Erin E. Johnson

New to Care: Demands on a Health System When Homeless Veterans Are Enrolled in a Medical Home Model

OBJECTIVES We compared service use among homeless and nonhomeless veterans newly enrolled in a medical home model and identified patterns of use among homeless veterans associated with reductions in emergency department (ED) use. METHODS We used case-control matching with a nested cohort analysis to measure 6-month health services use, new diagnoses, and care use patterns in veterans at the Providence, Rhode Island, Veterans Affairs Medical Center from 2008 to 2011. RESULTS We followed 127 homeless and 106 nonhomeless veterans. Both groups had similar rates of chronic medical and mental health diagnoses; 25.4% of the homeless and 18.1% of the nonhomeless group reported active substance abuse. Homeless veterans used significantly more primary, mental health, substance abuse, and ED care during the first 6 months. Homeless veterans who accessed primary care at higher rates (relative risk ratio [RRR] = 1.46; 95% confidence interval [CI] = 1.11, 1.92) or who used specialty and primary care (RRR = 10.95; 95% CI = 1.58, 75.78) had reduced ED usage. Homeless veterans in transitional housing or doubled-up at baseline (RRR = 3.41; 95% CI = 1.24, 9.42) had similar reductions in ED usage. CONCLUSIONS Homeless adults had substantial health needs when presenting for care. High-intensity primary care and access to specialty care services could reduce ED use.

Needing Primary Care But Not Getting It: The Role of Trust, Stigma and Organizational Obstacles reported by Homeless Veterans

We describe data from a multi-center community-based survey of homeless veterans who were not accessing available primary care to identify reasons for not getting this care as well as for not seeking health care when it was needed. Overall, 185 homeless veterans were interviewed: The average age was 48.7 years (SD 10.8), 94.6% were male, 43.2% were from a minority population. The majority identified a recent need for care and interest in having a primary care provider. Reasons for delaying care fell into three domains: 1) trust; 2) stigma; and 3) care processes. Identifying a place for care (OR 3.3; 95% CI: 1.4–7.7), having a medical condition (OR 5.5; 95% CI 1.9–15.4) and having depression (OR 3.4; 95% CI: 1.4–8.7) were associated with receiving care while not being involved in care decisions was associated with no care (OR 0.7; 95% CI 0.5–0.9). Our findings support the importance of considering health access within an expanded framework that includes perceived stigma, inflexible care systems and trust issues.

Losing work: Regional unemployment and its effect on homeless demographic characteristics, needs, and health care

Background. Who becomes homeless because of unemployment and what they need are poorly understood. Methods. Four-year time-series study. Homeless characteristics, co-morbid conditions, and needs are correlated with unemployment rates. Results. The unemployment rate averaged 6.7% during years 1–2 (N=198) and 11.8% during years 3–4 (N=202). Those presenting during high unemployment worked most recently in clerical positions (10.4% vs. 4.5%, p= .02) and reported unemployment (OR=2.0; 95% CI; 1.07, 3.76) and unaffordable housing (28.7% vs. 15.2%; p<.01) causing homelessness. Those reporting unemployment were more likely to be local residents (OR=2.1; CI=1.01, 4.53), but less likely to have family support (OR=0.4; CI=0.19, 0.87). While comparable proportions reported mental health conditions and received care, more high unemployment individuals reported needing additional care (59.9% vs. 42.9%; p<.001) and that this was necessary for leaving homelessness (58.9% vs. 44.1%; p=.05). Conclusions. High unemployment expands the population vulnerable to homelessness and influences health care needs and social needs.

Screening for Food Insecurity in Six Veterans Administration Clinics for the Homeless, June–December 2015

Objective We assessed findings from a food-insecurity screening of a national sample of Veterans Administration clinics for homeless and formerly homeless veterans. Methods We reviewed results from initial screenings administered at 6 Veterans Administration primary care clinics for the homeless and responses from clinic staff members interviewed about the screening program. Results A total of 270 patients were screened. The average age was 53 years, and most were male (93.1%). Screening showed a high prevalence of food insecurity. Of the 270, 48.5% reported they experienced food insecurity in the previous 3 months, 55.0% reported averaging 2 meals a day, and 27.3% averaged 1 meal a day. Eighty-seven percent prepared their own meals, relying on food they bought (54.2%), help from friends and family (19.1%), and soup kitchens and food pantries (22%); 47.3% received Supplemental Nutrition Assistance Program benefits (food stamps). Additionally, of those who screened positive for food insecurity 19.8% had diabetes or prediabetes, and 43.5% reported hypoglycemia symptoms when without food. Clinic staff members responded positively to the screening program and described it as a good rapport builder with patients. Conclusions Integrating screening for food insecurity among patients in clinical settings was well received by both patients and health care providers. Addressing these positive findings of food insecurity requires a multidisciplinary health care approach.

Patient-aligned Care Team Engagement to Connect Veterans Experiencing Homelessness With Appropriate Health Care

Background: Veterans experiencing homelessness frequently use emergency and urgent care (ED). Objective: To examine the effect of a Patient-aligned Care Team (PACT) model tailored to the unique needs of Veterans experiencing homelessness (H-PACT) on frequency and type of ED visits in Veterans Health Administration (VHA) medical facilities. Research Design: During a 12-month period, ED visits for 3981 homeless Veterans enrolled in (1) H-PACT at 20 VHA medical centers (enrolled) were compared with those of (2) 24,363 homeless Veterans not enrolled in H-PACT at the same sites (nonenrolled), and (3) 23,542 homeless Veterans at 12 non-H-PACT sites (usual care) using a difference-in-differences approach. Measure(s): The primary outcome was ED and other health care utilization and the secondary outcome was emergent (not preventable/avoidable) ED visits. Results: H-PACT enrollees were predominantly white males with a higher baseline Charlson comorbidity index. In comparing H-PACT enrollees with usual care, there was a significant decrease in ED usage among the highest ED utilizers (difference-in-differences, −4.43; P<0.001). The decrease in ED visits were significant though less intense for H-PACT enrollees versus nonenrolled (−0.29, P<0.001). H-PACT enrollees demonstrated a significant increase in the proportion of ED care visits that were not preventable/avoidable in the 6 months after enrollment, but had stable rates of primary care, mental health, social work, and substance abuse visits over the 12 months. Conclusions: Primary care treatment engagement can reduce ED visits and increase appropriate use of ED services in VHA for Veterans experiencing homelessness, especially in the highest ED utilizers.

No wrong door: Can clinical care facilitate veteran engagement in housing services?

It is well established that providing stable housing to homeless persons improves health outcomes. It is less clear whether engagement in clinical care facilitates housing outcomes. We present a post hoc analysis of a prospective, community-based randomized controlled trial of homeless veterans not actively receiving or assigned to a primary care. Study subjects were interviewed at baseline, 1 month and 6 months and survey results were supplemented/verified by review of all notes in their VA electronic medical record for 6 months postenrollment. A total of 142 subjects with complete data were included in this analysis: 82 (57.7%) were in a stable sheltering/housing arrangement (transitional housing, stably doubled-up, independent housing) at baseline and stayed stable; 36 (25.4%) started in an unstable sheltering arrangement (unsheltered, emergency sheltered, unstable doubled-up arrangement) and moved into stable sheltering/housing while 24 (17.0%) individuals either started in and stayed unstably sheltered or went from a stable to an unstable arrangement. Of 36 individuals who transitioned from unstable to stable sheltering/housing, 25 (69.4%) accessed primary care within 1 month compared with 37.5% of the persistently unstable sheltering group and 57.3% of the stably sheltered/housed group (p = .05). Of those with care within 1 month, their average time from unstable to stable housing was 84.8 days compared with 165.9 days for those who do not access care (p = .02). Of those receiving primary care within 1 month of enrollment, 88.9% were in stable sheltering at 6 months. These findings suggest an important role for clinical engagement in helping achieve housing stability for homeless veterans.

Persistent Super-Utilization of Acute Care Services Among Subgroups of Veterans Experiencing Homelessness

Background: Acute health care utilization often occurs among persons experiencing homelessness. However, knowing which individuals will be persistent super-utilizers of acute care is less well understood. Objective: The objective of the study was to identify those more likely to be persistent super-utilizers of acute care services. Research Design: We conducted a latent class analysis of secondary data from the Veterans Health Administration Corporate Data Warehouse, and Homeless Operations Management and Evaluation System. The study sample included 16,912 veterans who experienced homelessness and met super-utilizer criteria in any quarter between July 1, 2014 and December 31, 2015. The latent class analysis included veterans’ diagnoses and acute care utilization. Results: Medical, mental health, and substance use morbidity rates were high. More than half of the sample utilized Veterans Health Administration Homeless Programs concurrently with their super-utilization of acute care. There were 7 subgroups of super-utilizers, which varied considerably on the degree to which their super-utilization persisted over time. Approximately a third of the sample met super-utilizer criteria for ≥3 quarters; this group was older and disproportionately male, non-Hispanic white, and unmarried, with lower rates of post-9/11 service and higher rates of rural residence and service-connected disability. They were much more likely to be currently homeless with more medical, mental health, and substance use morbidity. Conclusion: Only a subset of homeless veterans were persistent super-utilizers, suggesting the need for more targeted interventions.