions such as hypertension and diabetes.

Conclusions

Dual diagnosis is particularly strongly associated with primary health care daytime visits among homeless persons staying in shelters, while after hours visits to primary health care level emergency rooms are strongly associated with both dual diagnosis and SUDs. Active treatment for SUDs could reduce the amount of emergency visits made by homeless shelter users.

Feasibility and Acceptability of a Colocated Homeless-Tailored Primary Care Clinic and Emergency Department

Objectives: Homeless adults have low primary care engagement and high emergency department (ED) utilization. Homeless-tailored, patient-centered medical homes (PCMH) decrease this population’s acute care use. We studied the feasibility (focused on patient recruitment) and acceptability (conceptualized as clinicians’ attitudes/beliefs) of a pilot initiative to colocate a homeless-tailored PCMH with an ED. After ED triage, low-acuity patients appropriate for outpatient care were screened for homelessness; homeless patients chose between a colocated PCMH or ED visit. Methods: To study feasibility, we captured (from May to September 2012) the number of patients screened for homelessness, positive screens, unique patients seen, and primary care visits. We focused on acceptability to ED clinicians (physicians, nurses, social workers); we sent a 32-item survey to ED clinicians (n = 57) who worked during clinic hours. Questions derived from an instrument measuring clinician attitudes toward homeless persons; acceptability of homelessness screening and the clinic itself were also explored. Results: Over the 5 months of interest, 281 patients were screened; 172 (61.2%) screened positive for homelessness; 112 (65.1%) of these positive screens were seen over 215 visits. Acceptability data were obtained from 56% (n = 32) of surveyed clinicians. Attitudes toward homeless patients were similar to prior studies of primary care physicians. Most (54.6%) clinicians agreed with the homelessness screening procedures. Nearly all (90.3%) clinicians supported expansion of the homeless-tailored clinic; a minority (42.0%) agreed that ED colocation worked well. Conclusion: Our data suggest the feasibility of recruiting patients to a homeless-tailored primary care clinic colocated with the ED; however, the clinic’s acceptability was mixed. Future quality improvement work should focus on tailoring the clinic to increase its acceptability among ED clinicians, while assessing its impact on health, housing, and costs.

Moving From Discovery to System-Wide Change: The Role of Research in a Learning Health Care System: Experience from Three Decades of Health Systems Research in the Veterans Health Administration

The Veterans Health Administration is unique, functioning as an integrated health care system that provides care to more than six million veterans annually and as a home to an established scientific enterprise that conducts more than $1 billion of research each year. The presence of research, spanning the continuum from basic health services to translational research, has helped the Department of Veterans Affairs (VA) realize the potential of a learning health care system and has contributed to significant improvements in clinical quality over the past two decades. It has also illustrated distinct pathways by which research influences clinical care and policy and has provided lessons on challenges in translating research into practice on a national scale. These lessons are increasingly relevant to other health care systems, as the issues confronting the VA—the need to provide timely access, coordination of care, and consistent high quality across a diverse system—mirror those of the larger US health care system.

Comparing the Utilization and Cost of Health Services between Veterans Experiencing Brief and Ongoing Episodes of Housing Instability

Housing instability is associated with costly patterns of health and behavioral health service use. However, little prior research has examined patterns of service use associated with higher costs among those experiencing ongoing housing instability. To address this gap, we compared inpatient and outpatient medical and behavioral health service utilization and costs between veterans experiencing brief and ongoing episodes of housing instability. We used data from a brief screening instrument for homelessness and housing instability that has been implemented throughout the US Department of Veterans Affairs (VA) health care system to identify a national sample of veterans experiencing housing instability. Veterans were classified as experiencing either brief or ongoing housing instability, based on two consecutive responses to the instrument, and we used a series of two-part regression models to conduct adjusted comparisons of costs between veterans experiencing brief and ongoing episodes of housing instability. Among 5794 veterans screening positive for housing instability, 4934 (85%) were experiencing brief and 860 (15%) ongoing instability. The average total annual incremental cost associated with ongoing versus brief episodes of housing instability was estimated at $7573, with the bulk of this difference found in inpatient services. Cost differences resulted more from a higher probability of service use among those experiencing ongoing episodes of housing instability than from higher costs among service users. Our findings suggest that VA programmatic efforts aimed at preventing extended episodes of housing instability could potentially result in substantial cost offsets for the VA health care system.

Differential Impact of Homelessness on Glycemic Control in Veterans with Type 2 Diabetes Mellitus

BACKGROUND

Veterans with evidence of homelessness have high rates of mental health and substance abuse disorders, but chronic medical conditions such as diabetes are also prevalent.

OBJECTIVE

We aimed to determine the impact of homelessness on glycemic control in patients with type 2 diabetes mellitus.

DESIGN

Longitudinal analysis of a retrospective cohort.

SUBJECTS

A national cohort of 1,263,906 Veterans with type 2 diabetes. Subjects with evidence of homelessness were identified using a combination of diagnostic and administrative codes.

MAIN MEASURES

Odds for poor glycemic control using hemoglobin A1C (HbA1C) cutoff values of 8 % and 9 %. Homeless defined as a score based on the number of indicator variables for homelessness within a veterans chart.

KEY RESULTS

Veterans with evidence of homelessness had a significantly greater annual mean HbA1C ≥ 8 (32.6 % vs. 20.43 %) and HbA1C ≥ 9 (21.4 % vs. 9.9 %), tended to be younger (58 vs. 67 years), were more likely to be non-Hispanic black (39.1 %), divorced (43 %) or never married (34 %), to be urban dwelling (88.8 %), and to have comorbid substance abuse (46.7 %), depression (42.3 %), psychoses (39.7 %), liver disease (18.8 %), and fluid/electrolyte disorders (20.4 %), relative to non-homeless veterans (all p < 0.0001). Homelessness was modeled as an ordinal variable that scored the number of times a homelessness indicator was found in the Veterans medical record. We observed a significant interaction between homelessness and race/ethnicity on the odds of poor glycemic control. Homelessness, across all racial-ethnic groups, was associated with increased odds of uncontrolled diabetes at a cut-point of 8 % and 9 % for hemoglobin A1C ; however, the magnitude of the association was greater in non-Hispanic whites [8 %, OR 1.55 (1.47;1.63)] and Hispanics [8 %, OR 2.11 (1.78;2.51)] than in non-Hispanic blacks [8 %, OR 1.22 (1.15;1.28)].

CONCLUSIONS

Homelessness is a significant risk factor for uncontrolled diabetes in Veterans, especially among non-Hispanic white and Hispanic patients. While efforts to engage homeless patients in primary care services have had some success in recent years, these data suggest that broader efforts targeting management of diabetes and other chronic medical conditions remain warranted.

Access to Diabetes Care for Populations Experiencing Homelessness: an Integrated Review

Populations experiencing homelessness with diabetes may encounter barriers to accessing comprehensive diabetes care to manage the condition, yet it is unclear to what extent this population is able to access care. We reviewed the literature to identify and describe the barriers and facilitators to accessing diabetes care and managing diabetes for homeless populations using the Equity of Access to Medical Care Framework. An integrated review of the literature was conducted and yielded 10 articles that met inclusion criteria. Integrated reviews search, summarize, and critique the state of the research evidence. Findings were organized using the dimensions of a comprehensive conceptual framework, the Equity of Access to Medical Care Framework, to identify barriers and facilitators to accessing care and managing diabetes. Barriers included competing priorities, limited access to healthy food, and inadequate healthcare resources. Facilitators to care included integrated delivery systems that provided both social and health-related services, and increased patient knowledge. Recommendations are provided for healthcare providers and public health practitioners to optimize diabetes outcomes for this population.

Diagnoses Treated in Ambulatory Care Among Homeless-Experienced Veterans: Does Supported Housing Matter?

PURPOSE

Little is known about how permanent supported housing influences ambulatory care received by homeless persons. To fill this gap, we compared diagnoses treated in VA Greater Los Angeles (VAGLA) ambulatory care between Veterans who are formerly homeless-now housed/case managed through VA Supported Housing ("VASH Veterans")-and currently homeless.

METHODS

We performed secondary database analyses of homeless-experienced Veterans (n = 3631) with VAGLA ambulatory care use from October 1, 2010 to September 30, 2011. We compared diagnoses treated-adjusting for demographics and need characteristics in regression analyses-between VASH Veterans (n = 1904) and currently homeless Veterans (n = 1727).

RESULTS

On average, considering 26 studied diagnoses, VASH (vs currently homeless) Veterans received care for more (P < .05) diagnoses (mean = 2.9/1.7). Adjusting for demographics and need characteristics, VASH Veterans were more likely (P < .05) than currently homeless Veterans to receive treatment for diagnoses across categories: chronic physical illness, acute physical illness, mental illness, and substance use disorders. Specifically, VASH Veterans had 2.5, 1.7, 2.1, and 1.8 times greater odds of receiving treatment for at least 2 condition in these categories, respectively. Among participants treated for chronic illnesses, adjusting for predisposing and need characteristics, VASH (vs currently homeless) Veterans were 9%, 8%, and 11% more likely to have 2 or more visits for chronic physical illnesses, mental illnesses, and substance use disorder, respectively.

CONCLUSION

Among homeless-experienced Veterans, permanent supported housing may reduce disparities in the treatment of diagnoses commonly seen in ambulatory care.

Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans Health Administration's "Homeless Patient Aligned Care Team" Program

INTRODUCTION

Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a "homeless medical home" initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites.

METHODS

We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services.

RESULTS

More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies.

CONCLUSION

Integrating social determinants of health into clinical care can be effective for high-risk homeless veterans.

Factors Associated With Premature Exits From Supported Housing

OBJECTIVE

Many homeless consumers who enroll in supported housing programs--which offer subsidized housing and supportive services--disengage prematurely, before placement in permanent community-based housing. This study explored factors associated with exiting a supported housing program before achieving housing placement.

METHODS

With the use of administrative data, a roster was obtained for consumers enrolled in the Veterans Affairs (VA) Greater Los Angeles supported housing program from 2011 to 2012. Fewer (4%) consumers exited this program before achieving housing ("exiters") compared with consumers described in national VA figures (18%). Exiters with available demographic data (N=51) were matched 1:1 on age, gender, marital status, and race-ethnicity with consumers housed through this program ("stayers," N=51). Medical records were reviewed to compare diagnoses, health care utilization, housing histories, vocational history, and criminal justice involvement of exiters versus stayers. Exiters' housing outcomes were identified. Recursive partitioning identified variables that best differentiated exiters from stayers.

RESULTS

Several factors were associated with premature exits from this supported housing program: residing in temporary housing on hospital grounds during program enrollment, poor adherence to outpatient care, substance use disorders, hepatitis C, chronic pain, justice involvement, frequent emergency department utilization, and medical-surgical admissions. The first of these factors and poor adherence to outpatient medical-surgical care best differentiated exiters from stayers. Moreover, >50% of exiters became street homeless or incarcerated after leaving the program.

CONCLUSIONS

In that diverse social factors, diagnoses, and health care utilization patterns were associated with premature disengagement from supported housing, future research is needed to implement and evaluate rehabilitative services that address these factors, adapted to the context of supported housing.

Priorities in the primary care of persons experiencing homelessness: convergence and divergence in the views of patients and provider/experts

PURPOSE

Homeless individuals face unique challenges in health care. Several US initiatives seeking to advance patient-centered primary care for homeless persons are more likely to succeed if they incorporate the priorities of the patients they are to serve. However, there has been no prior research to elicit their priorities in primary care. This study sought to identify aspects of primary care important to persons familiar with homelessness based on personal experience or professional commitment, and to highlight where the priorities of patients and professionals dedicated to their care converge or diverge.

METHODS

This qualitative exercise asked 26 homeless patients and ten provider/experts to rank 16 aspects of primary care using a card sort. Patient-level respondents (n=26) were recruited from homeless service organizations across all regions of the USA and from an established board of homeless service users. Provider/expert-level respondents (n=10) were recruited from veteran and non-veteran-focused homeless health care programs with similar geographic diversity.

RESULTS

Both groups gave high priority to accessibility, evidence-based care, coordination, and cooperation. Provider/experts endorsed patient control more strongly than patients. Patients ranked information about their care more highly than provider/experts.

CONCLUSION

Accessibility and the perception of care based on medical evidence represent priority concerns for homeless patients and provider/experts. Patient control, a concept endorsed by experts, is not strongly endorsed by homeless patients. Understanding how to assure fluid communication, coordination, and team member cooperation could represent more worthy targets for research and quality improvement in this domain.

Systematic Review of Programs Treating High-Need and High-Cost People With Multiple Chronic Diseases or Disabilities in the United States, 2008-2014

Introduction

Finding ways to provide better and less expensive health care for people with multiple chronic conditions or disability is a pressing concern. The purpose of this systematic review was to evaluate different approaches for caring for this high-need and high-cost population.

Methods

We searched Medline for articles published from May 31, 2008, through June 10, 2014, for relevant studies. Articles were considered eligible for this review if they met the following criteria: included people with multiple chronic conditions (behavioral or mental health) or disabilities (2 or more); addressed 1 or more of clinical outcomes, health care use and spending, or patient satisfaction; and compared results from an intervention group with a comparison group or baseline measurements. We extracted information on program characteristics, participant characteristics, and significant (positive and negative) clinical findings, patient satisfaction, and health care use outcomes. For each outcome, the number of significant and positive results was tabulated.

Results

Twenty-seven studies were included across 5 models of care. Of the 3 studies reporting patient satisfaction outcomes, 2 reported significant improvements; both were randomized controlled trials (RCTs). Of the 14 studies reporting clinical outcomes, 12 reported improvements (8 were RCTs). Of the 13 studies reporting health care use and spending outcomes, 12 reported significant improvements (2 were RCTs). Two models of care — care and case management and disease management — reported improvements in all 3 outcomes. For care and case management models, most improvements were related to health care use. For the disease management models, most improvements were related to clinical outcomes.

Conclusions

Care and case management as well as disease management may be promising models of care for people with multiple chronic conditions or disabilities. More research and consistent methods are needed to understand the most appropriate care for these high-need and high-cost patients.

Preliminary needs assessment of mobile technology use for healthcare among homeless veterans

Background. Homeless veterans have complex healthcare needs, but experience many barriers to treatment engagement. While information technologies (IT), especially mobile phones, are used to engage patients in care, little is known about homeless veterans' IT use. This study examines homeless veterans' access to and use of IT, attitudes toward health-related IT use, and barriers to IT in the context of homelessness. Methods. Qualitative interviews were conducted with 30 homeless veterans in different housing programs in Boston, MA, ranging from emergency shelters to supportive transitional housing that allow stays of up to 2 years. Interviews were conducted in person, audio recorded and then transcribed. Three researchers coded transcripts. Inductive thematic analysis was used. Results. Most participants (90%) had a mobile phone and were receptive to IT use for health-related communications. A common difficulty communicating with providers was the lack of a stable mailing address. Some participants were using mobile phones to stay in touch with providers. Participants felt mobile-phone calls or text messages could be used to remind patients of appointments, prescription refills, medication taking, and returning for laboratory results. Mobile phone text messaging was seen as convenient, and helped participants stay organized because necessary information was saved in text messages. Some reported concerns about the costs associated with mobile phone use (calls and texting), the potential to be annoyed by too many text messages, and not knowing how to use text messaging. Conclusion. Homeless veterans use IT and welcome its use for health-related purposes. Technology-assisted outreach among this population may lead to improved engagement in care.

The Prevalence and Characteristics of Emergency Medicine Patient Use of New Media

Background

Little is known about “new media” use, defined as media content created or consumed on demand on an electronic device, by patients in emergency department (ED) settings. The application of this technology has the potential to enhance health care beyond the index visit.

Objective

The objectives are to determine the prevalence and characteristics of ED patients’ use of new media and to then define and identify the potential of new media to transcend health care barriers and improve the public’s health.

Methods

Face-to-face, cross-sectional surveys in Spanish and English were given to 5,994 patients who were sequentially enrolled from July 12 to August 30, 2012. Data were collected from across a Southern Connecticut health care system’s 3 high-volume EDs for 24 hours a day, 7 days a week for 6 weeks. The EDs were part of an urban academic teaching hospital, an urban community hospital, and an academic affiliate hospital.

Results

A total of 5,994 (89% response rate) ED patients reported identical ownership of cell phones (85%, P<.001) and smartphones (51%, P<.001) that were used for calling (99%, P<.001). The older the patient, however, the less likely it was that the patient used the phone for texting (96% vs 16%, P<.001). Income was positively associated with smartphone ownership (P<.001) and the use of health apps (P>.05) and personal health records (P<.001). Ownership of iPhones compared to Android phones were similar (44% vs 45%, P<.05). Race and ethnicity played a significant role in texting and smartphone ownership, with Hispanics reporting the highest rates of 79% and 56%, respectively, followed by black non-Hispanics at 77% and 54%, respectively, and white non-Hispanics at 65% and 42%, respectively (P<.05).

Conclusions

There is a critical mass of ED patients who use new media. Older persons are less comfortable texting and using smartphone apps. Income status has a positive relationship with smartphone ownership and use of smartphone apps. Regardless of income, however, texting and ownership of smartphones was highest for Latinos and black non-Latinos. These findings have implications for expanding health care beyond the ED visit through the use of cell phones, smartphones, texting, the Internet, and health care apps to improve the health of the public.

Effectiveness of chronic care models: opportunities for improving healthcare practice and health outcomes: a systematic review

Background

The increasing prevalence of chronic disease and even multiple chronic diseases faced by both developed and developing countries is of considerable concern. Many of the interventions to address this within primary healthcare settings are based on a chronic care model first developed by MacColl Institute for Healthcare Innovation at Group Health Cooperative.

Methods

This systematic literature review aimed to identify and synthesise international evidence on the effectiveness of elements that have been included in a chronic care model for improving healthcare practices and health outcomes within primary healthcare settings. The review broadens the work of other similar reviews by focusing on effectiveness of healthcare practice as well as health outcomes associated with implementing a chronic care model. In addition, relevant case series and case studies were also included.

Results

Of the 77 papers which met the inclusion criteria, all but two reported improvements to healthcare practice or health outcomes for people living with chronic disease. While the most commonly used elements of a chronic care model were self-management support and delivery system design, there were considerable variations between studies regarding what combination of elements were included as well as the way in which chronic care model elements were implemented. This meant that it was impossible to clearly identify any optimal combination of chronic care model elements that led to the reported improvements.

Conclusions

While the main argument for excluding papers reporting case studies and case series in systematic literature reviews is that they are not of sufficient quality or generalizability, we found that they provided a more detailed account of how various chronic care models were developed and implemented. In particular, these papers suggested that several factors including supporting reflective healthcare practice, sending clear messages about the importance of chronic disease care and ensuring that leaders support the implementation and sustainability of interventions may have been just as important as a chronic care model’s elements in contributing to the improvements in healthcare practice or health outcomes for people living with chronic disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0854-8) contains supplementary material, which is available to authorized users.

Diabetes and hypertension prevalence in homeless adults in the United States: a systematic review and meta-analysis

We estimated hypertension and diabetes prevalence among US homeless adults compared with the general population, and investigated prevalence trends. We systematically searched 5 databases for published studies (1980-2014) that included hypertension or diabetes prevalence for US homeless adults, pooled disease prevalence, and explored heterogeneity sources. We used the National Health Interview Survey for comparison. We included data from 97366 homeless adults. The pooled prevalence of self-reported hypertension was 27.0% (95% confidence interval=23.8%, 29.9%; n=43 studies) and of diabetes was 8.0% (95% confidence interval=6.8%, 9.2%; n=39 studies). We found no difference in hypertension or diabetes prevalence between the homeless and general population. Additional health care and housing resources are needed to meet the significant, growing burden of chronic disease in the homeless population.

Secondary care clinic for chronic disease: protocol

Background

The complexity of chronic disease management activities and the associated financial burden have prompted the development of organizational models, based on the integration of care and services, which rely on primary care services. However, since the institutions providing these services are continually undergoing reorganization, the Centre hospitalier affilié universitaire de Québec wanted to innovate by adapting the Chronic Care Model to create a clinic for the integrated follow-up of chronic disease that relies on hospital-based specialty care.

Objective

The aim of the study is to follow the project in order to contribute to knowledge about the way in which professional and management practices are organized to ensure better care coordination and the successful integration of the various follow-ups implemented.

Methods

The research strategy adopted is based on the longitudinal comparative case study with embedded units of analysis. The case study uses a mixed research method.

Results

We are currently in the analysis phase of the project. The results will be available in 2015.

Conclusions

The project’s originality lies in its consideration of the macro, meso, and micro contexts structuring the creation of the clinic in order to ensure the integration process is successful and to allow a theoretical generalization of the reorganization of practices to be developed.

Experience of primary care among homeless individuals with mental health conditions

The delivery of primary care to homeless individuals with mental health conditions presents unique challenges. To inform healthcare improvement, we studied predictors of favorable primary care experience among homeless persons with mental health conditions treated at sites that varied in degree of homeless-specific service tailoring. This was a multi-site, survey-based comparison of primary care experiences at three mainstream primary care clinics of the Veterans Administration (VA), one homeless-tailored VA clinic, and one tailored non-VA healthcare program. Persons who accessed primary care service two or more times from July 2008 through June 2010 (N = 366) were randomly sampled. Predictor variables included patient and organization characteristics suggested by the patient perception model developed by Sofaer and Firminger (2005), with an emphasis on mental health. The primary care experience was assessed with the Primary Care Quality-Homeless (PCQ-H) questionnaire, a validated survey instrument. Multiple regression identified predictors of positive experiences (i.e. higher PCQ-H total score). Significant predictors of a positive experience included a site offering tailored service design, perceived choice among providers, and currently domiciled status. There was an interaction effect between site and severe psychiatric symptoms. For persons with severe psychiatric symptoms, a homeless-tailored service design was significantly associated with a more favorable primary care experience. For persons without severe psychiatric symptoms, this difference was not significant. This study supports the importance of tailored healthcare delivery designed for homeless persons’ needs, with such services potentially holding special relevance for persons with mental health conditions. To improve patient experience among the homeless, organizations may want to deliver services that are tailored to homelessness and offer a choice of providers.

Access to disease treatment among patients presenting to the emergency department with asthma or hypertension

BACKGROUND

Asthma and hypertension are common among Emergency Department (ED) patients. Primary care providers are integral in managing these conditions, yet these patients are often in the ED.

OBJECTIVE

To determine access to care among ED patients with asthma or hypertension and the association with sociodemographic factors and disease acuity.

METHODS

This was a prospective, cross-sectional study of ED patients at an urban county hospital conducted between June 4 and August 31, 2008. Consenting patients were surveyed, and peak flow or blood pressure measured as appropriate. Access to disease treatment was defined as self-reported access to a primary care provider or current prescription for asthma or hypertension, or both. Descriptive statistics and multinomial logistic regression were used to analyze data.

RESULTS

There were 2303 patients enrolled; 283 had asthma, 543 had hypertension, and 187 had both. Seventy-one patients (25.1%) with asthma, 151 patients (27.8%) with hypertension, and 19 patients (10.2%) with both had poor access to disease treatment. Seeking ED medical attention was related to having poor access to treatment for patients with both asthma and hypertension. Females with asthma had poor access to treatment. In hypertension patients, good access to treatment was associated with excellent/good health status, housing status, and decreasing age. Poor access to treatment was associated with increasing blood pressure.

CONCLUSIONS

Poor access to disease treatment and aspects of socioeconomic status were associated with seeking care in the ED. Changes in access to treatment may affect the number of patients seeking ED care, but not the severity of the presenting illness.