Thomas P. O’Toole

Retaining homeless veterans in outpatient care: A pilot study of mobile phone text message appointment reminders

OBJECTIVES We examined the feasibility of using mobile phone text messaging with homeless veterans to increase their engagement in care and reduce appointment no-shows. METHODS We sent 2 text message reminders to participants (n = 20) before each of their outpatient appointments at an urban Veterans Affairs medical center. Evaluation included pre- and postsurvey questionnaires, open-ended questions, and review of medical records. We estimated costs and savings of large-scale implementation. RESULTS Participants were satisfied with the text-messaging intervention, had very few technical difficulties, and were interested in continuing. Patient-cancelled visits and no-shows trended downward from 53 to 37 and from 31 to 25, respectively. Participants also experienced a statistically significant reduction in emergency department visits, from 15 to 5 (difference of 10; 95% confidence interval [CI]  = 2.2, 17.8; P = .01), and a borderline significant reduction in hospitalizations, from 3 to 0 (difference of 3; 95% CI = -0.4, 6.4; P = .08). CONCLUSIONS Text message reminders are a feasible means of reaching homeless veterans, and users consider it acceptable and useful. Implementation may reduce missed visits and emergency department use, and thus produce substantial cost savings.

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.

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

Introduction Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a “homeless medical home” initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites. Methods We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services. Results More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies. Conclusion Integrating social determinants of health into clinical care can be effective for high-risk homeless veterans.

Ending Homelessness—Then What?

Our current Administration has set an ambitious goal of ending chronic and veteran homelessness in 2015.1 To meet this challenge the US Department of Veteran Affairs (VA) launched a comprehensive, evidence-based, data- and outcome-driven strategy. They have coupled this with significant federal and local partnerships and a financial commitment that has greatly increased access to health care benefits, and employment and permanent housing for homeless and at-risk veterans. The early results of this transformational effort have been promising, with substantial reductions in both overall numbers of homeless veterans on any given night and reductions in chronically homeless veterans in the point-in-time count. This is especially notable in that progress has occurred during one of the worst recessions our country has ever faced and with a significant influx of new veterans returning from combat, many with substantial comorbidities that place them at imminent risk for homelessness.

Challenges of Providing End-of-Life Care for Homeless Veterans

Objective: To describe challenges of caring for homeless veterans at end of life (EOL) as perceived by Veterans Affairs Medical Center (VAMC) homeless and EOL care staff. Design: E-mail survey. Setting/participants: Homelessness and EOL programs at VAMCs. Measurements: Programs and their ratings of personal, structural, and clinical care challenges were described statistically. Homelessness and EOL program responses were compared in unadjusted analyses and using multivariable models. Results: Of 152 VAMCs, 50 (33%) completed the survey. The VAMCs treated an average of 6.5 homeless veterans at EOL annually. Lack of appropriate housing was the most critical challenge. The EOL programs expressed somewhat more concern about lack of appropriate care site and care coordination than did homelessness programs. Conclusions: Personal, clinical, and structural challenges face care providers for veterans who are homeless at EOL. Deeper understanding of these challenges will require qualitative study of homeless veterans and care providers.

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.

Addressing the Challenges of Palliative Care for Homeless Veterans

Background: Veterans who nearing the end of life (EOL) in unstable housing are not adequately served by current palliative care or homeless programs. Methods: Multidisciplinary focus groups, interviews with community and Veterans Affairs (VA) leaders and with 29 homeless veterans were conducted in five cities. A forum of national palliative and homelessness care leaders (n=5) and representatives from each focus group (n=10), then convened. The forum used Nominal Group Process to suggest improvements in EOL care for veterans without homes. Modified Delphi Process was used to consolidate and prioritize recommendations during two subsequent tele-video conferences. Qualitative content analysis drew on meeting transcripts and field notes. Results: The Forum developed 12 recommendations to address the following barriers: (1) Declining health often makes independent living or plans to abstain impossible, but housing programs usually require functional independence and sobriety. (2) Managing symptoms within the homelessness context is challenging. (3) Discontinuities within and between systems restrict care. (4) VA regulations challenge collaboration with community providers. (5) Veterans with unstable housing who are at EOL and those who care for them must compete nationally for prioritization of their care. Conclusion: Care of veterans at EOL without homes may be substantially improved through policy changes to facilitate access to appropriate housing and care; better dissemination of existing policy; cross-discipline and cross-system education; facilitated communication among VA, community, homeless and EOL providers; and pilot testing of VA group homes or palliative care facilities that employ harm reduction strategies.

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.