Homeless Veterans Patient Aligned Care Team (H-PACT)

Homeless Veterans Patient Aligned Care Team (H-PACT)

December 2012

Office of Homeless ProgramsOffice of Primary Care Operations

VETERANS HEALTH ADMINISTRATION2

Background

• Homeless Veterans have more chronic medical, mental health and substance abuse needs that are more difficult to treat in traditional care models and to coordinate within fragmented delivery systems.

• Transportation and scheduling challenges, competing priorities, and services not aligned with their needs keep many homeless Veterans from accessing primary care and receiving services necessary to exit homelessness.

• Homeless Veterans end up relying on emergency departments for care and are hospitalized at much higher rates than their housed counterparts.

• Homeless Veterans are three to six times more likely to become ill than housed people and cost three times more to care for than non-homeless Veterans.


Background

• Integrated Primary Care-Homeless Services care models tailored to the needs and specific challenges of homeless Veterans have been able to:

– Reduce emergency department use by up to 40%– Reduce hospitalizations by 30-50%– Improve chronic disease management outcomes– Expedite housing placement and retention


The Need for a Paradigm Shift

How do we take advantage of health care seeking behavior and the “treatable moment” embedded in a health care episode?

How can the resources and “safe haven” of the health care setting be used to break the cycle of homelessness and poor health?


Homeless Patient Aligned Care Team

• Program goal is creating a collaborative Homeless Programs-Primary Care model that eliminates barriers to quality health care and improves health and housing outcomes of Veterans that are homeless or at imminent risk of homelessness.

• Not intended to replace care being provided or alter ongoing care relationships for those homeless Veterans engaged in treatment models (e.g. Severe Mental Illness (SMI), HIV care).


H-PACT Model

• Three different homeless-oriented primary care PACT models will be supported by this initiative for local station implementation. Model adoption will be based on site-specific need, capacity, geography and targeted focus:

– Co-located, integrated Homeless PACT.

– PACT team enhanced with homeless case management.

– Community Resource and Referral Center (CRRC)-based Homeless outreach/PACT.

Health and Homelessness

Housing Security for Homeless Persons

Health Care sites as “First Stops” for newly homeless

The health encounter as a “treatable moment”

for behavior change and treatment engagement

Health maintenance and support as a means of keeping people in housing


H-PACT Program

• H-PACT’s must be able to:

– Provide Accessible, Just-in-Time Continuity Care to homeless Veteranswhen and where they need it.

– Respond to the “Treatable Moment” with staff trained and prepared to engage patients in behavior change, and with resources in place to act on patient motivation.

– Create a care setting that promotes trust and relationship building necessary for longitudinal primary care and care coordination.

– Address competing social and sustenance needs of the Veteran trying to access health services.

– Employ a Rapid Engagement/Housing-First approach.


H-PACT Goals

• Deliverables:– Systems redesign – Population-Centered Homeless PACTs:

– Rapid Access – Reduce barriers and obstacles to receiving care; bring homeless into care earlier in their homelessness.

– Sustained Engagement – Provide ongoing, longitudinal care that responds to changing needs, interests and readiness of the Veteran.

– Improved Clinical Outcomes for multi-morbid homeless Veterans– Improved Quality of Life – Provide comprehensive chronic disease and

preventive care to a traditionally disenfranchised group – Greater Efficiencies in our care delivery system

– Care Offsets – Reduce emergency department and hospital use; increase primary care, outpatient mental health, and substance abuse treatment.

– Ending Veteran homelessness– Housing placement/stabilization – Integrate clinical care with housing

objectives; partner with housing staff and community agencies.

H-PACT Model for Treatment Engagement of Homeless Veteran

Disengaged/Disenfranchised from Care Treatment Engagement StabilizationUnstable sheltering Housing First Chronic disease managementSignificant barriers to treatmentengagement Facilitated access/population tailored care Prevent recidivismHealth Care low amongMaslow Hierarchy of needs Care management of conditions Early identification new needsHigh rates of ED and inpatient care Leading to homelessnessPremature morbidity/mortality Perpetuating homelessness

Delayed and deferred because of homelessness

Address competing needs

Identification and Referral

Emergency Departments

Inpatient Wards

Community outreach/ Agency referrals

Homeless PACT

Enhanced, open access

Intensive case management

Care tailored to population needs/de-stigmatizing care One-stop care – On-site addressing of competing sustenance needs

Homeless situation stabilized; transferred to general population PACT team w/ specialty care access

Homeless situation not stabilized: Patient stays in Homeless PACT due to ongoing homelessness, imminent risk of return to homelessness

Homeless situation stabilized; transferred to Special Population PACT based on patient need: SMI PACT Women’s Health PACT HIV PACT

Intervention Disposition


H-PACT Program

• Implementation Update

– 37 sites funded to develop H-PACTs

– 19 VISNs, 24 states, 20 in high impact/high volume

cities, 7 in rural communities

– Active engagement from Primary Care, Homeless and

Mental Health programs


Data Snapshot

• 30 H-PACT sites are actively seeing homeless Veterans.

• Over 4000 patients enrolled to date. Anticipated approximately 10,000 will be enrolled by end of FY 2013.

• H-PACT enrollment increasing by approximately 400 Veterans per month.

• Most Veterans will stay in the H-PACT 12 to 18 months, depending on individual circumstances, preferences.

April 22, 2023

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VISN Station VISN Station VISN Station VISN Station 1 Providence VAMC 4 Philadelphia VAMC

10 Chalmers P. Wylie

VAMC (Columbus)20 VA Puget Sound HCS

(Seattle)

1 VA Connecticut Healthcare System

(West Haven)

4 VA Pittsburgh HCS 11 Battle Creek VAMC

20 Portland VAMC

1 VA Maine HCS (Togus)

5 VA Maryland HCS (Baltimore)

11 John D. Dingell VAMC (Detroit)

21 VA Northern California HCS

1 VA Boston HCS (Causeway Street

CBOC)

5 Washington DC VAMC

12 Jesse Brown VAMC (Chicago)

21 VA Pacific Islands HCS (Honolulu)

1 Leeds VA Primary Care Center (New Bedford)

6 Hampton VAMC 16 Micheal E. DeBakey VAMC

(Houston)

21 San Francisco VAMC

2 Canandiagua VAMC 7 Ralph H. Johnson VAMC (Charleston)

16 Southeast Louisiana

Veterans HCS (New Orleans)

22 VA San Diego HCS

3 Northport VAMC 7 Birmingham VAMC

17 South Texas Veterans HCS

(San Antonio)

22 VA Greater Los Angeles HCS

3 James J. Peters VAMC (Bronx)

8 James A. Haley VAMC (Tampa)

18 Phoenix VA HCS 22 VA Southern Nevada HCS

3 VA Hudson Valley HCS (Montrose)

9 Lexington VAMC 19 VA Eastern Colorado HCS

(Denver)

23 Minneapolis VA HCS

23 Iowa City VA HCS


Anticipated outcomes

– Reduced emergency department visits, hospital admissions

– Increased ambulatory care use (primary care, specialty, mental health, addictions)

– Expedited housing/reduced recidivism– Improved chronic disease monitoring/management– Enhanced care, cost-efficiencies

April 22, 2023


H-PACT and Community Partners

• Referral source

• Development of partnerships

• Collaborative effort to serve homeless Veterans

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Questions?

For more information please contact:

Rico Aiello, H-PACT Project [email protected]

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mailto:[email protected]

Documents

Homeless Veterans Patient Aligned Care Team (H-PACT)