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Crane M, Joly L, Daly BJ, Gage H, Manthorpe J, Cetrano G, Ford C, Williams P. Integration, effectiveness and costs of different models of primary health care provision for people who are homeless: an evaluation study. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-217. [PMID: 37839804 DOI: 10.3310/wxuw5103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
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.
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Affiliation(s)
- Maureen Crane
- National Institute for Health and Care Research Health and Social Care Workforce Research Unit, King's College London, London, UK
| | - Louise Joly
- National Institute for Health and Care Research Health and Social Care Workforce Research Unit, King's College London, London, UK
| | - Blánaid Jm Daly
- Special Care Dentistry, Division of Population and Patient Health, King's College London, London, UK
| | - Heather Gage
- Surrey Health Economics Centre, Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Jill Manthorpe
- National Institute for Health and Care Research Health and Social Care Workforce Research Unit, King's College London, London, UK
| | - Gaia Cetrano
- National Institute for Health and Care Research Health and Social Care Workforce Research Unit, King's College London, London, UK
| | | | - Peter Williams
- Department of Mathematics, University of Surrey, Guildford, UK
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Kalofonos I, McCoy M, Altman L, Gelberg L, Hamilton AB, Gabrielian S. A Sanctioned Encampment as a Strategy for Increasing Homeless Veterans' Access to Housing and Healthcare During the COVID-19 Pandemic. J Gen Intern Med 2023; 38:857-864. [PMID: 37340271 PMCID: PMC10356730 DOI: 10.1007/s11606-023-08124-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 02/24/2023] [Indexed: 06/22/2023]
Abstract
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.
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Affiliation(s)
- Ippolytos Kalofonos
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- UCLA/VA Center for Excellence for Veteran Resilience and Recovery in Homelessness and Behavioral Health, Los Angeles, CA, USA.
- Center for Social Medicine and Humanities, Jane and Terry Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA.
- UCLA International Institute, Los Angeles, CA, USA.
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
| | - Matthew McCoy
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
- UCLA/VA Center for Excellence for Veteran Resilience and Recovery in Homelessness and Behavioral Health, Los Angeles, CA, USA.
| | - Lisa Altman
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- UCLA/VA Center for Excellence for Veteran Resilience and Recovery in Homelessness and Behavioral Health, Los Angeles, CA, USA
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Lillian Gelberg
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- UCLA/VA Center for Excellence for Veteran Resilience and Recovery in Homelessness and Behavioral Health, Los Angeles, CA, USA
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Alison B Hamilton
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- UCLA/VA Center for Excellence for Veteran Resilience and Recovery in Homelessness and Behavioral Health, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Sonya Gabrielian
- HSR&D Center for the Study of Healthcare Innovation, Implementation & Policy (CSHIIP), VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- UCLA/VA Center for Excellence for Veteran Resilience and Recovery in Homelessness and Behavioral Health, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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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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Austin AE, Shiue KY, Naumann RB, Figgatt MC, Gest C, Shanahan ME. Associations of housing stress with later substance use outcomes: A systematic review. Addict Behav 2021; 123:107076. [PMID: 34385075 DOI: 10.1016/j.addbeh.2021.107076] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 07/30/2021] [Accepted: 07/31/2021] [Indexed: 12/20/2022]
Abstract
A synthesis of existing evidence regarding the association of housing stress with later substance use outcomes can help support and inform housing interventions as a potential strategy to address problematic substance use. We conducted a comprehensive search of PubMed, Web of Science, PsycInfo, CINAHL, Social Work Abstracts, and Sociological Abstracts and systematically screened for articles examining housing stress and later substance use outcomes among U.S. adults. Across 38 relevant articles published from 1991 to 2020, results demonstrated an association of homelessness with an increased likelihood of substance use, substance use disorders (SUD), and overdose death. Results regarding the association of homelessness with receipt and completion of SUD treatment were mixed, and one study indicated no association of homelessness with motivation to change substance use behaviors. Several studies did not find an association of unstable housing with substance use or receipt of SUD treatment, while others found an association of unstable housing with intensified SUD symptoms and a decreased likelihood of completing SUD treatment. Overall, while there is evidence of an association of homelessness with later substance use, SUD, and overdose death, results for other forms of housing stress and some substance use outcomes are less consistent. There are several methodological considerations specific to selected measures of housing stress and substance use, study populations, and analytic approaches that have implications for results and directions for future research. Despite these considerations, results collectively suggest that innovative interventions to address housing stress, namely homelessness, may help mitigate some substance use outcomes.
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Affiliation(s)
- Anna E Austin
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States; Injury Prevention Research Center, University of North Carolina at Chapel Hill, United States.
| | - Kristin Y Shiue
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, United States; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States
| | - Rebecca B Naumann
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, United States; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States
| | - Mary C Figgatt
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, United States; Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States
| | - Caitlin Gest
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States
| | - Meghan E Shanahan
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States; Injury Prevention Research Center, University of North Carolina at Chapel Hill, United States
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Crone B, Metraux S, Sbrocco T. Health Service Access Among Homeless Veterans: Health Access Challenges Faced by Homeless African American Veterans. J Racial Ethn Health Disparities 2021; 9:1828-1844. [PMID: 34402040 PMCID: PMC8367031 DOI: 10.1007/s40615-021-01119-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Baylee Crone
- Uniformed Service University of the Health Sciences, Bethesda, MD, USA.
| | | | - Tracy Sbrocco
- Uniformed Service University of the Health Sciences, Bethesda, MD, USA
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O'Carroll A, Wainwright D. Doctor-patient interactions that exclude patients experiencing homelessness from health services: an ethnographic exploration. BJGP Open 2021; 5:BJGPO.2021.0031. [PMID: 33785567 PMCID: PMC8278504 DOI: 10.3399/bjgpo.2021.0031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 02/25/2021] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND People experiencing homelessness have poor health indices and poor access to health care. Their health service utilisation (HSU) is typified by: late illness presentations; poor attendance rates at appointments; low usage of primary care services and outpatient departments; and high utilisation of emergency departments and inpatient services. Why people experiencing homelessness have these particular HSU patterns is poorly understood. AIM This research sought to explore barriers to health service usage for people experiencing homelessness. DESIGN & SETTING The authors conducted critical realist ethnography over 13 months in Dublin with people experiencing homelessness at four purposively chosen sites (a food hall, a drop-in centre, an emergency department, and an outreach service for rough sleepers). METHOD Ethnographic research was supplemented with focus groups of hospital doctors and people experiencing homelessness, and with 50 semi-structured interviews with people experiencing homelessness. The epistemological framework was critical realism. RESULTS One of the factors identified in the research as contributing to the HSU pattern of people experiencing homelessness was recurrent interactions between health professionals and patients, whereby patients were either excluded or discouraged from attending health services, or self-excluded themselves from services. These interactions were described as 'conversations of exclusion'. Four such conversations were described: 'the benzodiazepine conversation'; 'the mistrustful conversation'; 'the blaming conversation'; and 'the assertive conversation'. CONCLUSION There are certain recurrent interactions between people experiencing homelessness and doctors that result in the exclusion of people experiencing homelessness from health services.
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Affiliation(s)
- Austin O'Carroll
- Programme Director, North Dublin City General Practice Training Programme, Catherine McAuley Centre, Dublin, Republic of Ireland
- Doctoral Graduate, University of Bath, Department for Health, Bath, UK
- GP, Grangegorman Primary Care Centre, Dublin, Republic of Ireland
| | - David Wainwright
- Senior Lecturer, University of Bath, Department for Health, Bath, UK
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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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Schutt RK, Ellison ML, Chinman M, Mitchell-Miland C, McCarthy S, Shah M, Schultz MR. Health service preferences among veterans in supported housing in relation to needs expressed and services used. J Ment Health 2019; 30:27-35. [PMID: 30862215 DOI: 10.1080/09638237.2019.1581353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Understanding consumer service preferences is important for recovery-oriented care. AIMS To test the influence of perceived service needs on importance attached to treatment for alcohol, drug, mental health, and physical health problems and identify the influence of service needs and preferences on service use. METHODS Formerly homeless dually diagnosed Veterans in supported housing were surveyed in three waves for 1 year, with measures of treatment interests, health problems, social support, clinician-assessed risk of housing loss, and sociodemographics. Multiple regression analysis was used to identify independent influences on preferences in each wave. Different health services at the VA were distinguished in administrative records and baseline predictors for services used throughout the project were identified with multiple regression analysis. RESULTS Self-assessed problem severity was associated with the importance of treatment for alcohol, drug, mental health, and physical health problems. Social support also had some association with treatment interest for alcohol abuse, as did baseline clinician risk rating at the project's end. Preferences, but not perceived problem severity, predicted the use of the corresponding health services. CONCLUSIONS The health beliefs model of service interests was supported, but more integrated service delivery models may be needed to strengthen the association of health needs with service use.
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Affiliation(s)
- Russell K Schutt
- Department of Sociology, University of Massachusetts at Boston, Boston, MA, USA
| | | | | | | | | | - Mala Shah
- VA Pittsburgh Health Care System, Pittsburgh, PA, USA
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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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Weber JJ. A systematic review of nurse-led interventions with populations experiencing homelessness. Public Health Nurs 2018; 36:96-106. [DOI: 10.1111/phn.12552] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 06/27/2018] [Accepted: 08/23/2018] [Indexed: 01/20/2023]
Affiliation(s)
- Jillian J. Weber
- Homeless-PACT RN Care Manager, Community Outreach Division; Cincinnati VA Medical Center; Cincinnati Ohio
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11
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Weber J, Lee RC, Martsolf D. Pursuing the Mission: How Homeless Veterans Manage Chronic Disease. Glob Qual Nurs Res 2018; 5:2333393618792093. [PMID: 30116766 PMCID: PMC6088465 DOI: 10.1177/2333393618792093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 11/17/2022] Open
Abstract
The purpose of this study was to describe and explain the process by which homeless veterans manage their chronic health problems. In the United States, over 550,000 people experience homelessness on any given night. Of these, over 11% are veterans of the military, many whom suffer from at least one chronic disease. Study participants included male homeless veterans with at least one chronic health problem recruited at a Veterans Affairs emergency department, a homeless shelter, and a soup kitchen. Semi-structured interviews with 32 veterans from the Vietnam/post-Vietnam era were audio-recorded, verified, and coded resulting in a theory entitled “pursuing the mission,” which describes and explains four ways (deferring, exploring, embarking, embracing) they manage their chronic health problems. The findings from this study provide insight from individuals living this experience and will help guide the future delivery of health care to homeless veterans.
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Affiliation(s)
- Jillian Weber
- Cincinnati VA Medical Center, Community Outreach Division, Cincinnati, Ohio, USA
| | - Rebecca C Lee
- University of Cincinnati, College of Nursing, Cincinnati, Ohio, USA
| | - Donna Martsolf
- University of Cincinnati, College of Nursing, Cincinnati, Ohio, USA
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12
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Amato S, Nobay F, Amato DP, Abar B, Adler D. Sick and unsheltered: Homelessness as a major risk factor for emergency care utilization. Am J Emerg Med 2018; 37:415-420. [PMID: 29891125 DOI: 10.1016/j.ajem.2018.06.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/31/2018] [Accepted: 06/01/2018] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Homelessness is a critical public health issue and socioeconomic epidemic associated with a disproportionate burden of disease and significant decrease in life expectancy. We compared emergency care utilization between individuals with documented homelessness to those enrolled in Medicaid without documented homelessness. METHODS We conducted a retrospective cohort study consisting of electronic medical record review of demographics, chief complaints, and health care utilization metrics of adults with homelessness compared to a group enrolled in Medicaid without identified homelessness. The chart review spanned two years of emergency visits at a single urban, academic, tertiary care medical center. Descriptive statistics, bivariate and multivariate analyses were utilized. RESULTS Over the study period, 986 patients experiencing homelessness accounted for 7532 ED visits, with a mean of 7.6 (SD 19.9) and max of 316 visits. The control group of 3482 Medicaid patients had 5477 ED visits, with a mean of 1.6 visits (SD 2.1) and max of 49 visits. When controlling for age, sex, race, ethnicity, and ESI, those living with homelessness were 7.65 times more likely to return to the ED within 30 days of their previous visit, 9.97 times more likely to return within 6 months, 10.63 times more likely to return within one year, and 11 times more likely to return within 2 years. CONCLUSIONS Compared to non-homeless Medicaid patients, patients with documented homelessness were over seven times more likely to return to the ED within 30 days and over eleven times more likely to return to the ED in two years.
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Affiliation(s)
- Stas Amato
- University of Vermont Medical Center, Department of General Surgery, 111 Colchester Avenue, Burlington, VT 05401, United States; University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Rochester, NY 14642, United States
| | - Flavia Nobay
- University of Rochester Medical Center, Department of Emergency Medicine, 601 Elmwood Avenue, Rochester, NY 14642, United States
| | | | - Beau Abar
- University of Rochester Medical Center, Department of Emergency Medicine, 601 Elmwood Avenue, Rochester, NY 14642, United States
| | - David Adler
- University of Rochester Medical Center, Department of Emergency Medicine, 601 Elmwood Avenue, Rochester, NY 14642, United States.
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13
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O'Toole TP, Johnson EE, Borgia M, Noack A, Yoon J, Gehlert E, Lo J. Population-Tailored Care for Homeless Veterans and Acute Care Use, Cost, and Satisfaction: A Prospective Quasi-Experimental Trial. Prev Chronic Dis 2018; 15:E23. [PMID: 29451116 PMCID: PMC5814153 DOI: 10.5888/pcd15.170311] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas P O'Toole
- National Center on Homelessness Among Veterans, US Veterans Health Administration, Providence, Rhode Island.,National Center on Homelessness Among Veterans, Providence VA Medical Center, 830 Chalkstone Ave, Providence, RI 02908. .,Alpert Medical School at Brown University, Providence, Rhode Island
| | - Erin E Johnson
- National Center on Homelessness Among Veterans, US Veterans Health Administration, Providence, Rhode Island.,Providence VA Medical Center, Providence, Rhode Island
| | | | - Amy Noack
- San Francisco VA Medical Center, San Francisco, California.,University of California, San Francisco, San Francisco, California
| | - Jean Yoon
- VA Palo Alto Health Care System, Palo Alto, California
| | | | - Jeanie Lo
- VA Palo Alto Health Care System, Palo Alto, California
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14
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Jego M, Abcaya J, Ștefan DE, Calvet-Montredon C, Gentile S. Improving Health Care Management in Primary Care for Homeless People: A Literature Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:E309. [PMID: 29439403 PMCID: PMC5858378 DOI: 10.3390/ijerph15020309] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Revised: 02/04/2018] [Accepted: 02/07/2018] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Maeva Jego
- EA 3279 Research Unit-Public Health, Chronic Diseases and Quality of Life, Faculty of Medicine, Aix-Marseille University, 27 Bd Jean Moulin, 13385 Marseille CEDEX 5, France.
- Department of General Practice, Faculty of Medicine, Aix-Marseille University, 27 Bd Jean Moulin, 13385 Marseille CEDEX 5, France.
| | - Julien Abcaya
- Department of General Practice, Faculty of Medicine, Aix-Marseille University, 27 Bd Jean Moulin, 13385 Marseille CEDEX 5, France.
| | - Diana-Elena Ștefan
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy, 37 Street Dionisie Lupu, Sector 1, 030167 Bucharest, Romania.
| | - Céline Calvet-Montredon
- Department of General Practice, Faculty of Medicine, Aix-Marseille University, 27 Bd Jean Moulin, 13385 Marseille CEDEX 5, France.
| | - Stéphanie Gentile
- EA 3279 Research Unit-Public Health, Chronic Diseases and Quality of Life, Faculty of Medicine, Aix-Marseille University, 27 Bd Jean Moulin, 13385 Marseille CEDEX 5, France.
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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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Patient-aligned Care Team Engagement to Connect Veterans Experiencing Homelessness With Appropriate Health Care. Med Care 2017; 55 Suppl 9 Suppl 2:S104-S110. [DOI: 10.1097/mlr.0000000000000770] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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17
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Weber J, Lee RC, Martsolf D. Understanding the health of veterans who are homeless: A review of the literature. Public Health Nurs 2017; 34:505-511. [PMID: 28675540 DOI: 10.1111/phn.12338] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
| | - Rebecca C Lee
- College of Nursing, University of Cincinnati, Cincinnati, OH, USA
| | - Donna Martsolf
- College of Nursing, University of Cincinnati, Cincinnati, OH, USA
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18
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Watson DP, Shuman V, Kowalsky J, Golembiewski E, Brown M. Housing First and harm reduction: a rapid review and document analysis of the US and Canadian open-access literature. Harm Reduct J 2017; 14:30. [PMID: 28535804 PMCID: PMC5442650 DOI: 10.1186/s12954-017-0158-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/16/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Housing First is an evidence-based practice intended to serve chronically homeless individuals with co-occurring serious mental illness and substance use disorders. Despite housing active substance users, harm reduction is an often-overlooked element during the Housing First implementation process in real-world settings. In this paper, we explore the representation of the Housing First model within the open-access scholarly literature as a potential contributing factor for this oversight. METHODS We conducted a rapid review of the US and Canadian open-access Housing First literature. We followed a document analysis approach, to form an interpretation of the articles' content related to our primary research questions. RESULTS A total of 55 articles on Housing First were included in the final analysis. Only 21 of these articles (38.1%) included explicit mention of harm reduction. Of the 34 articles that did not discuss harm reduction, 22 provided a description of the Housing First model indicating it does not require abstinence from substance use; however, descriptions did not all clearly indicate abstinence was not required beyond program entry. Additional Housing First descriptions focused on the low-barrier entry criteria and/or the intervention's client-centeredness. CONCLUSIONS Our review demonstrated a lack of both explicit mention and informed discussion of harm reduction in the Housing First literature, which is likely contributing to the Housing First research-practice gap to some degree. Future Housing First literature should accurately explain the role of harm reduction when discussing it in the context of Housing First programming, and public agencies promoting Housing First uptake should provide resources for proper implementation and monitor program fidelity to prevent model drift.
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Affiliation(s)
- Dennis P. Watson
- Department of Social and Behavioral Sciences, Indiana University Fairbanks School of Public Health, 1050 Wishard Blvd, Indianapolis, IN 46202 USA
| | - Valery Shuman
- Heartland Health Outreach, Midwest Harm Reduction Institute, 1207 W. Leland Ave., Chicago, IL 60640 USA
| | - James Kowalsky
- Heartland Health Outreach, Midwest Harm Reduction Institute, 1207 W. Leland Ave., Chicago, IL 60640 USA
| | - Elizabeth Golembiewski
- Department of Health Policy and Management, Indiana University Fairbanks School of Public Health, 1050 Wishard Blvd, Indianapolis, IN 46202 USA
| | - Molly Brown
- Department of Psychology, DePaul University, 2219 N. Kenmore Ave., Chicago, IL 60614 USA
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19
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Simmons MM, Gabrielian S, Byrne T, McCullough MB, Smith JL, Taylor TJ, O'Toole TP, Kane V, Yakovchenko V, McInnes DK, Smelson DA. A Hybrid III stepped wedge cluster randomized trial testing an implementation strategy to facilitate the use of an evidence-based practice in VA Homeless Primary Care Treatment Programs. Implement Sci 2017; 12:46. [PMID: 28376839 PMCID: PMC5379611 DOI: 10.1186/s13012-017-0563-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 03/01/2017] [Indexed: 11/20/2022] Open
Abstract
Background Homeless veterans often have multiple health care and psychosocial needs, including assistance with access to housing and health care, as well as support for ongoing treatment engagement. The Department of Veterans Affairs (VA) developed specialized Homeless Patient Alignment Care Teams (HPACT) with the goal of offering an integrated, “one-stop program” to address housing and health care needs of homeless veterans. However, while 70% of HPACT’s veteran enrollees have co-occurring mental health and substance use disorders, HPACT does not have a uniform, embedded treatment protocol for this subpopulation. One wraparound intervention designed to address the needs of homeless veterans with co-occurring mental health and substance use disorders which is suitable to be integrated into HPACT clinic sites is the evidence-based practice called Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Veterans Edition, or MISSION-Vet. Despite the promise of MISSION-Vet within HPACT clinics, implementation of an evidence-based intervention within a busy program like HPACT can be difficult. The current study is being undertaken to identify an appropriate implementation strategy for MISSION-Vet within HPACT. The study will test the implementation platform called Facilitation and compared to implementation as usual (IU). The aims of this study are as follows: (1) Compare the extent to which IU or Facilitation strategies achieve fidelity to the MISSION-Vet intervention as delivered by HPACT homeless provider staff. (2) Compare the effects of Facilitation and IU strategies on the National HPACT Performance Measures. (3) Compare the effects of IU and Facilitation on the permanent housing status. (4) Identify and describe key stakeholders’ (patients, providers, staff) experiences with, and perspectives on, the barriers to, and facilitators of implementing MISSION. Design Type III Hybrid modified stepped wedge implementation comparing IU to Facilitation across seven HPACT teams in three sites in the greater Los Angeles VA system. This is a cluster randomized trial. Discussion Integrating MISSION-Vet within HPACT has the potential to improve the health of thousands of veterans, but it is crucial to implement the intervention appropriately in order for it to succeed. The lessons learned in this protocol could assist with a larger roll-out of MISSION within HPACT. This protocol is registered with clinicaltrials.gov and was assigned the number NCT 02942979.
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Affiliation(s)
- Molly M Simmons
- VA National Center on Homelessness among Veterans, Washington, DC, USA. .,VA Center for Health Organization and Implementation Research, Bedford, MA, USA. .,Boston University School of Public Health, Boston, MA, USA.
| | - Sonya Gabrielian
- VA Greater Los Angeles Health Care System, Los Angeles, CA, USA.,UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Thomas Byrne
- VA National Center on Homelessness among Veterans, Washington, DC, USA.,Boston University School of Social Work, Boston, MA, USA
| | - Megan B McCullough
- VA Center for Health Organization and Implementation Research, Bedford, MA, USA.,Boston University School of Public Health, Boston, MA, USA
| | - Jeffery L Smith
- VA Greater Los Angeles Health Care System, Los Angeles, CA, USA.,College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.,VA Quality Enhancement Research Initiative for Team-Based Behavioral Health, Palo Alto, CA, USA
| | - Thom J Taylor
- VA Palo Alto Health Care System, Palo Alto, CA, USA.,VA Quality Enhancement Research Initiative for Team-Based Behavioral Health, Palo Alto, CA, USA
| | - Tom P O'Toole
- VA National Center on Homelessness among Veterans, Washington, DC, USA.,Alpert Medical School at Brown University, Providence, RI, USA
| | - Vincent Kane
- VA Medical Center Wilmington, Wilmington, DE, USA
| | - Vera Yakovchenko
- VA Center for Health Organization and Implementation Research, Bedford, MA, USA.,Boston University School of Public Health, Boston, MA, USA
| | - D Keith McInnes
- VA Center for Health Organization and Implementation Research, Bedford, MA, USA.,Boston University School of Public Health, Boston, MA, USA.,VA Bridging the Care Continuum-Quality Enhancement Research Initiative, Bedford, MA, USA
| | - David A Smelson
- VA National Center on Homelessness among Veterans, Washington, DC, USA.,VA Center for Health Organization and Implementation Research, Bedford, MA, USA.,VA Bridging the Care Continuum-Quality Enhancement Research Initiative, Bedford, MA, USA.,University of Massachusetts Medical School, Worcester, MA, USA
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20
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Gabrielian S, Chen JC, Minhaj BP, Manchanda R, Altman L, Koosis E, Gelberg L. Feasibility and Acceptability of a Colocated Homeless-Tailored Primary Care Clinic and Emergency Department. J Prim Care Community Health 2017; 8:338-344. [PMID: 28367682 PMCID: PMC5932723 DOI: 10.1177/2150131917699751] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Sonya Gabrielian
- 1 VA Greater Los Angeles, Los Angeles, CA, USA.,2 UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Jennifer C Chen
- 2 UCLA David Geffen School of Medicine, Los Angeles, CA, USA.,3 Harbor-UCLA Medical Center, Torrance, CA, USA
| | | | | | - Lisa Altman
- 1 VA Greater Los Angeles, Los Angeles, CA, USA.,2 UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Ella Koosis
- 1 VA Greater Los Angeles, Los Angeles, CA, USA
| | - Lillian Gelberg
- 1 VA Greater Los Angeles, Los Angeles, CA, USA.,2 UCLA David Geffen School of Medicine, Los Angeles, CA, USA.,6 UCLA Fielding School of Public Health, Los Angeles, CA, USA
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21
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Noska AJ, Belperio PS, Loomis TP, O’Toole TP, Backus LI. Engagement in the Hepatitis C Care Cascade Among Homeless Veterans, 2015. Public Health Rep 2017; 132:136-139. [PMID: 28135425 PMCID: PMC5349485 DOI: 10.1177/0033354916689610] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The Veterans Health Administration (VHA) is the largest provider of hepatitis C virus (HCV) care nationally and provides health care to >200 000 homeless veterans each year. We used the VHA's Corporate Data Warehouse and HCV Clinical Case Registry to evaluate engagement in the HCV care cascade among homeless and nonhomeless veterans in VHA care in 2015. We estimated that, among 242 740 homeless veterans in care and 5 424 712 nonhomeless veterans in care, 144 964 (13.4%) and 188 156 (3.5%), respectively, had chronic HCV infection. Compared with nonhomeless veterans, homeless veterans were more likely to be diagnosed with chronic HCV infection and linked to HCV care but less likely to have received antiviral therapy despite comparable sustained virologic response rates. Homelessness should not necessarily preclude HCV treatment eligibility with available all-oral antiviral regimens.
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Affiliation(s)
- Amanda J. Noska
- Department of Internal Medicine, Providence VA Medical Center, Providence, RI, USA
| | - Pamela S. Belperio
- Patient Care Services/Population Health Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Timothy P. Loomis
- Patient Care Services/Population Health Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Thomas P. O’Toole
- Department of Internal Medicine, Providence VA Medical Center, Providence, RI, USA
| | - Lisa I. Backus
- Patient Care Services/Population Health Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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22
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Axon RN, Gebregziabher M, Dismuke CE, Hunt KJ, Yeager D, Ana EJS, Egede LE. Differential Impact of Homelessness on Glycemic Control in Veterans with Type 2 Diabetes Mellitus. J Gen Intern Med 2016; 31:1331-1337. [PMID: 27418346 PMCID: PMC5071286 DOI: 10.1007/s11606-016-3786-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 01/21/2016] [Accepted: 06/15/2016] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- R Neal Axon
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Division of General Internal Medicine, Department of Medicine, The Medical University of South Carolina, Charleston, SC, USA
| | - Mulugeta Gebregziabher
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Clara E Dismuke
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Division of General Internal Medicine, Department of Medicine, The Medical University of South Carolina, Charleston, SC, USA
| | - Kelly J Hunt
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Department of Public Health Sciences, The Medical University of South Carolina, Charleston, SC, USA
| | - Derik Yeager
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
| | - Elizabeth J Santa Ana
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA
- Department of Psychiatry, The Medical University of South Carolina, Charleston, SC, USA
| | - Leonard E Egede
- Charleston Health Equity and Rural Outreach Innovation Center, Ralph H. Johnson VA Medical Center, Charleston, SC, USA.
- Division of General Internal Medicine, Department of Medicine, The Medical University of South Carolina, Charleston, SC, USA.
- Center for Health Disparities Research Medical University of South Carolina, 135 Rutledge Avenue, MSC 593, Charleston, SC, 29425-0593, USA.
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23
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Abstract
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.
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Affiliation(s)
- Brandi M White
- Division of Healthcare Studies, College of Health Professions, Medical University of South Carolina, 151B Rutledge Avenue, MSC 962, Charleston, SC, 29425-1600, USA.
| | - Ayaba Logan
- Department of Library Science and Informatics, Medical University of South Carolina, 171 Ashley Avenue, PO Box 250403, Charleston, SC, 29425-1600, USA
| | - Gayenell S Magwood
- College of Nursing, Medical University of South Carolina, 99 Jonathan Lucas St., MSC 160, Charleston, SC, 29425-1600, USA
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24
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O'Toole TP, Johnson EE, Aiello R, Kane V, Pape L. Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans Health Administration's "Homeless Patient Aligned Care Team" Program. Prev Chronic Dis 2016; 13:E44. [PMID: 27032987 PMCID: PMC4825747 DOI: 10.5888/pcd13.150567] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas P O'Toole
- National Center on Homelessness Among Veterans, Providence VA Medical Center, 830 Chalkstone Ave, Providence, RI 02909.
| | - Erin E Johnson
- The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island
| | - Riccardo Aiello
- The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island
| | - Vincent Kane
- The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island and Lebanon VA Medical Center, Lebanon, Pennsylvania
| | - Lisa Pape
- The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island
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25
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Abstract
This article discusses the unique considerations when caring for patients who lack housing, one of the most essential human needs. Special attention is provided to diseases and conditions that are affected by homelessness as well as to particularly vulnerable populations of homeless patients.
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Affiliation(s)
- Jared Wilson Klein
- Division of General Internal Medicine, Department of Medicine, Harborview Medical Center, University of Washington, 325 Ninth Avenue, Box 359780, Seattle, WA 98104, USA.
| | - Simha Reddy
- Division of General Internal Medicine, Department of Medicine, VA Puget Sound Health Care System, University of Washington, 1660 South Columbian Way, Seattle, WA 98108, USA
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26
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Tailoring Outreach Efforts to Increase Primary Care Use Among Homeless Veterans: Results of a Randomized Controlled Trial. J Gen Intern Med 2015; 30:886-98. [PMID: 25673574 PMCID: PMC4471019 DOI: 10.1007/s11606-015-3193-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 12/01/2014] [Accepted: 12/16/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Homeless individuals often have significant unmet health care needs that are critical to helping them leave homelessness. However, engaging them in primary and mental health care services is often elusive and difficult to achieve. OBJECTIVE We aimed to increase health-seeking behavior and receipt of health care among homeless Veterans. DESIGN This was a multi-center, prospective, community-based, two-by-two randomized controlled trial of homeless Veterans. PARTICIPANTS Homeless Veterans not receiving primary care participated in the study. INTERVENTIONS An outreach intervention that included a personal health assessment and brief intervention (PHA/BI), and/or a clinic orientation (CO) was implemented. MAIN MEASURE We measured receipt of primary care within 4 weeks of study enrollment. KEY RESULTS Overall, 185 homeless Veterans were enrolled: the average age was 48.6 years (SD 10.8), 94.6% were male, 43.0% were from a minority population, 12.0% were unsheltered, 25.5% were staying in a dusk-to-dawn emergency shelter, 26.1% were in transitional housing, while 27.7% were in an unstable, doubled-up arrangement. At one month, 77.3% of the PHA/BI plus CO group accessed primary care and by 6 months, 88.7% had been seen in primary care. This was followed by the CO-only group, 50.0% of whom accessed care in the first 4 weeks, the PHI/BI-only arm at 41.0% and the Usual Care arm at 30.6%. Chi-squared tests by group were significant (p < 0.001) at both 4 weeks and 6 months. There was no difference in attitudes about care at baseline and 6 months or in use patterns once enrolled in care. CONCLUSIONS Our findings suggest that treatment-resistant/avoidant homeless Veterans can be effectively engaged in primary and other clinical care services through a relatively low intensity, targeted and tailored outreach effort.
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Bernstein RS, Meurer LN, Plumb EJ, Jackson JL. Diabetes and hypertension prevalence in homeless adults in the United States: a systematic review and meta-analysis. Am J Public Health 2015; 105:e46-60. [PMID: 25521899 DOI: 10.2105/ajph.2014.302330] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
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.
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Affiliation(s)
- Rebecca S Bernstein
- Rebecca S. Bernstein and Linda N. Meurer are with Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee. Ellen J. Plumb is with Department of Family and Community Medicine, Thomas Jefferson University Hospital, Philadelphia, PA. Jeffrey L. Jackson is with Medical College of Wisconsin and Department of Internal Medicine, Division of General Internal Medicine, Zablocki VA Medical Center, Milwaukee
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28
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Experience of primary care among homeless individuals with mental health conditions. PLoS One 2015; 10:e0117395. [PMID: 25659142 PMCID: PMC4319724 DOI: 10.1371/journal.pone.0117395] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 12/23/2014] [Indexed: 11/29/2022] Open
Abstract
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.
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29
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Kilbourne AM, Atkins D. Partner or perish: VA health services and the emerging bi-directional paradigm. J Gen Intern Med 2014; 29 Suppl 4:817-9. [PMID: 25355094 PMCID: PMC4239279 DOI: 10.1007/s11606-014-3050-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Amy M Kilbourne
- VA Health Services Research and Development Service, Department of Veterans Affairs, 810 Vermont Avenue NW, Washington, DC, 20420, USA,
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30
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White BM, Newman SD. Access to Primary Care Services Among the Homeless. J Prim Care Community Health 2014; 6:77-87. [DOI: 10.1177/2150131914556122] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To identify barriers and facilitators to primary care access among the homeless using the Equity of Access to Medical Care Framework and to provide recommendations for medical and public health practitioners to improve health among this underserved population. Methods: A quasi-systematic review of the literature was conducted using the PubMed, CINAHL, and PsycINFO databases. Study elements from articles in the final analysis were extracted and categorized into dimensions of access from the Framework. Results: The review identified multiple barriers to primary care access for the homeless. This included lack of insurance coverage and competing priorities. Facilitators to access included tailored health care delivery systems and having a regular source of care. Conclusion: This review provides evidence that health policy initiatives, patient-centered care, and targeted interventions can assist with improving primary care access among the homeless.
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31
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The effects of homelessness on Veterans' health care service use: an evaluation of independence from comorbidities. Public Health 2014; 128:985-92. [PMID: 25443100 DOI: 10.1016/j.puhe.2014.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/03/2014] [Accepted: 07/04/2014] [Indexed: 01/11/2023]
Abstract
OBJECTIVES This study evaluates the prevalence of Multiple Comorbid Chronic Disease (MCCD) within homeless and non-homeless Veterans and the association between MCCD and inpatient medical care. METHODS All individuals seen in the VA North Texas Health Care System between October 1, 2009 and September 30, 2010 (n = 102,034) were evaluated. Homelessness during the year and the number of common chronic diseases were evaluated for an association with likelihood of medical and psychiatric hospitalizations, bed days of care, inpatient substance treatment, rehabilitation admissions, and emergency department visits. RESULTS Homeless Veterans had higher all-cause mortality rates and rates of use of almost all resources after controlling for chronic disease burden using the Charlson Comorbidity Index, psychiatric illnesses, substance use disorders, and demographic variables. CONCLUSIONS Homelessness Veterans are vulnerable to a high use of resources and mortality, independent of medical and psychiatric conditions. This finding should focus additional attention on reducing homelessness.
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Development of the Primary Care Quality-Homeless (PCQ-H) instrument: a practical survey of homeless patients' experiences in primary care. Med Care 2014; 52:734-42. [PMID: 25023918 DOI: 10.1097/mlr.0000000000000160] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Homeless patients face unique challenges in obtaining primary care responsive to their needs and context. Patient experience questionnaires could permit assessment of patient-centered medical homes for this population, but standard instruments may not reflect homeless patients' priorities and concerns. OBJECTIVES This report describes (a) the content and psychometric properties of a new primary care questionnaire for homeless patients; and (b) the methods utilized in its development. METHODS Starting with quality-related constructs from the Institute of Medicine, we identified relevant themes by interviewing homeless patients and experts in their care. A multidisciplinary team drafted a preliminary set of 78 items. This was administered to homeless-experienced clients (n=563) across 3 VA facilities and 1 non-VA Health Care for the Homeless Program. Using Item Response Theory, we examined Test Information Function (TIF) curves to eliminate less informative items and devise plausibly distinct subscales. RESULTS The resulting 33-item instrument (Primary Care Quality-Homeless) has 4 subscales: Patient-Clinician Relationship (15 items), Cooperation among Clinicians (3 items), Access/Coordination (11 items), and Homeless-specific Needs (4 items). Evidence for divergent and convergent validity is provided. TIF graphs showed adequate informational value to permit inferences about groups for 3 subscales (Relationship, Cooperation, and Access/Coordination). The 3-item Cooperation subscale had lower informational value (TIF<5) but had good internal consistency (α=0.75) and patients frequently reported problems in this aspect of care. CONCLUSIONS Systematic application of qualitative and quantitative methods supported the development of a brief patient-reported questionnaire focused on the primary care of homeless patients and offers guidance for future population-specific instrument development.
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