Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Where there is variation, there is room for improvement. The Institute of Medicine’s report on geographic variation in Medicare spending concluded that the largest contributor to overall spending variation is spending for post-acute care services.1 Furthermore, we know that a significant amount of overall spending is devoted to post-acute care. For example, for patients hospitalized with a flare-up of a chronic condition like COPD or heart failure, Medicare spends nearly as much on post-acute care and readmissions in the first 30 days after discharge as it does on the initial admission.¹

What does this mean for hospitalists?

Numerous research articles and quality improvement projects have focused on what makes a good hospital discharge or hand off to the ‘next provider of care’; however, hospitalists are increasingly participating in value-based payment programs like accountable care organizations (ACOs), risk contracts, and bundled payments. This means they must begin to pay attention to the cost side of the value equation (quality divided by cost) as it relates to hospital discharge.

A day of home care represents a more cost-effective alternative than a day of care in a skilled nursing facility (SNF). Hospitalists who can identify those patients who are appropriate to send home with home health services—and who otherwise would have gone to a SNF—will serve the dual goals of improving patient experience and decreasing costs.

Hospitalists will need to develop a decision-making process that determines the appropriate level of care for the patient after discharge. The decision-making process should address questions like:

• What skilled services lead a patient to go to a SNF instead of home with home health?
• Which patients go to a SNF instead of home simply because they don’t have family or a caregiver to help them with activities of daily living?
• Are there services requiring a nurse or a therapist that can’t be delivered in the home?

Hospitalists also will need to develop a more intimate understanding of the following levels of care:

• Skilled nursing includes management of a nursing care plan, assessment of a patient’s changing condition, and services like wound care, infusion therapy, and management of medications, feeding or drainage tubes, and pain.
• Skilled rehabilitation refers to the array of services provided by physical, occupational, speech, and respiratory therapists.
• Custodial care, usually supplied by a home health aid or family member, includes help with activities of daily living (feeding, dressing, bathing, grooming, personal hygiene, and toileting).

It should be noted that most skilled nursing or therapy services can be delivered in the home setting if the patient’s custodial care needs are met—a big ‘if’ in some cases. Some patients go to a SNF because they require three or more skilled nursing or therapy services, and it is therefore impractical for them to go home.

Here are my suggestions to hospitalists seeking to reengineer the discharge process with the goals of “right-sizing” the number of patients who go to SNFs and optimizing the utilization of home healthcare services:

• Become familiar with the range of post-acute care providers and care coordination services in your community.
• Refer any patient who wishes to go home, either directly or after a SNF stay, for a home care evaluation. Home care agencies are experts in determining if and how patients can return home.
• If a need for help with activities of daily living is the major barrier to having a patient discharged to home, create a system in which case management develops a custodial care plan with the patient and caregivers during the inpatient stay. Currently, this step is delayed until well into the SNF stay and may prolong that stay. Such a plan includes a financial analysis, screening for Medicaid eligibility, and evaluating whether a family member can assume some or all of the custodial care needs.
• If a patient is being discharged to a SNF, review the list of needed services leading to the SNF transfer. Ask the case manager if these services can be provided in the home. If not, then why?
• Bed capacity permitting, consider keeping patients who are functionally improving in the hospital an extra day so they can be discharged directly home instead of to a SNF.²

In his seminal work, The Innovator’s Dilemma, Clayton Christensen describes “disruptive innovation” as that which gives rise to products or services that are cheaper, simpler, and more convenient to use. Even though home care has been around for a while, there is a sizeable group of patients, especially in geographic areas of high SNF spending, who might be better served in the home environment. As we create better systems under value-based payment, we should see an increase in the use of home healthcare as a disruptive innovation when applied to appropriate patients transitioning out of the hospital or a SNF.

Dr. Whitcomb is Chief Medical Officer of Remedy Partners. He is co-founder and past president of SHM. Email him at [email protected].

References

1. Newhouse JP, Garber AM. Geographic variation in Medicare services. N Engl J Med. 2013;368:1465-1468.
2. Mechanic R. Post-acute care—The next frontier for controlling Medicare spending. N Engl J Med. 2014;370(8):692-694.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Engaging patients more effectively in their own treatment is becoming a growing focus for hospitals and hospitalists. The Wall Street Journal earlier this year described how hospitals are scoring patients on their “activation”—how engaged they are likely to be in their ongoing care and recovery—with measurement tools such as the Patient Activation Measure (www.insigniahealth.com/solutions/patient-activation-measure)—in order to customize their care through special coaching or other interventions.⁴ Information Week Healthcare notes that more hospitals are putting patient experience officers in the C-suite to help them learn how to treat patients more like valued customers.⁵

One of the country’s first chief experience officers (CXOs), James Merlino, MD, CXO for Cleveland Clinic, heads a department that hosts the annual Patient Experience Summit, which was held in Cleveland in May with co-sponsorship by the Society for Hospital Medicine and the American Hospital Association. It’s one thing to talk about how important patient experience is, Dr. Merlino told Information Week Healthcare. “But it’s another to hold people accountable for it.”

Larry Beresford is a freelance writer in Alameda, Calif.

References

1. Nagasako EM, Reidhead M, Waterman B, Dunagan WC. Adding socioeconomic data to hospital readmissions calculations may produce more useful results. Health Affair. 2014;33(5):786-791.
2. Hu J, Gonsahn MD, Nerenz DR. Socioeconomic status and readmissions: Evidence from an urban teaching hospital. Health Affair. 2014;33(5):778-785.
3. Hoyer EH, Needham DM, Atanelov L, Knox B, Friedman M, Brotman DJ. Association of impaired functional status at hospital discharge and subsequent rehospitalization. J Hosp Med. 2014;9(5):277–282.
4. Landro L. How doctors rate patients. The Wall Street Journal. March 31, 2014. Available at: http://online.wsj.com/news/articles/SB10001424052702304432604579473301109907412. Accessed July 31, 2014.
5. Diana A. Hospitals elevate patient satisfaction to the C-suite. Information Week Healthcare. March 24, 2014. Available at: http://www.informationweek.com/healthcare/leadership/ hospitals-elevate-patient-satisfaction-to-the-c-suite/d/d-id/1127860. Accessed July 31, 2014.
6. The Press Association. London trust now testing seriously ill patients for HIV. Nursing Times. May 8, 2014. Available at: http://www.nursingtimes.net/confirmation?rtn=%252fbarts-to-rollout-routine-hiv-testing-for-intensive-care-patients%252f5070642.article. Accessed July 31, 2014.
7. Pallin DJ, Espinola JA, Camargo CA Jr. US population aging and demand for inpatient services. J Hosp Med. 2014;9(3):193-196.

Following a successful pilot at The Royal London Hospital in Whitechapel, the Barts Health NHS Trust of the British National Health Service has begun routinely offering the blood test for HIV infection to all critical care patients served by the trust, aiming to get more HIV cases diagnosed earlier, thereby helping to stop the virus’ spread by those who don’t know they are infected. Fifty-two percent of 899 patients on the pilot critical care unit agreed to the test, three of whom tested positive for HIV, enabling their doctors to commence treatment.⁶

Patients on critical care units are receiving blood tests already, and the HIV test was presented as just one more test, albeit one with the potential to save lives and stop HIV transmission to partners, said Barts Health NHS Trust HIV medicine consultant Chloe Orkin, MD.

“People are still dying of HIV in the UK—but only because they test too late,” Dr. Orkin says.

The new policy at the UK’s largest regional health trust is in line with guidelines recommending the introduction of universal opt-out testing for HIV in critical care departments where local prevalence of the infection exceeds two per 1,000 individuals.

Larry Beresford is a freelance writer in Alameda, Calif.

Following a successful pilot at The Royal London Hospital in Whitechapel, the Barts Health NHS Trust of the British National Health Service has begun routinely offering the blood test for HIV infection to all critical care patients served by the trust, aiming to get more HIV cases diagnosed earlier, thereby helping to stop the virus’ spread by those who don’t know they are infected. Fifty-two percent of 899 patients on the pilot critical care unit agreed to the test, three of whom tested positive for HIV, enabling their doctors to commence treatment.⁶

Patients on critical care units are receiving blood tests already, and the HIV test was presented as just one more test, albeit one with the potential to save lives and stop HIV transmission to partners, said Barts Health NHS Trust HIV medicine consultant Chloe Orkin, MD.

“People are still dying of HIV in the UK—but only because they test too late,” Dr. Orkin says.

The new policy at the UK’s largest regional health trust is in line with guidelines recommending the introduction of universal opt-out testing for HIV in critical care departments where local prevalence of the infection exceeds two per 1,000 individuals.

Larry Beresford is a freelance writer in Alameda, Calif.

Following a successful pilot at The Royal London Hospital in Whitechapel, the Barts Health NHS Trust of the British National Health Service has begun routinely offering the blood test for HIV infection to all critical care patients served by the trust, aiming to get more HIV cases diagnosed earlier, thereby helping to stop the virus’ spread by those who don’t know they are infected. Fifty-two percent of 899 patients on the pilot critical care unit agreed to the test, three of whom tested positive for HIV, enabling their doctors to commence treatment.⁶

Patients on critical care units are receiving blood tests already, and the HIV test was presented as just one more test, albeit one with the potential to save lives and stop HIV transmission to partners, said Barts Health NHS Trust HIV medicine consultant Chloe Orkin, MD.

“People are still dying of HIV in the UK—but only because they test too late,” Dr. Orkin says.

The new policy at the UK’s largest regional health trust is in line with guidelines recommending the introduction of universal opt-out testing for HIV in critical care departments where local prevalence of the infection exceeds two per 1,000 individuals.

Larry Beresford is a freelance writer in Alameda, Calif.

72%

Total growth in hospital capacity needed by the year 2050, according to an analysis in the Journal of Hospital Medicine.⁷ The estimate is based on a predicted 67% increase in the annual number of hospitalizations—assuming that other factors such as age-specific hospitalization rates and lengths of stay do not change—and derived from U.S. Census Bureau projections that by 2050 the U.S. population will increase by 41%. Total U.S. hospital capacity has steadily decreased for the past three decades.

Larry Beresford is a freelance writer in Alameda, Calif.

72%

Total growth in hospital capacity needed by the year 2050, according to an analysis in the Journal of Hospital Medicine.⁷ The estimate is based on a predicted 67% increase in the annual number of hospitalizations—assuming that other factors such as age-specific hospitalization rates and lengths of stay do not change—and derived from U.S. Census Bureau projections that by 2050 the U.S. population will increase by 41%. Total U.S. hospital capacity has steadily decreased for the past three decades.

Larry Beresford is a freelance writer in Alameda, Calif.

72%

Total growth in hospital capacity needed by the year 2050, according to an analysis in the Journal of Hospital Medicine.⁷ The estimate is based on a predicted 67% increase in the annual number of hospitalizations—assuming that other factors such as age-specific hospitalization rates and lengths of stay do not change—and derived from U.S. Census Bureau projections that by 2050 the U.S. population will increase by 41%. Total U.S. hospital capacity has steadily decreased for the past three decades.

Larry Beresford is a freelance writer in Alameda, Calif.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to [email protected].

Larry Beresford is a freelance writer in Alameda, Calif.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to [email protected].

Larry Beresford is a freelance writer in Alameda, Calif.

Costs of Care (www.costsofcare.org), a nonprofit dedicated to empowering patients and their caregivers to deflate medical bills, and the American Board of Internal Medicine (ABIM) Foundation plan to launch their second annual Teaching Value and Choosing Wisely Competition this fall to highlight healthcare innovations promoting value. The submission deadline is Feb. 1, 2015.

The Teaching Value Project, the main educational arm of Costs of Care, has developed web-based video training modules based on actual cases, along with other educational materials to help residents and medical students learn to make clinical decisions optimizing quality and cost, says Christopher Moriates, MD, hospitalist and co-chair of the University of California-San Francisco’s High-Value Care Committee.

Details of the contest will be posted at www.teachingvalue.org. For more information, send an e-mail to [email protected].

Larry Beresford is a freelance writer in Alameda, Calif.

The role of nonclinical factors in shaping rates of rehospitalization has been explored in several recent studies—and targeted through new legislation endorsed by the Society of Hospital Medicine. A study in Health Affairs compared hospital performance on 30-day readmissions for the first three diagnoses included in penalty calculations for CMS’ Hospital Readmissions Reduction Program (HRRP) and found that adjusting for patients’ socioeconomic status significantly reduced the rates of variation in readmissions between hospitals across the state of Missouri.¹

For patients discharged between 2009 and 2012, analysis using a model enriched with census tract socioeconomic data found that the range of variation in readmissions between hospitals decreased to 1.8% from 6.5% for patients with acute myocardial infarction; to 7.4% from 14.0% for congestive heart failure; and to 3.7% from 7.4% for pneumonia, compared with rates unadjusted for these socioeconomic factors. Another study in the same journal by researchers at an urban teaching hospital found that patients living in high-poverty neighborhoods were 24% more likely to be readmitted to the hospital within 30 days, after adjusting for demographic and clinical characteristics.²

For a factor that may be more amenable to intervention by hospitalists, a standardized rehabilitation medicine test measuring patients’ ability to perform everyday tasks of living, such as the ability to move independently from bed to chair, wheelchair, or toilet was found to be a good predictor of readmissions.³ Few hospitals currently require assessment of their patients’ functional ability, notes the study’s lead author Erik Hoyer, MD, assistant professor in the department of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine in Baltimore. But the score “is a direct reflection of the patient’s ability to heal [outside of the hospital].”

The Functional Independence Measure used in this study and in inpatient rehabilitation facilities nationwide is probably not the right tool for hospitalists because of its length and the training required to administer it, Dr. Hoyer says.

“There are other, easier tools that are available or in development that may also serve a similar purpose,” he says. “The main point is that routine functional assessment is important in the hospital setting, and developing strategies to improve patient function is likely an important way to improve outcomes such as hospital readmissions.”

The documented role of socioeconomic status in determining readmissions also is addressed by legislation introduced by Rep. Jim Renacci (R-Ohio) and supported by both the Society of Hospital Medicine and the American Hospital Association. The Establishing Beneficiary Equity in the Hospital Readmission Program Act (HR-4188) would adjust HRRP readmissions penalties to reflect “certain socioeconomic and health factors that increase the patient’s risk of readmissions.”

Larry Beresford is a freelance writer in Alameda, Calif.

The role of nonclinical factors in shaping rates of rehospitalization has been explored in several recent studies—and targeted through new legislation endorsed by the Society of Hospital Medicine. A study in Health Affairs compared hospital performance on 30-day readmissions for the first three diagnoses included in penalty calculations for CMS’ Hospital Readmissions Reduction Program (HRRP) and found that adjusting for patients’ socioeconomic status significantly reduced the rates of variation in readmissions between hospitals across the state of Missouri.¹

For patients discharged between 2009 and 2012, analysis using a model enriched with census tract socioeconomic data found that the range of variation in readmissions between hospitals decreased to 1.8% from 6.5% for patients with acute myocardial infarction; to 7.4% from 14.0% for congestive heart failure; and to 3.7% from 7.4% for pneumonia, compared with rates unadjusted for these socioeconomic factors. Another study in the same journal by researchers at an urban teaching hospital found that patients living in high-poverty neighborhoods were 24% more likely to be readmitted to the hospital within 30 days, after adjusting for demographic and clinical characteristics.²

For a factor that may be more amenable to intervention by hospitalists, a standardized rehabilitation medicine test measuring patients’ ability to perform everyday tasks of living, such as the ability to move independently from bed to chair, wheelchair, or toilet was found to be a good predictor of readmissions.³ Few hospitals currently require assessment of their patients’ functional ability, notes the study’s lead author Erik Hoyer, MD, assistant professor in the department of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine in Baltimore. But the score “is a direct reflection of the patient’s ability to heal [outside of the hospital].”

The Functional Independence Measure used in this study and in inpatient rehabilitation facilities nationwide is probably not the right tool for hospitalists because of its length and the training required to administer it, Dr. Hoyer says.

“There are other, easier tools that are available or in development that may also serve a similar purpose,” he says. “The main point is that routine functional assessment is important in the hospital setting, and developing strategies to improve patient function is likely an important way to improve outcomes such as hospital readmissions.”

The documented role of socioeconomic status in determining readmissions also is addressed by legislation introduced by Rep. Jim Renacci (R-Ohio) and supported by both the Society of Hospital Medicine and the American Hospital Association. The Establishing Beneficiary Equity in the Hospital Readmission Program Act (HR-4188) would adjust HRRP readmissions penalties to reflect “certain socioeconomic and health factors that increase the patient’s risk of readmissions.”

Larry Beresford is a freelance writer in Alameda, Calif.

The role of nonclinical factors in shaping rates of rehospitalization has been explored in several recent studies—and targeted through new legislation endorsed by the Society of Hospital Medicine. A study in Health Affairs compared hospital performance on 30-day readmissions for the first three diagnoses included in penalty calculations for CMS’ Hospital Readmissions Reduction Program (HRRP) and found that adjusting for patients’ socioeconomic status significantly reduced the rates of variation in readmissions between hospitals across the state of Missouri.¹

For patients discharged between 2009 and 2012, analysis using a model enriched with census tract socioeconomic data found that the range of variation in readmissions between hospitals decreased to 1.8% from 6.5% for patients with acute myocardial infarction; to 7.4% from 14.0% for congestive heart failure; and to 3.7% from 7.4% for pneumonia, compared with rates unadjusted for these socioeconomic factors. Another study in the same journal by researchers at an urban teaching hospital found that patients living in high-poverty neighborhoods were 24% more likely to be readmitted to the hospital within 30 days, after adjusting for demographic and clinical characteristics.²

For a factor that may be more amenable to intervention by hospitalists, a standardized rehabilitation medicine test measuring patients’ ability to perform everyday tasks of living, such as the ability to move independently from bed to chair, wheelchair, or toilet was found to be a good predictor of readmissions.³ Few hospitals currently require assessment of their patients’ functional ability, notes the study’s lead author Erik Hoyer, MD, assistant professor in the department of physical medicine and rehabilitation at the Johns Hopkins University School of Medicine in Baltimore. But the score “is a direct reflection of the patient’s ability to heal [outside of the hospital].”

The Functional Independence Measure used in this study and in inpatient rehabilitation facilities nationwide is probably not the right tool for hospitalists because of its length and the training required to administer it, Dr. Hoyer says.

“There are other, easier tools that are available or in development that may also serve a similar purpose,” he says. “The main point is that routine functional assessment is important in the hospital setting, and developing strategies to improve patient function is likely an important way to improve outcomes such as hospital readmissions.”

The documented role of socioeconomic status in determining readmissions also is addressed by legislation introduced by Rep. Jim Renacci (R-Ohio) and supported by both the Society of Hospital Medicine and the American Hospital Association. The Establishing Beneficiary Equity in the Hospital Readmission Program Act (HR-4188) would adjust HRRP readmissions penalties to reflect “certain socioeconomic and health factors that increase the patient’s risk of readmissions.”

Larry Beresford is a freelance writer in Alameda, Calif.

Clinical question: Is once-weekly intravenous dalbavancin as effective as conventional therapy for the treatment of acute bacterial skin infections?

Background: Acute bacterial skin infections are common and often require hospitalization for intravenous antibiotic administration. Treatment covering gram-positive bacteria usually is indicated. Dalbavancin is effective against gram-positives, including MRSA. Its long half-life makes it an attractive alternative to other commonly used antibiotics, which require more frequent dosing.

Study design: Phase 3, double-blinded RCT.

Setting: Multiple international centers.

Synopsis: Researchers randomized 1,312 patients with acute bacterial skin and skin-structure infections with signs of systemic infection requiring intravenous antibiotics to receive dalbavancin on days one and eight, with placebo on other days, or several doses of vancomycin with an option to switch to oral linezolid. The primary endpoint was cessation of spread of erythema and temperature of ≤37.6°C at 48-72 hours. Secondary endpoints included a decrease in lesion area of ≥20% at 48-72 hours and clinical success at end of therapy (determined by clinical and historical features).

Results of the primary endpoint were similar with dalbavancin and vancomycin-linezolid groups (79.7% and 79.8%, respectively) and were within 10 percentage points of noninferiority. The secondary endpoints were similar between both groups.

Limitations of the study were the early primary endpoint, lack of noninferiority analysis of the secondary endpoints, and cost-effective analysis.

Bottom line: Once-weekly dalbavancin appears to be similarly efficacious to intravenous vancomycin in the treatment of acute bacterial skin infections in terms of outcomes within 48-72 hours of therapy and might provide an alternative to continued inpatient hospitalization for intravenous antibiotics in stable patients.

Citation: Boucher HW, Wilcox M, Talbot GH, Puttagunta S, Das AF, Dunne MW. Once-weekly dalbavancin versus daily conventional therapy for skin infection. N Engl J Med. 2014;370(23):2169-2179.

Clinical question: Is once-weekly intravenous dalbavancin as effective as conventional therapy for the treatment of acute bacterial skin infections?

Background: Acute bacterial skin infections are common and often require hospitalization for intravenous antibiotic administration. Treatment covering gram-positive bacteria usually is indicated. Dalbavancin is effective against gram-positives, including MRSA. Its long half-life makes it an attractive alternative to other commonly used antibiotics, which require more frequent dosing.

Study design: Phase 3, double-blinded RCT.

Setting: Multiple international centers.

Synopsis: Researchers randomized 1,312 patients with acute bacterial skin and skin-structure infections with signs of systemic infection requiring intravenous antibiotics to receive dalbavancin on days one and eight, with placebo on other days, or several doses of vancomycin with an option to switch to oral linezolid. The primary endpoint was cessation of spread of erythema and temperature of ≤37.6°C at 48-72 hours. Secondary endpoints included a decrease in lesion area of ≥20% at 48-72 hours and clinical success at end of therapy (determined by clinical and historical features).

Results of the primary endpoint were similar with dalbavancin and vancomycin-linezolid groups (79.7% and 79.8%, respectively) and were within 10 percentage points of noninferiority. The secondary endpoints were similar between both groups.

Limitations of the study were the early primary endpoint, lack of noninferiority analysis of the secondary endpoints, and cost-effective analysis.

Bottom line: Once-weekly dalbavancin appears to be similarly efficacious to intravenous vancomycin in the treatment of acute bacterial skin infections in terms of outcomes within 48-72 hours of therapy and might provide an alternative to continued inpatient hospitalization for intravenous antibiotics in stable patients.

Citation: Boucher HW, Wilcox M, Talbot GH, Puttagunta S, Das AF, Dunne MW. Once-weekly dalbavancin versus daily conventional therapy for skin infection. N Engl J Med. 2014;370(23):2169-2179.

Clinical question: Is once-weekly intravenous dalbavancin as effective as conventional therapy for the treatment of acute bacterial skin infections?

Background: Acute bacterial skin infections are common and often require hospitalization for intravenous antibiotic administration. Treatment covering gram-positive bacteria usually is indicated. Dalbavancin is effective against gram-positives, including MRSA. Its long half-life makes it an attractive alternative to other commonly used antibiotics, which require more frequent dosing.

Study design: Phase 3, double-blinded RCT.

Setting: Multiple international centers.

Synopsis: Researchers randomized 1,312 patients with acute bacterial skin and skin-structure infections with signs of systemic infection requiring intravenous antibiotics to receive dalbavancin on days one and eight, with placebo on other days, or several doses of vancomycin with an option to switch to oral linezolid. The primary endpoint was cessation of spread of erythema and temperature of ≤37.6°C at 48-72 hours. Secondary endpoints included a decrease in lesion area of ≥20% at 48-72 hours and clinical success at end of therapy (determined by clinical and historical features).

Results of the primary endpoint were similar with dalbavancin and vancomycin-linezolid groups (79.7% and 79.8%, respectively) and were within 10 percentage points of noninferiority. The secondary endpoints were similar between both groups.

Limitations of the study were the early primary endpoint, lack of noninferiority analysis of the secondary endpoints, and cost-effective analysis.

Bottom line: Once-weekly dalbavancin appears to be similarly efficacious to intravenous vancomycin in the treatment of acute bacterial skin infections in terms of outcomes within 48-72 hours of therapy and might provide an alternative to continued inpatient hospitalization for intravenous antibiotics in stable patients.

Citation: Boucher HW, Wilcox M, Talbot GH, Puttagunta S, Das AF, Dunne MW. Once-weekly dalbavancin versus daily conventional therapy for skin infection. N Engl J Med. 2014;370(23):2169-2179.

Clinical question: What is the effect of continuous positive airway pressure (CPAP) or supplemental oxygen on ambulatory blood pressures and markers of cardiovascular risk when combined with sleep hygiene education in patients with obstructive sleep apnea (OSA) and coronary artery disease or cardiac risk factors?

Background: OSA is considered a risk factor for the development of hypertension. One meta-analysis showed reduction of mean arterial pressure (MAP) with CPAP therapy, but randomized controlled data on blood pressure reduction with treatment of OSA is lacking.

Study design: Randomized, parallel-group trial.

Setting: Four outpatient cardiology practices.

Synopsis: Patients ages 45-75 with OSA were randomized to receive nocturnal CPAP and healthy lifestyle and sleep education (HLSE), nocturnal oxygen therapy and HSLE, or HSLE alone. The primary outcome was 24-hour MAP. Secondary outcomes included fasting blood glucose, lipid panel, insulin level, erythrocyte sedimentation rate, C-reactive protein (CRP), and N-terminal pro-brain naturetic peptide.

Participants had high rates of diabetes, hypertension, and coronary artery disease. At 12 weeks, the CPAP arm experienced greater reductions in 24-hour MAP compared to both the nocturnal oxygen and HSLE arms (-2.8 mmHg [P=0.02] and -2.4 mmHg [P=0.04], respectively). No significant decrease in MAP was identified in the nocturnal oxygen arm when compared to the HSLE arm. The only significant difference in secondary outcomes was a decrease in CRP in the CPAP arm when compared to the HSLE arm, the clinical significance of which is unclear.

Bottom line: CPAP therapy with sleep hygiene education appears superior to nocturnal oxygen therapy with sleep hygiene education and sleep hygiene education alone in decreasing 24-hour MAP in patients with OSA and coronary artery disease or cardiac risk factors.

Citation: Gottlieb DJ, Punjabi NM, Mehra R, et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med. 2014;370(24):2276-2285.

Clinical question: What is the effect of continuous positive airway pressure (CPAP) or supplemental oxygen on ambulatory blood pressures and markers of cardiovascular risk when combined with sleep hygiene education in patients with obstructive sleep apnea (OSA) and coronary artery disease or cardiac risk factors?

Background: OSA is considered a risk factor for the development of hypertension. One meta-analysis showed reduction of mean arterial pressure (MAP) with CPAP therapy, but randomized controlled data on blood pressure reduction with treatment of OSA is lacking.

Study design: Randomized, parallel-group trial.

Setting: Four outpatient cardiology practices.

Synopsis: Patients ages 45-75 with OSA were randomized to receive nocturnal CPAP and healthy lifestyle and sleep education (HLSE), nocturnal oxygen therapy and HSLE, or HSLE alone. The primary outcome was 24-hour MAP. Secondary outcomes included fasting blood glucose, lipid panel, insulin level, erythrocyte sedimentation rate, C-reactive protein (CRP), and N-terminal pro-brain naturetic peptide.

Participants had high rates of diabetes, hypertension, and coronary artery disease. At 12 weeks, the CPAP arm experienced greater reductions in 24-hour MAP compared to both the nocturnal oxygen and HSLE arms (-2.8 mmHg [P=0.02] and -2.4 mmHg [P=0.04], respectively). No significant decrease in MAP was identified in the nocturnal oxygen arm when compared to the HSLE arm. The only significant difference in secondary outcomes was a decrease in CRP in the CPAP arm when compared to the HSLE arm, the clinical significance of which is unclear.

Bottom line: CPAP therapy with sleep hygiene education appears superior to nocturnal oxygen therapy with sleep hygiene education and sleep hygiene education alone in decreasing 24-hour MAP in patients with OSA and coronary artery disease or cardiac risk factors.

Citation: Gottlieb DJ, Punjabi NM, Mehra R, et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med. 2014;370(24):2276-2285.

Clinical question: What is the effect of continuous positive airway pressure (CPAP) or supplemental oxygen on ambulatory blood pressures and markers of cardiovascular risk when combined with sleep hygiene education in patients with obstructive sleep apnea (OSA) and coronary artery disease or cardiac risk factors?

Background: OSA is considered a risk factor for the development of hypertension. One meta-analysis showed reduction of mean arterial pressure (MAP) with CPAP therapy, but randomized controlled data on blood pressure reduction with treatment of OSA is lacking.

Study design: Randomized, parallel-group trial.

Setting: Four outpatient cardiology practices.

Synopsis: Patients ages 45-75 with OSA were randomized to receive nocturnal CPAP and healthy lifestyle and sleep education (HLSE), nocturnal oxygen therapy and HSLE, or HSLE alone. The primary outcome was 24-hour MAP. Secondary outcomes included fasting blood glucose, lipid panel, insulin level, erythrocyte sedimentation rate, C-reactive protein (CRP), and N-terminal pro-brain naturetic peptide.

Participants had high rates of diabetes, hypertension, and coronary artery disease. At 12 weeks, the CPAP arm experienced greater reductions in 24-hour MAP compared to both the nocturnal oxygen and HSLE arms (-2.8 mmHg [P=0.02] and -2.4 mmHg [P=0.04], respectively). No significant decrease in MAP was identified in the nocturnal oxygen arm when compared to the HSLE arm. The only significant difference in secondary outcomes was a decrease in CRP in the CPAP arm when compared to the HSLE arm, the clinical significance of which is unclear.

Bottom line: CPAP therapy with sleep hygiene education appears superior to nocturnal oxygen therapy with sleep hygiene education and sleep hygiene education alone in decreasing 24-hour MAP in patients with OSA and coronary artery disease or cardiac risk factors.

Citation: Gottlieb DJ, Punjabi NM, Mehra R, et al. CPAP versus oxygen in obstructive sleep apnea. N Engl J Med. 2014;370(24):2276-2285.

Individuals with inflammatory rheumatic diseases such as inflammatory arthritis, vasculitis, and connective tissue diseases, have a threefold increase in the risk of venous thromboembolism, compared with the general population, according to a meta-analysis.

The meta-analysis of 25 studies – 10 of which included patients with rheumatoid arthritis (RA) – found those with RA were more than twice as likely to develop deep vein thrombosis or a pulmonary embolism, compared with an age- and sex-matched individuals who had other comorbidities such as diabetes, peripheral vascular disease/coronary artery disease, and malignancy (OR, 2.23; 95% confidence interval, 2.02-2.47). The RA patients had a cumulative venous thromboembolism (VTE) incidence of 2.18% (Arthritis Res. Ther. 2014;16:435 [doi:10.1186/s13075-014-0435-y]).

Ten studies comprising 54,697 patients with systemic lupus erythematosus showed a cumulative thrombosis incidence of 7.29% (95% CI, 5.82%-8.75%). Other diseases for which the investigators calculated cumulative incidence rates of VTE, based on four studies apiece, were Sjögren’s syndrome (2.18%; 95% CI, 0.79%-3.57%), inflammatory myositis (4.03%; 95% CI, 2.38%-5.67%), Antineutrophil cytoplasmic antibody vasculitis (7.97%; 95% CI, 5.67%-10.28%), and systemic sclerosis (3.13%; 95% CI, 1.73%-4.52%).

“We believe that the increased VTE risk is associated with the activity of the inflammatory diseases, rather than with the treatments used for controlling the disease,” wrote Dr. Jason Lee of the University of Western Ontario, London, and Dr. Janet Pope, of the division of rheumatology at St. Joseph’s Health Care, London, Ont.

The authors said that they had no conflicts of interest.

Individuals with inflammatory rheumatic diseases such as inflammatory arthritis, vasculitis, and connective tissue diseases, have a threefold increase in the risk of venous thromboembolism, compared with the general population, according to a meta-analysis.

The meta-analysis of 25 studies – 10 of which included patients with rheumatoid arthritis (RA) – found those with RA were more than twice as likely to develop deep vein thrombosis or a pulmonary embolism, compared with an age- and sex-matched individuals who had other comorbidities such as diabetes, peripheral vascular disease/coronary artery disease, and malignancy (OR, 2.23; 95% confidence interval, 2.02-2.47). The RA patients had a cumulative venous thromboembolism (VTE) incidence of 2.18% (Arthritis Res. Ther. 2014;16:435 [doi:10.1186/s13075-014-0435-y]).

Ten studies comprising 54,697 patients with systemic lupus erythematosus showed a cumulative thrombosis incidence of 7.29% (95% CI, 5.82%-8.75%). Other diseases for which the investigators calculated cumulative incidence rates of VTE, based on four studies apiece, were Sjögren’s syndrome (2.18%; 95% CI, 0.79%-3.57%), inflammatory myositis (4.03%; 95% CI, 2.38%-5.67%), Antineutrophil cytoplasmic antibody vasculitis (7.97%; 95% CI, 5.67%-10.28%), and systemic sclerosis (3.13%; 95% CI, 1.73%-4.52%).

“We believe that the increased VTE risk is associated with the activity of the inflammatory diseases, rather than with the treatments used for controlling the disease,” wrote Dr. Jason Lee of the University of Western Ontario, London, and Dr. Janet Pope, of the division of rheumatology at St. Joseph’s Health Care, London, Ont.

The authors said that they had no conflicts of interest.

Individuals with inflammatory rheumatic diseases such as inflammatory arthritis, vasculitis, and connective tissue diseases, have a threefold increase in the risk of venous thromboembolism, compared with the general population, according to a meta-analysis.

The meta-analysis of 25 studies – 10 of which included patients with rheumatoid arthritis (RA) – found those with RA were more than twice as likely to develop deep vein thrombosis or a pulmonary embolism, compared with an age- and sex-matched individuals who had other comorbidities such as diabetes, peripheral vascular disease/coronary artery disease, and malignancy (OR, 2.23; 95% confidence interval, 2.02-2.47). The RA patients had a cumulative venous thromboembolism (VTE) incidence of 2.18% (Arthritis Res. Ther. 2014;16:435 [doi:10.1186/s13075-014-0435-y]).

Ten studies comprising 54,697 patients with systemic lupus erythematosus showed a cumulative thrombosis incidence of 7.29% (95% CI, 5.82%-8.75%). Other diseases for which the investigators calculated cumulative incidence rates of VTE, based on four studies apiece, were Sjögren’s syndrome (2.18%; 95% CI, 0.79%-3.57%), inflammatory myositis (4.03%; 95% CI, 2.38%-5.67%), Antineutrophil cytoplasmic antibody vasculitis (7.97%; 95% CI, 5.67%-10.28%), and systemic sclerosis (3.13%; 95% CI, 1.73%-4.52%).

“We believe that the increased VTE risk is associated with the activity of the inflammatory diseases, rather than with the treatments used for controlling the disease,” wrote Dr. Jason Lee of the University of Western Ontario, London, and Dr. Janet Pope, of the division of rheumatology at St. Joseph’s Health Care, London, Ont.

The authors said that they had no conflicts of interest.

On a single night in 2012, 62,619 veterans experienced homelessness.¹ With high rates of illness, as well as alcohol, tobacco, and other drug (ATOD) use among homeless adults, ending veteran homelessness is a signature initiative of the VA.^2-4 However, despite increasing efforts to improve health care for homeless individuals, little is known about best practices in homeless-focused primary care.^2,5

With an age-adjusted mortality that is 2 to 10 times higher than that of their housed counterparts, homeless veterans pose a formidable challenge for primary care providers (PCPs).^6,7 The complexity of homeless persons’ primary care needs is compounded by poor social support and the need to navigate priorities (eg, shelter) that compete with medical care.^6,8,9 Moreover, veterans may face unique vulnerabilities conferred by military-specific experiences.^2,10

As of 2012, only 2 VA facilities had primary care clinics tailored to the needs of homeless veterans. McGuire and colleagues built a system of colocated primary care, mental health, and homeless services for mentally ill veterans in Los Angeles, California.¹¹ Over 18 months, this clinic facilitated greater primary and preventive care delivery, though the population’s physical health status did not improve.¹¹ More recently, O’Toole and colleagues implemented a homeless-focused primary care clinic in Providence, Rhode Island.⁶ Compared with a historical sample of homeless veterans in traditional VA primary care, veterans in this homeless-tailored clinic had greater improvements in some chronic disease outcomes.⁶ This clinic also decreased nonacute emergency department (ED) use and hospitalizations for general medical conditions.⁶

Despite these promising outcomes, the VA lacked a nationwide homeless-focused primary care initiative. In 2012 the VA Office of Homeless Programs and the Office of Primary Care Operations funded a national demonstration project to create Homeless Patient-Aligned Care Teams (HPACTs)—primary care medical clinics for homeless veterans—at 32 facilities. This demonstration project guided HPACTs to tailor clinical and social services to homeless veterans’ needs, establish processes to identify and refer appropriate veterans, and integrate distinct services.

There were no explicit instructions that detailed HPACT structure. Because new VA programs must fit local contextual factors, including infrastructure, space, personnel, and institutional/community resources, different models of homeless-focused primary care have evolved.

This article is a case study of HPACTs at 3 of the 32 participating VA facilities, each reflecting a distinct community and organizational context. In light of projected HPACT expansion and concerns that current services are better tailored to sheltered homeless veterans than to their unsheltered peers, there is particular importance to  detailed clinic descriptions that vividly portray the intricate relationships between service design and populations served.¹

METHODS

VA HPACTs established in May 2012 at 3 facilities were examined: Birmingham VAMC in Alabama (BIR), West Los Angeles VAMC in California (WLA), and VA Pittsburgh Healthcare System in Pennsylvania (PIT). Prior to this demonstration project, each facility offered a range of housing/social services and traditional primary care for veterans. These sites are a geographically diverse convenience sample that emerged from existing homeless-focused collaborations among the authors and represent geographically diverse HPACTs.

The national director of VA Homeless Programs formally determined that this comparison constitutes a VA operations activity that is not research.¹² This activity was exempt from Institutional Review Board review.

Study Design

Timed at an early stage of HPACT implementation, this project had 3 aims: (1) To identify noteworthy similarities and/or differences among the initial HPACT clinic structures; (2) To compare and contrast the patient characteristics of veterans enrolled in each of these clinics; and (3) To use these data to inform ongoing HPACT service design.

HPACT program evaluation data are not presented. Rather, a nascent system of care is illustrated that contributes to the limited literature concerning the design and implementation of homeless-focused primary care. Such organizational profiles inform novel program delivery and hold particular utility for heterogeneous populations who are difficult to engage in care.^13,14

Authors at each site independently developed lists of variables that fell within the 3 guiding principles of this demonstration project. These variables were compiled and iteratively reduced to a consolidated table that assessed each clinic, including location, operating hours, methods of patient identification and referral, and linkages to distinct services (eg, primary care, mental health, addiction, and social services).

This table also became a guide for HPACT directors to generate narrative clinic descriptions. Characteristics of VA medical homes that are embraced regardless of patients’ housing status (eg, patient-centered, team-based care) were also incorporated into these descriptions.¹⁵

Patient Characteristics

The VA electronic health record (EHR) was used to identify all patients enrolled in HPACTs at BIR, WLA, and PIT from May 1, 2012 (clinic inception), through September 30, 2012. Authors developed a standardized template for EHR review and coined the first HPACT record as the patient’s index visit. This record was used to code initial housing status, demographics, and acute medical conditions diagnosed/treated. If housing status was not recorded at the index visit, the first preceding informative record was used.

Records for 6 months preceding the index visit were used to identify the presence or absence of common medical conditions, psychiatric diagnoses, and ATOD abuse or dependence. Medical conditions were identified from a list of common outpatient diagnoses from the National Ambulatory Medical Care Survey, supplemented by common conditions among homeless men.^16-18 The EHR problem list (a list of diagnoses, by patient) was used to obtain diagnoses, supplemented by notes from inpatient admissions/discharges, as well as ED, primary care, and subspecialty consultations within 6 months preceding the index visit. Prior VA health care use was ascertained from the EHR review of the same 6-month window, reflecting ED visits, inpatient admissions, primary care visits, subspecialty visits, and individual/group therapy for ATOD or other mental health problems. Data were used to generate site-specific descriptive statistics.

RESULTS

Like all VA hospital-based clinics, a universal EHR captured all medical and social service notes, orders, medications, and administrative records. All facilities had on-site EDs, medical/mental health specialty care, and pharmacies. Social services, including benefits counseling and housing services, were available on site. Table 1 summarizes the HPACT structures at BIR, WLA, and PIT.

Birmingham

The BIR HPACT was devised as a new homeless-focused team located within a VA primary care clinic where other providers continued to see primary care patients. Staff and space were reallocated for this HPACT, which recruited patients in 4 ways: (1) the facility’s primary homeless program, Healthcare for Homeless Veterans, referred patients who previously sought VA housing but who required primary care; (2) an outreach specialist sought homeless veterans in shelters and on the streets; (3) HPACT staff marketed the clinic with presentations and flyers to other VA services and non-VA community agencies; and (4) a referral mechanism within the EHR.

A nurse practitioner was the PCP at this site, supervised by an academic internist experienced in the care of underserved populations, and the HPACT director, a physician certified in internal and addiction medicine. Patients at the BIR HPACT also received care from a social worker, registered nurse, licensed practical nurse, and psychiatrist who received all or a portion of their salaries from this demonstration project. This clinic accommodated walk-in appointments during business hours. Clinicians discussed clinical cases daily, and the full clinical and administrative team met weekly. To promote service integration, HPACT staff attended meetings of the BIR general primary care and Healthcare for Homeless Veterans programs, and vice versa.

West Los Angeles

At WLA, a previously established Homeless Screening Clinic that offered integrated social and medical services for homeless veterans with mental illness was already available during business hours and located within the site’s mental health program.¹¹ However, because ED use for homeless veterans peaked after hours, the new WLA HPACT was established within the WLA ED.

During WLA HPACT hours (3 weekday evenings/week), routine nursing triage occurred for all patients who presented to the ED. However, distinct from other times of day, veterans who were triaged with low-acuity and who were appropriate for outpatient care were given a self-administered, 4-item questionnaire to identify patients who were homeless or at risk for becoming homeless. Veterans who were identified with this screening tool were offered the choice of an ED or HPACT visit. Veterans who chose the latter were assigned to the queue for an HPACT primary care visit instead of the ED.

A physician led the clinical team, with additional services from a mental health clinical nurse specialist and clerks who worked with homeless and/or mental health patients during business hours and provided part-time HPACT coverage. When needed, additional services were provided from colocated ED nurses and social workers. Providers were chosen for their aptitude in culturally responsive communication.

Patients who chose to be seen in HPACT received a primary care visit that also addressed the reason for ED presentation. HPACT staff worked collaboratively, with interdisciplinary team huddles that preceded each clinic session and ended each patient visit. Referrals and social service needs were tracked and monitored by the PCP. Specialty care referrals were also tracked and facilitated when possible with direct communication between HPACT providers and specialty services. Meetings with daytime Homeless Screening Clinic and ED staff facilitated cross-departmental collaborations that helped veterans prepare for and retain housing.

Pittsburgh

The HPACT at PIT evolved from an existing PACT that provided primary care-based addiction services.² That team included an internist credentialed in addiction medicine and experienced in homeless health care, nurse practitioner, nurse care manager, nursing assistant, and clerks. At this site, HPACT providers had subspecialty expertise in the assessment and treatment of ATOD use, certification to prescribe buprenorphine for outpatient opioid detoxification and/or maintenance, and experience engaging homeless and other vulnerable veterans. The existing colocated clinic included 2 additional addiction medicine clinicians and a physician assistant experienced in ATOD use. The PIT HPACT was not restricted to patients with ATOD use.

At PIT, HPACT care was provided during business hours in a flexible model that allowed for walk-in visits. Providers from the existing addiction-focused PACT identified and referred homeless veterans, as well as patients deemed at-risk for becoming homeless. In addition, other homeless veterans who did not have a PCP could be referred through e-consults placed by any VA staff member. If a referred homeless veteran was already enrolled on a PCP’s panel, HPACT facilitated reengagement with the existing provider. Near the end of this data collection period, a peer support specialist also began community outreach to engage both enrolled and potential HPACT patients.

Patient Characteristics

Table 2 presents the demographic and housing characteristics of enrolled HPACT patients at BIR, WLA, and PIT from May 1, 2012, to September 30, 2012. Each site had a similar number of patients (n = 35/47/43 at BIR/WLA/PIT, respectively). Across sites, most patients were male and African American or white. The majority of patients at each site were housed in VA transitional housing/residential rehabilitation programs (33%/32%/40% at BIR/WLA/PIT, respectively). Fewer patients were unsheltered (on the streets or other places not meant for sleeping), though WLA had the most unsheltered patients (26%) compared with BIR (6%) and PIT (2%). BIR had more patients from emergency shelters (14%) than did the other 2 sites (4% at WLA and 0% at PIT). PIT had the most domiciled patients in houses/apartments (26%, compared with 6% each at BIR and WLA), but who were at risk for homelessness.

Table 3 summarizes the diagnoses and VA health care use patterns of these cohorts. In the first week of HPACT care, WLA addressed the most acute medical conditions (81% of patients had≥ 1 common condition), followed by BIR (54%) and PIT (23%). Among chronic conditions, chronic pain was diagnosed in 51% of patients at BIR, 30% of patients at WLA, and 12% of patients at PIT. Hepatitis C diagnoses were most common at WLA (36%), similar at PIT (33%), and lower at BIR (17%). Overall, chronic medical diagnoses were most common among patients at BIR (91%), followed by WLA (85%), and PIT (60%).

Among mental health diagnoses, mood disorders were the most prevalent across sites (49%/55%/42% at BIR/WLA/PIT, respectively), followed by posttraumatic stress disorder (17%/21%/9% at BIR/WLA/PIT, respectively). WLA had more patients with psychosis (19%) than did the other 2 sites (7% at PIT and 0% at BIR). Overall, mental illness was common among HPACT patients across sites (60%/72%/72% at BIR/WLA/PIT, respectively).

Health care use in the 6 months before HPACT enrollment differed between sites. BIR and PIT had similar rates of ED/urgent care use (46% and 47% sought care over the prior 6 months, respectively), but WLA had the highest rate (62%). However, inpatient admission rates were lowest at WLA (13%) and again similar at BIR (23%) and PIT (26%). BIR patients had the most VA primary care exposure before HPACT entry (71% obtained primary care in the past 6 months), followed by WLA (38%) and PIT (18%). Mental health specialty care was also highest at BIR (60%), followed by PIT (56%), then WLA (39%)

Table 4 presents the prevalence of ATOD abuse or dependence among HPACT patients in the6 months before clinic enrollment. The most commonly misused substances were alcohol (60%/35%/44% at BIR/WLA/PIT, respectively), tobacco (71%/47%/40% at BIR/WLA/PIT, respectively), and cocaine (37%/19%/23% at BIR/WLA/PIT, respectively). PIT had the highest percentages of patients with opioid misuse (21%), followed by BIR (9%) and WLA (6%). Overall, these disorders were prevalent across sites, highest at BIR (94%) and similar at WLA (72%) and PIT (67%).

DISCUSSION

In this case report of early HPACT implementation, strikingly different models of homeless-focused primary care at the geographically distinct facilities were found. The lack of a gold standard primary care medical home for homeless persons—compounded by contrasting local contextual features—led to distinct clinic designs. BIR capitalized on primary care needs among veterans who previously sought housing and relied on the available space within an operating primary care clinic. As WLA already offered primary care for homeless veterans that was colocated with mental health services, the HPACT at this site was devised as an after-hours clinic colocated with the ED.¹¹ At PIT, an existing primary care team with addiction expertise expanded its role to include a focus on homelessness, without needing new space or staff.

The initial HPACT patient cohorts likely reflected these contrasting clinic structures. That is, at WLA, the higher rates of unsheltered patients, prevalence of acute medical conditions and psychotic disorders, and greater ED use was likely driven by ED colocation. The physical location of this site’s HPACT may also speak to greater future decreases in ED use. At BIR, the use of a dedicated HPACT community outreach worker likely led to greater recruitment from emergency shelters. However, the clinic mainly recruited veterans who had previously engaged in VA mainstream primary care services and individuals with ATOD use. At PIT, higher rates of psychotherapy were likely facilitated by the HPACT’s placement within an addiction treatment setting, which may favor psychosocial rehabilitation. The distinctly higher rate of patients with opioid misuse at PIT likely paralleled the ATOD expertise of its providers and/or buprenorphine availability.

The more challenging questions surround the implementation of the current clinic models to address the needs of these patient cohorts and possible avenues to improve each clinic. High rates of chronic medical illness, mental illness, and ATOD use are well known in the homeless veteran and general populations.^2,9 Within these 3 HPACTs, the high rates of medical/mental illness and ATOD use speak favorably about the clinics’ respective recruitment strategies; ie, normative homeless populations with high rates of illness are enrolling in these clinics. However, current service integration practices may be enhanced with the specific knowledge gained from this examination. For example, the very high rates of mood and anxiety disorders at each site suggest a role for an embedded mental health provider with prescribing privileges (the model adopted by BIR) as opposed to mental health referrals used at WLA and PIT. There may also be a role for cognitive behavioral therapy services within these clinics. Similarly, the high rates of ATOD (especially alcohol, tobacco, and cocaine) misuse suggest a role for addiction medicine training among the PCPs (the PIT model) as well as psychosocial rehabilitation for ATOD use within the HPACTs. High rates of chronic medical conditions, such as diabetes, hepatitis C, and hypertension elucidate possible roles for specialty care integration and/or chronic disease management programs tailored to the homeless.

Comparing the housing status of these cohorts can help in the design of future homeless-tailored primary care operations and improve these HPACTs. Most patients across sites lived in VA transitional housing/residential rehabilitation programs. As such, current referral practices at these 3 HPACTs proved sufficient in recruiting this subpopulation of homeless veterans. However, in light of national data showing that the count of unsheltered homeless veterans has not declined as rapidly as the count of homeless veterans overall, the higher numbers of veterans recruited from interim sheltering arrangements suggest a need for enhanced outreach to unsheltered individuals.¹ WLA data suggest that linkages to EDs can advance this objective. BIR data show that targeted outreach in shelters can engage this high-risk, transiently sheltered subpopulation in primary care. At the time of this project, PIT just began using a peer support specialist for outreach to unsheltered veterans. It will be important to evaluate the outcomes of this new referral strategy.

Limitations

These exploratory findings—though from a small convenience sample within a nascent, growing program—generated critical and detailed information to guide ongoing policies and service design. However, these findings have limitations. First, though this research contributes to limited existing literature about the operational design of homeless-focused primary care, no outcome data were included. Although a comprehensive evaluation of all HPACT sites is a distinct and useful endeavor, this project instead offers a rapid, detailed illustration of 3 early-stage clinics. Though smaller in scope, this effort informs other facilities developing homeless-focused primary care initiatives and the larger demonstration project.

Second, a convenience sample of 3 urban facilities with strong academic ties and community commitment to providing services for homeless persons was presented. It may be difficult to translate these findings to communities with fewer resources.

Third, EHR review was used to determine patient demographics, diagnoses, and patterns of health care use. Though EHR review offers detailed information that is unavailable from administrative data, EHR is subject to variations in documentation patterns.

Last, differing characteristics of the homeless veteran population in each city may interact with contrasting HPACT structures to influence the characteristics of patients served. For example, though the data suggest that linkages with the ED may facilitate greater recruitment of unsheltered veterans in WLA, Los Angeles is known to have particularly high rates of unsheltered individuals.¹

CONCLUSIONS

Clinicians, administrators, and researchers in the safety net may benefit from the experience implementing new clinics to recruit and engage homeless veterans in primary care. In a relatively nascent field with few accepted models of care, this paper offers detailed descriptions of newly developed homeless-focused primary care clinics at 3 VA facilities, which can inform other sites undertaking similar initiatives. This study highlights the wide range of approaches to building such clinics, with important variations in structural characteristics such as clinic location and operating hours, as well as within the intricacies of service integration patterns.

Within primary care clinics for homeless adults, this study suggests a role for embedded mental health (medication management and psychotherapy) and substance abuse services, chronic disease management programs tailored to this vulnerable population, and the role of linkages to the ED or community-based outreach to recruit unsheltered homeless patients. To pave a path toward identifying an evidence-based model of homeless-focused primary care, future studies are needed to study nationwide HPACT outcomes, including health status, patient satisfaction, quality of life, housing, and cost-effectiveness.

Acknowledgements
This work was undertaken in part by the VA’s PACT Demonstration Laboratory initiative, supporting and evaluating VA’s transition to a patient-centered medical home. Funding for the PACT Demonstration Laboratory initiative was provided by the VA Office of Patient Care Services. This project received support from the VISN 22 VA Assessment and Improvement Lab for Patient Centered Care (VAIL-PCC) (XVA 65-018; PI: Rubenstein).

Dr. Gabrielian was supported in part by the VA Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment. Drs. Gelberg and Andersen were supported in part by NIDA DA 022445. Dr. Andersen received additional support from the UCLA/DREW Project EXPORT, National Center on Minority Health and Health Disparities, P20MD000148/P20MD000182. Dr. Broyles was supported by a Career Development Award (CDA 10–014) from the VA Health Services Research & Development service. Dr. Kertesz was supported through funding of VISN 7.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

On a single night in 2012, 62,619 veterans experienced homelessness.¹ With high rates of illness, as well as alcohol, tobacco, and other drug (ATOD) use among homeless adults, ending veteran homelessness is a signature initiative of the VA.^2-4 However, despite increasing efforts to improve health care for homeless individuals, little is known about best practices in homeless-focused primary care.^2,5

With an age-adjusted mortality that is 2 to 10 times higher than that of their housed counterparts, homeless veterans pose a formidable challenge for primary care providers (PCPs).^6,7 The complexity of homeless persons’ primary care needs is compounded by poor social support and the need to navigate priorities (eg, shelter) that compete with medical care.^6,8,9 Moreover, veterans may face unique vulnerabilities conferred by military-specific experiences.^2,10

As of 2012, only 2 VA facilities had primary care clinics tailored to the needs of homeless veterans. McGuire and colleagues built a system of colocated primary care, mental health, and homeless services for mentally ill veterans in Los Angeles, California.¹¹ Over 18 months, this clinic facilitated greater primary and preventive care delivery, though the population’s physical health status did not improve.¹¹ More recently, O’Toole and colleagues implemented a homeless-focused primary care clinic in Providence, Rhode Island.⁶ Compared with a historical sample of homeless veterans in traditional VA primary care, veterans in this homeless-tailored clinic had greater improvements in some chronic disease outcomes.⁶ This clinic also decreased nonacute emergency department (ED) use and hospitalizations for general medical conditions.⁶

Despite these promising outcomes, the VA lacked a nationwide homeless-focused primary care initiative. In 2012 the VA Office of Homeless Programs and the Office of Primary Care Operations funded a national demonstration project to create Homeless Patient-Aligned Care Teams (HPACTs)—primary care medical clinics for homeless veterans—at 32 facilities. This demonstration project guided HPACTs to tailor clinical and social services to homeless veterans’ needs, establish processes to identify and refer appropriate veterans, and integrate distinct services.

There were no explicit instructions that detailed HPACT structure. Because new VA programs must fit local contextual factors, including infrastructure, space, personnel, and institutional/community resources, different models of homeless-focused primary care have evolved.

This article is a case study of HPACTs at 3 of the 32 participating VA facilities, each reflecting a distinct community and organizational context. In light of projected HPACT expansion and concerns that current services are better tailored to sheltered homeless veterans than to their unsheltered peers, there is particular importance to  detailed clinic descriptions that vividly portray the intricate relationships between service design and populations served.¹

METHODS

VA HPACTs established in May 2012 at 3 facilities were examined: Birmingham VAMC in Alabama (BIR), West Los Angeles VAMC in California (WLA), and VA Pittsburgh Healthcare System in Pennsylvania (PIT). Prior to this demonstration project, each facility offered a range of housing/social services and traditional primary care for veterans. These sites are a geographically diverse convenience sample that emerged from existing homeless-focused collaborations among the authors and represent geographically diverse HPACTs.

The national director of VA Homeless Programs formally determined that this comparison constitutes a VA operations activity that is not research.¹² This activity was exempt from Institutional Review Board review.

Study Design

Timed at an early stage of HPACT implementation, this project had 3 aims: (1) To identify noteworthy similarities and/or differences among the initial HPACT clinic structures; (2) To compare and contrast the patient characteristics of veterans enrolled in each of these clinics; and (3) To use these data to inform ongoing HPACT service design.

HPACT program evaluation data are not presented. Rather, a nascent system of care is illustrated that contributes to the limited literature concerning the design and implementation of homeless-focused primary care. Such organizational profiles inform novel program delivery and hold particular utility for heterogeneous populations who are difficult to engage in care.^13,14

Authors at each site independently developed lists of variables that fell within the 3 guiding principles of this demonstration project. These variables were compiled and iteratively reduced to a consolidated table that assessed each clinic, including location, operating hours, methods of patient identification and referral, and linkages to distinct services (eg, primary care, mental health, addiction, and social services).

This table also became a guide for HPACT directors to generate narrative clinic descriptions. Characteristics of VA medical homes that are embraced regardless of patients’ housing status (eg, patient-centered, team-based care) were also incorporated into these descriptions.¹⁵

Patient Characteristics

The VA electronic health record (EHR) was used to identify all patients enrolled in HPACTs at BIR, WLA, and PIT from May 1, 2012 (clinic inception), through September 30, 2012. Authors developed a standardized template for EHR review and coined the first HPACT record as the patient’s index visit. This record was used to code initial housing status, demographics, and acute medical conditions diagnosed/treated. If housing status was not recorded at the index visit, the first preceding informative record was used.

Records for 6 months preceding the index visit were used to identify the presence or absence of common medical conditions, psychiatric diagnoses, and ATOD abuse or dependence. Medical conditions were identified from a list of common outpatient diagnoses from the National Ambulatory Medical Care Survey, supplemented by common conditions among homeless men.^16-18 The EHR problem list (a list of diagnoses, by patient) was used to obtain diagnoses, supplemented by notes from inpatient admissions/discharges, as well as ED, primary care, and subspecialty consultations within 6 months preceding the index visit. Prior VA health care use was ascertained from the EHR review of the same 6-month window, reflecting ED visits, inpatient admissions, primary care visits, subspecialty visits, and individual/group therapy for ATOD or other mental health problems. Data were used to generate site-specific descriptive statistics.

RESULTS

Like all VA hospital-based clinics, a universal EHR captured all medical and social service notes, orders, medications, and administrative records. All facilities had on-site EDs, medical/mental health specialty care, and pharmacies. Social services, including benefits counseling and housing services, were available on site. Table 1 summarizes the HPACT structures at BIR, WLA, and PIT.

Birmingham

The BIR HPACT was devised as a new homeless-focused team located within a VA primary care clinic where other providers continued to see primary care patients. Staff and space were reallocated for this HPACT, which recruited patients in 4 ways: (1) the facility’s primary homeless program, Healthcare for Homeless Veterans, referred patients who previously sought VA housing but who required primary care; (2) an outreach specialist sought homeless veterans in shelters and on the streets; (3) HPACT staff marketed the clinic with presentations and flyers to other VA services and non-VA community agencies; and (4) a referral mechanism within the EHR.

A nurse practitioner was the PCP at this site, supervised by an academic internist experienced in the care of underserved populations, and the HPACT director, a physician certified in internal and addiction medicine. Patients at the BIR HPACT also received care from a social worker, registered nurse, licensed practical nurse, and psychiatrist who received all or a portion of their salaries from this demonstration project. This clinic accommodated walk-in appointments during business hours. Clinicians discussed clinical cases daily, and the full clinical and administrative team met weekly. To promote service integration, HPACT staff attended meetings of the BIR general primary care and Healthcare for Homeless Veterans programs, and vice versa.

West Los Angeles

At WLA, a previously established Homeless Screening Clinic that offered integrated social and medical services for homeless veterans with mental illness was already available during business hours and located within the site’s mental health program.¹¹ However, because ED use for homeless veterans peaked after hours, the new WLA HPACT was established within the WLA ED.

During WLA HPACT hours (3 weekday evenings/week), routine nursing triage occurred for all patients who presented to the ED. However, distinct from other times of day, veterans who were triaged with low-acuity and who were appropriate for outpatient care were given a self-administered, 4-item questionnaire to identify patients who were homeless or at risk for becoming homeless. Veterans who were identified with this screening tool were offered the choice of an ED or HPACT visit. Veterans who chose the latter were assigned to the queue for an HPACT primary care visit instead of the ED.

A physician led the clinical team, with additional services from a mental health clinical nurse specialist and clerks who worked with homeless and/or mental health patients during business hours and provided part-time HPACT coverage. When needed, additional services were provided from colocated ED nurses and social workers. Providers were chosen for their aptitude in culturally responsive communication.

Patients who chose to be seen in HPACT received a primary care visit that also addressed the reason for ED presentation. HPACT staff worked collaboratively, with interdisciplinary team huddles that preceded each clinic session and ended each patient visit. Referrals and social service needs were tracked and monitored by the PCP. Specialty care referrals were also tracked and facilitated when possible with direct communication between HPACT providers and specialty services. Meetings with daytime Homeless Screening Clinic and ED staff facilitated cross-departmental collaborations that helped veterans prepare for and retain housing.

Pittsburgh

The HPACT at PIT evolved from an existing PACT that provided primary care-based addiction services.² That team included an internist credentialed in addiction medicine and experienced in homeless health care, nurse practitioner, nurse care manager, nursing assistant, and clerks. At this site, HPACT providers had subspecialty expertise in the assessment and treatment of ATOD use, certification to prescribe buprenorphine for outpatient opioid detoxification and/or maintenance, and experience engaging homeless and other vulnerable veterans. The existing colocated clinic included 2 additional addiction medicine clinicians and a physician assistant experienced in ATOD use. The PIT HPACT was not restricted to patients with ATOD use.

At PIT, HPACT care was provided during business hours in a flexible model that allowed for walk-in visits. Providers from the existing addiction-focused PACT identified and referred homeless veterans, as well as patients deemed at-risk for becoming homeless. In addition, other homeless veterans who did not have a PCP could be referred through e-consults placed by any VA staff member. If a referred homeless veteran was already enrolled on a PCP’s panel, HPACT facilitated reengagement with the existing provider. Near the end of this data collection period, a peer support specialist also began community outreach to engage both enrolled and potential HPACT patients.

Patient Characteristics

Table 2 presents the demographic and housing characteristics of enrolled HPACT patients at BIR, WLA, and PIT from May 1, 2012, to September 30, 2012. Each site had a similar number of patients (n = 35/47/43 at BIR/WLA/PIT, respectively). Across sites, most patients were male and African American or white. The majority of patients at each site were housed in VA transitional housing/residential rehabilitation programs (33%/32%/40% at BIR/WLA/PIT, respectively). Fewer patients were unsheltered (on the streets or other places not meant for sleeping), though WLA had the most unsheltered patients (26%) compared with BIR (6%) and PIT (2%). BIR had more patients from emergency shelters (14%) than did the other 2 sites (4% at WLA and 0% at PIT). PIT had the most domiciled patients in houses/apartments (26%, compared with 6% each at BIR and WLA), but who were at risk for homelessness.

Table 3 summarizes the diagnoses and VA health care use patterns of these cohorts. In the first week of HPACT care, WLA addressed the most acute medical conditions (81% of patients had≥ 1 common condition), followed by BIR (54%) and PIT (23%). Among chronic conditions, chronic pain was diagnosed in 51% of patients at BIR, 30% of patients at WLA, and 12% of patients at PIT. Hepatitis C diagnoses were most common at WLA (36%), similar at PIT (33%), and lower at BIR (17%). Overall, chronic medical diagnoses were most common among patients at BIR (91%), followed by WLA (85%), and PIT (60%).

Among mental health diagnoses, mood disorders were the most prevalent across sites (49%/55%/42% at BIR/WLA/PIT, respectively), followed by posttraumatic stress disorder (17%/21%/9% at BIR/WLA/PIT, respectively). WLA had more patients with psychosis (19%) than did the other 2 sites (7% at PIT and 0% at BIR). Overall, mental illness was common among HPACT patients across sites (60%/72%/72% at BIR/WLA/PIT, respectively).

Health care use in the 6 months before HPACT enrollment differed between sites. BIR and PIT had similar rates of ED/urgent care use (46% and 47% sought care over the prior 6 months, respectively), but WLA had the highest rate (62%). However, inpatient admission rates were lowest at WLA (13%) and again similar at BIR (23%) and PIT (26%). BIR patients had the most VA primary care exposure before HPACT entry (71% obtained primary care in the past 6 months), followed by WLA (38%) and PIT (18%). Mental health specialty care was also highest at BIR (60%), followed by PIT (56%), then WLA (39%)

Table 4 presents the prevalence of ATOD abuse or dependence among HPACT patients in the6 months before clinic enrollment. The most commonly misused substances were alcohol (60%/35%/44% at BIR/WLA/PIT, respectively), tobacco (71%/47%/40% at BIR/WLA/PIT, respectively), and cocaine (37%/19%/23% at BIR/WLA/PIT, respectively). PIT had the highest percentages of patients with opioid misuse (21%), followed by BIR (9%) and WLA (6%). Overall, these disorders were prevalent across sites, highest at BIR (94%) and similar at WLA (72%) and PIT (67%).

DISCUSSION

In this case report of early HPACT implementation, strikingly different models of homeless-focused primary care at the geographically distinct facilities were found. The lack of a gold standard primary care medical home for homeless persons—compounded by contrasting local contextual features—led to distinct clinic designs. BIR capitalized on primary care needs among veterans who previously sought housing and relied on the available space within an operating primary care clinic. As WLA already offered primary care for homeless veterans that was colocated with mental health services, the HPACT at this site was devised as an after-hours clinic colocated with the ED.¹¹ At PIT, an existing primary care team with addiction expertise expanded its role to include a focus on homelessness, without needing new space or staff.

The initial HPACT patient cohorts likely reflected these contrasting clinic structures. That is, at WLA, the higher rates of unsheltered patients, prevalence of acute medical conditions and psychotic disorders, and greater ED use was likely driven by ED colocation. The physical location of this site’s HPACT may also speak to greater future decreases in ED use. At BIR, the use of a dedicated HPACT community outreach worker likely led to greater recruitment from emergency shelters. However, the clinic mainly recruited veterans who had previously engaged in VA mainstream primary care services and individuals with ATOD use. At PIT, higher rates of psychotherapy were likely facilitated by the HPACT’s placement within an addiction treatment setting, which may favor psychosocial rehabilitation. The distinctly higher rate of patients with opioid misuse at PIT likely paralleled the ATOD expertise of its providers and/or buprenorphine availability.

The more challenging questions surround the implementation of the current clinic models to address the needs of these patient cohorts and possible avenues to improve each clinic. High rates of chronic medical illness, mental illness, and ATOD use are well known in the homeless veteran and general populations.^2,9 Within these 3 HPACTs, the high rates of medical/mental illness and ATOD use speak favorably about the clinics’ respective recruitment strategies; ie, normative homeless populations with high rates of illness are enrolling in these clinics. However, current service integration practices may be enhanced with the specific knowledge gained from this examination. For example, the very high rates of mood and anxiety disorders at each site suggest a role for an embedded mental health provider with prescribing privileges (the model adopted by BIR) as opposed to mental health referrals used at WLA and PIT. There may also be a role for cognitive behavioral therapy services within these clinics. Similarly, the high rates of ATOD (especially alcohol, tobacco, and cocaine) misuse suggest a role for addiction medicine training among the PCPs (the PIT model) as well as psychosocial rehabilitation for ATOD use within the HPACTs. High rates of chronic medical conditions, such as diabetes, hepatitis C, and hypertension elucidate possible roles for specialty care integration and/or chronic disease management programs tailored to the homeless.

Comparing the housing status of these cohorts can help in the design of future homeless-tailored primary care operations and improve these HPACTs. Most patients across sites lived in VA transitional housing/residential rehabilitation programs. As such, current referral practices at these 3 HPACTs proved sufficient in recruiting this subpopulation of homeless veterans. However, in light of national data showing that the count of unsheltered homeless veterans has not declined as rapidly as the count of homeless veterans overall, the higher numbers of veterans recruited from interim sheltering arrangements suggest a need for enhanced outreach to unsheltered individuals.¹ WLA data suggest that linkages to EDs can advance this objective. BIR data show that targeted outreach in shelters can engage this high-risk, transiently sheltered subpopulation in primary care. At the time of this project, PIT just began using a peer support specialist for outreach to unsheltered veterans. It will be important to evaluate the outcomes of this new referral strategy.

Limitations

These exploratory findings—though from a small convenience sample within a nascent, growing program—generated critical and detailed information to guide ongoing policies and service design. However, these findings have limitations. First, though this research contributes to limited existing literature about the operational design of homeless-focused primary care, no outcome data were included. Although a comprehensive evaluation of all HPACT sites is a distinct and useful endeavor, this project instead offers a rapid, detailed illustration of 3 early-stage clinics. Though smaller in scope, this effort informs other facilities developing homeless-focused primary care initiatives and the larger demonstration project.

Second, a convenience sample of 3 urban facilities with strong academic ties and community commitment to providing services for homeless persons was presented. It may be difficult to translate these findings to communities with fewer resources.

Third, EHR review was used to determine patient demographics, diagnoses, and patterns of health care use. Though EHR review offers detailed information that is unavailable from administrative data, EHR is subject to variations in documentation patterns.

Last, differing characteristics of the homeless veteran population in each city may interact with contrasting HPACT structures to influence the characteristics of patients served. For example, though the data suggest that linkages with the ED may facilitate greater recruitment of unsheltered veterans in WLA, Los Angeles is known to have particularly high rates of unsheltered individuals.¹

CONCLUSIONS

Clinicians, administrators, and researchers in the safety net may benefit from the experience implementing new clinics to recruit and engage homeless veterans in primary care. In a relatively nascent field with few accepted models of care, this paper offers detailed descriptions of newly developed homeless-focused primary care clinics at 3 VA facilities, which can inform other sites undertaking similar initiatives. This study highlights the wide range of approaches to building such clinics, with important variations in structural characteristics such as clinic location and operating hours, as well as within the intricacies of service integration patterns.

Within primary care clinics for homeless adults, this study suggests a role for embedded mental health (medication management and psychotherapy) and substance abuse services, chronic disease management programs tailored to this vulnerable population, and the role of linkages to the ED or community-based outreach to recruit unsheltered homeless patients. To pave a path toward identifying an evidence-based model of homeless-focused primary care, future studies are needed to study nationwide HPACT outcomes, including health status, patient satisfaction, quality of life, housing, and cost-effectiveness.

Acknowledgements
This work was undertaken in part by the VA’s PACT Demonstration Laboratory initiative, supporting and evaluating VA’s transition to a patient-centered medical home. Funding for the PACT Demonstration Laboratory initiative was provided by the VA Office of Patient Care Services. This project received support from the VISN 22 VA Assessment and Improvement Lab for Patient Centered Care (VAIL-PCC) (XVA 65-018; PI: Rubenstein).

Dr. Gabrielian was supported in part by the VA Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment. Drs. Gelberg and Andersen were supported in part by NIDA DA 022445. Dr. Andersen received additional support from the UCLA/DREW Project EXPORT, National Center on Minority Health and Health Disparities, P20MD000148/P20MD000182. Dr. Broyles was supported by a Career Development Award (CDA 10–014) from the VA Health Services Research & Development service. Dr. Kertesz was supported through funding of VISN 7.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

On a single night in 2012, 62,619 veterans experienced homelessness.¹ With high rates of illness, as well as alcohol, tobacco, and other drug (ATOD) use among homeless adults, ending veteran homelessness is a signature initiative of the VA.^2-4 However, despite increasing efforts to improve health care for homeless individuals, little is known about best practices in homeless-focused primary care.^2,5

With an age-adjusted mortality that is 2 to 10 times higher than that of their housed counterparts, homeless veterans pose a formidable challenge for primary care providers (PCPs).^6,7 The complexity of homeless persons’ primary care needs is compounded by poor social support and the need to navigate priorities (eg, shelter) that compete with medical care.^6,8,9 Moreover, veterans may face unique vulnerabilities conferred by military-specific experiences.^2,10

As of 2012, only 2 VA facilities had primary care clinics tailored to the needs of homeless veterans. McGuire and colleagues built a system of colocated primary care, mental health, and homeless services for mentally ill veterans in Los Angeles, California.¹¹ Over 18 months, this clinic facilitated greater primary and preventive care delivery, though the population’s physical health status did not improve.¹¹ More recently, O’Toole and colleagues implemented a homeless-focused primary care clinic in Providence, Rhode Island.⁶ Compared with a historical sample of homeless veterans in traditional VA primary care, veterans in this homeless-tailored clinic had greater improvements in some chronic disease outcomes.⁶ This clinic also decreased nonacute emergency department (ED) use and hospitalizations for general medical conditions.⁶

Despite these promising outcomes, the VA lacked a nationwide homeless-focused primary care initiative. In 2012 the VA Office of Homeless Programs and the Office of Primary Care Operations funded a national demonstration project to create Homeless Patient-Aligned Care Teams (HPACTs)—primary care medical clinics for homeless veterans—at 32 facilities. This demonstration project guided HPACTs to tailor clinical and social services to homeless veterans’ needs, establish processes to identify and refer appropriate veterans, and integrate distinct services.

There were no explicit instructions that detailed HPACT structure. Because new VA programs must fit local contextual factors, including infrastructure, space, personnel, and institutional/community resources, different models of homeless-focused primary care have evolved.

This article is a case study of HPACTs at 3 of the 32 participating VA facilities, each reflecting a distinct community and organizational context. In light of projected HPACT expansion and concerns that current services are better tailored to sheltered homeless veterans than to their unsheltered peers, there is particular importance to  detailed clinic descriptions that vividly portray the intricate relationships between service design and populations served.¹

METHODS

VA HPACTs established in May 2012 at 3 facilities were examined: Birmingham VAMC in Alabama (BIR), West Los Angeles VAMC in California (WLA), and VA Pittsburgh Healthcare System in Pennsylvania (PIT). Prior to this demonstration project, each facility offered a range of housing/social services and traditional primary care for veterans. These sites are a geographically diverse convenience sample that emerged from existing homeless-focused collaborations among the authors and represent geographically diverse HPACTs.

The national director of VA Homeless Programs formally determined that this comparison constitutes a VA operations activity that is not research.¹² This activity was exempt from Institutional Review Board review.

Study Design

Timed at an early stage of HPACT implementation, this project had 3 aims: (1) To identify noteworthy similarities and/or differences among the initial HPACT clinic structures; (2) To compare and contrast the patient characteristics of veterans enrolled in each of these clinics; and (3) To use these data to inform ongoing HPACT service design.

HPACT program evaluation data are not presented. Rather, a nascent system of care is illustrated that contributes to the limited literature concerning the design and implementation of homeless-focused primary care. Such organizational profiles inform novel program delivery and hold particular utility for heterogeneous populations who are difficult to engage in care.^13,14

Authors at each site independently developed lists of variables that fell within the 3 guiding principles of this demonstration project. These variables were compiled and iteratively reduced to a consolidated table that assessed each clinic, including location, operating hours, methods of patient identification and referral, and linkages to distinct services (eg, primary care, mental health, addiction, and social services).

This table also became a guide for HPACT directors to generate narrative clinic descriptions. Characteristics of VA medical homes that are embraced regardless of patients’ housing status (eg, patient-centered, team-based care) were also incorporated into these descriptions.¹⁵

Patient Characteristics

The VA electronic health record (EHR) was used to identify all patients enrolled in HPACTs at BIR, WLA, and PIT from May 1, 2012 (clinic inception), through September 30, 2012. Authors developed a standardized template for EHR review and coined the first HPACT record as the patient’s index visit. This record was used to code initial housing status, demographics, and acute medical conditions diagnosed/treated. If housing status was not recorded at the index visit, the first preceding informative record was used.

Records for 6 months preceding the index visit were used to identify the presence or absence of common medical conditions, psychiatric diagnoses, and ATOD abuse or dependence. Medical conditions were identified from a list of common outpatient diagnoses from the National Ambulatory Medical Care Survey, supplemented by common conditions among homeless men.^16-18 The EHR problem list (a list of diagnoses, by patient) was used to obtain diagnoses, supplemented by notes from inpatient admissions/discharges, as well as ED, primary care, and subspecialty consultations within 6 months preceding the index visit. Prior VA health care use was ascertained from the EHR review of the same 6-month window, reflecting ED visits, inpatient admissions, primary care visits, subspecialty visits, and individual/group therapy for ATOD or other mental health problems. Data were used to generate site-specific descriptive statistics.

RESULTS

Like all VA hospital-based clinics, a universal EHR captured all medical and social service notes, orders, medications, and administrative records. All facilities had on-site EDs, medical/mental health specialty care, and pharmacies. Social services, including benefits counseling and housing services, were available on site. Table 1 summarizes the HPACT structures at BIR, WLA, and PIT.

Birmingham

The BIR HPACT was devised as a new homeless-focused team located within a VA primary care clinic where other providers continued to see primary care patients. Staff and space were reallocated for this HPACT, which recruited patients in 4 ways: (1) the facility’s primary homeless program, Healthcare for Homeless Veterans, referred patients who previously sought VA housing but who required primary care; (2) an outreach specialist sought homeless veterans in shelters and on the streets; (3) HPACT staff marketed the clinic with presentations and flyers to other VA services and non-VA community agencies; and (4) a referral mechanism within the EHR.

A nurse practitioner was the PCP at this site, supervised by an academic internist experienced in the care of underserved populations, and the HPACT director, a physician certified in internal and addiction medicine. Patients at the BIR HPACT also received care from a social worker, registered nurse, licensed practical nurse, and psychiatrist who received all or a portion of their salaries from this demonstration project. This clinic accommodated walk-in appointments during business hours. Clinicians discussed clinical cases daily, and the full clinical and administrative team met weekly. To promote service integration, HPACT staff attended meetings of the BIR general primary care and Healthcare for Homeless Veterans programs, and vice versa.

West Los Angeles

At WLA, a previously established Homeless Screening Clinic that offered integrated social and medical services for homeless veterans with mental illness was already available during business hours and located within the site’s mental health program.¹¹ However, because ED use for homeless veterans peaked after hours, the new WLA HPACT was established within the WLA ED.

During WLA HPACT hours (3 weekday evenings/week), routine nursing triage occurred for all patients who presented to the ED. However, distinct from other times of day, veterans who were triaged with low-acuity and who were appropriate for outpatient care were given a self-administered, 4-item questionnaire to identify patients who were homeless or at risk for becoming homeless. Veterans who were identified with this screening tool were offered the choice of an ED or HPACT visit. Veterans who chose the latter were assigned to the queue for an HPACT primary care visit instead of the ED.

A physician led the clinical team, with additional services from a mental health clinical nurse specialist and clerks who worked with homeless and/or mental health patients during business hours and provided part-time HPACT coverage. When needed, additional services were provided from colocated ED nurses and social workers. Providers were chosen for their aptitude in culturally responsive communication.

Patients who chose to be seen in HPACT received a primary care visit that also addressed the reason for ED presentation. HPACT staff worked collaboratively, with interdisciplinary team huddles that preceded each clinic session and ended each patient visit. Referrals and social service needs were tracked and monitored by the PCP. Specialty care referrals were also tracked and facilitated when possible with direct communication between HPACT providers and specialty services. Meetings with daytime Homeless Screening Clinic and ED staff facilitated cross-departmental collaborations that helped veterans prepare for and retain housing.

Pittsburgh

The HPACT at PIT evolved from an existing PACT that provided primary care-based addiction services.² That team included an internist credentialed in addiction medicine and experienced in homeless health care, nurse practitioner, nurse care manager, nursing assistant, and clerks. At this site, HPACT providers had subspecialty expertise in the assessment and treatment of ATOD use, certification to prescribe buprenorphine for outpatient opioid detoxification and/or maintenance, and experience engaging homeless and other vulnerable veterans. The existing colocated clinic included 2 additional addiction medicine clinicians and a physician assistant experienced in ATOD use. The PIT HPACT was not restricted to patients with ATOD use.

At PIT, HPACT care was provided during business hours in a flexible model that allowed for walk-in visits. Providers from the existing addiction-focused PACT identified and referred homeless veterans, as well as patients deemed at-risk for becoming homeless. In addition, other homeless veterans who did not have a PCP could be referred through e-consults placed by any VA staff member. If a referred homeless veteran was already enrolled on a PCP’s panel, HPACT facilitated reengagement with the existing provider. Near the end of this data collection period, a peer support specialist also began community outreach to engage both enrolled and potential HPACT patients.

Patient Characteristics

Table 2 presents the demographic and housing characteristics of enrolled HPACT patients at BIR, WLA, and PIT from May 1, 2012, to September 30, 2012. Each site had a similar number of patients (n = 35/47/43 at BIR/WLA/PIT, respectively). Across sites, most patients were male and African American or white. The majority of patients at each site were housed in VA transitional housing/residential rehabilitation programs (33%/32%/40% at BIR/WLA/PIT, respectively). Fewer patients were unsheltered (on the streets or other places not meant for sleeping), though WLA had the most unsheltered patients (26%) compared with BIR (6%) and PIT (2%). BIR had more patients from emergency shelters (14%) than did the other 2 sites (4% at WLA and 0% at PIT). PIT had the most domiciled patients in houses/apartments (26%, compared with 6% each at BIR and WLA), but who were at risk for homelessness.

Table 3 summarizes the diagnoses and VA health care use patterns of these cohorts. In the first week of HPACT care, WLA addressed the most acute medical conditions (81% of patients had≥ 1 common condition), followed by BIR (54%) and PIT (23%). Among chronic conditions, chronic pain was diagnosed in 51% of patients at BIR, 30% of patients at WLA, and 12% of patients at PIT. Hepatitis C diagnoses were most common at WLA (36%), similar at PIT (33%), and lower at BIR (17%). Overall, chronic medical diagnoses were most common among patients at BIR (91%), followed by WLA (85%), and PIT (60%).

Among mental health diagnoses, mood disorders were the most prevalent across sites (49%/55%/42% at BIR/WLA/PIT, respectively), followed by posttraumatic stress disorder (17%/21%/9% at BIR/WLA/PIT, respectively). WLA had more patients with psychosis (19%) than did the other 2 sites (7% at PIT and 0% at BIR). Overall, mental illness was common among HPACT patients across sites (60%/72%/72% at BIR/WLA/PIT, respectively).

Health care use in the 6 months before HPACT enrollment differed between sites. BIR and PIT had similar rates of ED/urgent care use (46% and 47% sought care over the prior 6 months, respectively), but WLA had the highest rate (62%). However, inpatient admission rates were lowest at WLA (13%) and again similar at BIR (23%) and PIT (26%). BIR patients had the most VA primary care exposure before HPACT entry (71% obtained primary care in the past 6 months), followed by WLA (38%) and PIT (18%). Mental health specialty care was also highest at BIR (60%), followed by PIT (56%), then WLA (39%)

Table 4 presents the prevalence of ATOD abuse or dependence among HPACT patients in the6 months before clinic enrollment. The most commonly misused substances were alcohol (60%/35%/44% at BIR/WLA/PIT, respectively), tobacco (71%/47%/40% at BIR/WLA/PIT, respectively), and cocaine (37%/19%/23% at BIR/WLA/PIT, respectively). PIT had the highest percentages of patients with opioid misuse (21%), followed by BIR (9%) and WLA (6%). Overall, these disorders were prevalent across sites, highest at BIR (94%) and similar at WLA (72%) and PIT (67%).

DISCUSSION

In this case report of early HPACT implementation, strikingly different models of homeless-focused primary care at the geographically distinct facilities were found. The lack of a gold standard primary care medical home for homeless persons—compounded by contrasting local contextual features—led to distinct clinic designs. BIR capitalized on primary care needs among veterans who previously sought housing and relied on the available space within an operating primary care clinic. As WLA already offered primary care for homeless veterans that was colocated with mental health services, the HPACT at this site was devised as an after-hours clinic colocated with the ED.¹¹ At PIT, an existing primary care team with addiction expertise expanded its role to include a focus on homelessness, without needing new space or staff.

The initial HPACT patient cohorts likely reflected these contrasting clinic structures. That is, at WLA, the higher rates of unsheltered patients, prevalence of acute medical conditions and psychotic disorders, and greater ED use was likely driven by ED colocation. The physical location of this site’s HPACT may also speak to greater future decreases in ED use. At BIR, the use of a dedicated HPACT community outreach worker likely led to greater recruitment from emergency shelters. However, the clinic mainly recruited veterans who had previously engaged in VA mainstream primary care services and individuals with ATOD use. At PIT, higher rates of psychotherapy were likely facilitated by the HPACT’s placement within an addiction treatment setting, which may favor psychosocial rehabilitation. The distinctly higher rate of patients with opioid misuse at PIT likely paralleled the ATOD expertise of its providers and/or buprenorphine availability.

The more challenging questions surround the implementation of the current clinic models to address the needs of these patient cohorts and possible avenues to improve each clinic. High rates of chronic medical illness, mental illness, and ATOD use are well known in the homeless veteran and general populations.^2,9 Within these 3 HPACTs, the high rates of medical/mental illness and ATOD use speak favorably about the clinics’ respective recruitment strategies; ie, normative homeless populations with high rates of illness are enrolling in these clinics. However, current service integration practices may be enhanced with the specific knowledge gained from this examination. For example, the very high rates of mood and anxiety disorders at each site suggest a role for an embedded mental health provider with prescribing privileges (the model adopted by BIR) as opposed to mental health referrals used at WLA and PIT. There may also be a role for cognitive behavioral therapy services within these clinics. Similarly, the high rates of ATOD (especially alcohol, tobacco, and cocaine) misuse suggest a role for addiction medicine training among the PCPs (the PIT model) as well as psychosocial rehabilitation for ATOD use within the HPACTs. High rates of chronic medical conditions, such as diabetes, hepatitis C, and hypertension elucidate possible roles for specialty care integration and/or chronic disease management programs tailored to the homeless.

Comparing the housing status of these cohorts can help in the design of future homeless-tailored primary care operations and improve these HPACTs. Most patients across sites lived in VA transitional housing/residential rehabilitation programs. As such, current referral practices at these 3 HPACTs proved sufficient in recruiting this subpopulation of homeless veterans. However, in light of national data showing that the count of unsheltered homeless veterans has not declined as rapidly as the count of homeless veterans overall, the higher numbers of veterans recruited from interim sheltering arrangements suggest a need for enhanced outreach to unsheltered individuals.¹ WLA data suggest that linkages to EDs can advance this objective. BIR data show that targeted outreach in shelters can engage this high-risk, transiently sheltered subpopulation in primary care. At the time of this project, PIT just began using a peer support specialist for outreach to unsheltered veterans. It will be important to evaluate the outcomes of this new referral strategy.

Limitations

These exploratory findings—though from a small convenience sample within a nascent, growing program—generated critical and detailed information to guide ongoing policies and service design. However, these findings have limitations. First, though this research contributes to limited existing literature about the operational design of homeless-focused primary care, no outcome data were included. Although a comprehensive evaluation of all HPACT sites is a distinct and useful endeavor, this project instead offers a rapid, detailed illustration of 3 early-stage clinics. Though smaller in scope, this effort informs other facilities developing homeless-focused primary care initiatives and the larger demonstration project.

Second, a convenience sample of 3 urban facilities with strong academic ties and community commitment to providing services for homeless persons was presented. It may be difficult to translate these findings to communities with fewer resources.

Third, EHR review was used to determine patient demographics, diagnoses, and patterns of health care use. Though EHR review offers detailed information that is unavailable from administrative data, EHR is subject to variations in documentation patterns.

Last, differing characteristics of the homeless veteran population in each city may interact with contrasting HPACT structures to influence the characteristics of patients served. For example, though the data suggest that linkages with the ED may facilitate greater recruitment of unsheltered veterans in WLA, Los Angeles is known to have particularly high rates of unsheltered individuals.¹

CONCLUSIONS

Clinicians, administrators, and researchers in the safety net may benefit from the experience implementing new clinics to recruit and engage homeless veterans in primary care. In a relatively nascent field with few accepted models of care, this paper offers detailed descriptions of newly developed homeless-focused primary care clinics at 3 VA facilities, which can inform other sites undertaking similar initiatives. This study highlights the wide range of approaches to building such clinics, with important variations in structural characteristics such as clinic location and operating hours, as well as within the intricacies of service integration patterns.

Within primary care clinics for homeless adults, this study suggests a role for embedded mental health (medication management and psychotherapy) and substance abuse services, chronic disease management programs tailored to this vulnerable population, and the role of linkages to the ED or community-based outreach to recruit unsheltered homeless patients. To pave a path toward identifying an evidence-based model of homeless-focused primary care, future studies are needed to study nationwide HPACT outcomes, including health status, patient satisfaction, quality of life, housing, and cost-effectiveness.

Acknowledgements
This work was undertaken in part by the VA’s PACT Demonstration Laboratory initiative, supporting and evaluating VA’s transition to a patient-centered medical home. Funding for the PACT Demonstration Laboratory initiative was provided by the VA Office of Patient Care Services. This project received support from the VISN 22 VA Assessment and Improvement Lab for Patient Centered Care (VAIL-PCC) (XVA 65-018; PI: Rubenstein).

Dr. Gabrielian was supported in part by the VA Office of Academic Affiliations, Advanced Fellowship Program in Mental Illness Research and Treatment. Drs. Gelberg and Andersen were supported in part by NIDA DA 022445. Dr. Andersen received additional support from the UCLA/DREW Project EXPORT, National Center on Minority Health and Health Disparities, P20MD000148/P20MD000182. Dr. Broyles was supported by a Career Development Award (CDA 10–014) from the VA Health Services Research & Development service. Dr. Kertesz was supported through funding of VISN 7.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.