Homeless Veteran Patient Aligned Care Teams

1. Homeless Veteran Patient Aligned Care Teams June 20, 2013

2. Homeless Veteran Demographics

3. The National Center on Homelessness Among Veterans Promoting data-driven, evidence-based services for Veterans who are homeless or at risk for homelessness What We Know about Veteran Homelessness • Epidemiologic studies consistently show that the homeless population is not homogenous. • Veterans are over-represented within the homeless population, comprising approximately 10% of all homeless adults. • Estimates indicate that 1 in 9 Veterans living in poverty will experience homelessness over the course of a year. • The majority of persons are homeless for less than 90 days; only about 20% experience chronic or long-term homelessness. • While males account for three-quartersof the single adult homeless population; homeless women and homeless families comprised of female-headed households with young children are two of the fastest growing subpopulations. • 559,870 Veterans have received homeless services across the Veterans Health Administration (VHA) since 2005 (source: VA National Homeless Registry)

4. The National Center on Homelessness Among Veterans Promoting data-driven, evidence-based services for Veterans who are homeless or at risk for homelessness What we know about Veteran homelessness Homeless Registry through 2012

5. Outreach /Education Treatment Prevention Housing Employment /Income /Benefits Partnerships Veteran Homelessness Unemployment/Economics Poverty Substance Use Lack of Affordable Housing Medical/Mental Health Issues Domestic Violence Prior History of Incarceration Unsuccessful Transition from Military Family Decomposition Prior history of homelessness

6. The National Center on Homelessness Among Veterans Promoting data-driven, evidence-based services for Veterans who are homeless or at risk for homelessness Medical Comorbidities among Homeless Veterans • The overwhelming majority of homeless Veterans have at least one chronic medical problem (66.1–85.1%) • Significantly higher rates than for non-Veteran homeless (55.4%) • Most common medical conditions: • Arthritis/joint pain 53.3% • Hypertension 22.2–45.2% • Hepatitis 18.9–28.0% • COPD/Emphysema 12.7–17.3% • Diabetes 7.1–9.3% • Heart disease 7.1% O’Toole TP, Conde-Martel A, Gibbon JL, et al. Health care of homeless veterans. JGIM. 2003;18:929-933 Garibaldi B, Conde-Martel A, O’Toole TP. Self-reported comorbidities , perceived needs and sources for usual care for older and younger homeless adults. JGIM. 2005;20:726-730. O’Toole TP, Buckel L, Bourgault C, et al. Applying the chronic care model to homeless Veterans. AJPH. 2010;100:2493-2499

7. The National Center on Homelessness Among Veterans Promoting data-driven, evidence-based services for Veterans who are homeless or at risk for homelessness T Mental Health Diagnoses among Homeless Veterans Homeless Registry contacts new assessments 2012

8. Homeless Veteran Care Complexity • The DCG Severity Index is the average Diagnostic Care Group (DCG) score for a cohort of patients. • A patient’s DCG score is based on his/her demographics (age, gender, etc.) and recorded diagnoses from Veterans Health Administration (VHA) inpatient, outpatient and fee records over a 12 month period. • A high DCG Severity Index score indicates a panel of patients that are complex. • DCG Severity Index for homeless Veterans is significantly higher than the VA general population (1.016 vs. 0.633)

9. Homeless Veteran Health Services Use • It is more difficult to treat homeless persons in traditional settings: Transportation, Access, Provider Competencies, Fragmented Care and Stigma are all significant barriers. • Homeless Veterans disproportionately rely on Emergency Departments (EDs) and hospitalizations for care: • > 1/3 had at least one ED visit in the past year (three times higher than U.S. norm); 12 percent had four or more visits (30 percent higher than non-Veteran homeless) • 23.3 percent were hospitalized in the past year - over two times more likely and at younger ages than non-Veteran homeless; Admissions were 36 percent longer and cost 20 percent more • 24.6 percent could not receive care when they needed it

10. The National Center on Homelessness Among Veterans Promoting data-driven, evidence-based services for Veterans who are homeless or at risk for homelessness Life Expectancy: Homeless Mortality Data • Mean age of death: 51 years • Mortality rate is 4.5x higher than general population • 25–44 year age group: drug overdose is 16x higher than general population • 45–64 year age group: • Cancer is 2.2x higher than general population • Heart disease is 3.5x higher than general population • Homelessness increases the risk for early death, especially among older Veterans and those with chronic medical problems Kasprow WJ, Rosenheck R. Mortality among homeless and nonhomeless mentally ill veterans. J NervMent Dis. 2000; 188(3):141-7 Baggett TP, Hwang SW, O’Connell JJ. Mortality among homeless adults in Boston. JAMA Intern Med. 2013;173(3):189-195

11. Health and Homelessness Biologic Accelerated Aging/Premature Morbidity Increased Cell Death Stress hormones Micronutrient Malnutrition Environmental High Risk Environment Inadequate care system capacity to address social determinants of health Homeless-Driven Adverse Health Outcomes Behavioral Poor compliance due to behavioral and substance use issues, competing sustenance needs

12. Homeless Veteran Health Inequity: Environmental drivers* • Health rating: fair/poor 48.4% • Homelessness effects on health 73.1% (definite/most likely) • Personal motivations for wanting a regular source for health care(very/most important) • “Want to do more with my life” 84.2% • “To take better care of myself” 83.2% • “To get or keep a job” 70.7% • “Need health care to leave homelessness” 66.0% • “Concern about my mental health” 65.1% • “Chronic pain” 48.8% • “Concern about substance abuse” 37.2% *Research data from “Engaging homeless veterans in care” study (HSR&D IIR 07-184). Principal Investigator: O’Toole; Community sample of 215 out-of-treatment homeless veterans not receiving primary care

13. Homeless Veteran health inequity: Access to routine care* *Research data from “Engaging homeless veterans in care” study HSR&D IIR 07-184. Principal Investigator: O’Toole; Community sample of 215 out-of-treatment homeless veterans not receiving primary care • Reasons for not having a source for usual care • Couldn’t afford 42.9% • Didn’t know where to go 27.0% • Didn’t think needed it 25.1% • Not convenient 24.2% • Concerned about what they might find 20.5%

14. Homeless Veteran Health Inequity: Delayed/deferred care* • 79.1% reported needing health care in the previous 6 months: • 53.9% reported seeking care in an ER during that time • 25.2% did not receive any health care when needed • Reasons for delaying care • No transportation 51.2% • Can’t afford it 44.7% • Embarrassed about being homeless 43.7% • Can’t keep an appointment 40.5% • Too much of a run-around 33.5% • Don’t trust the VA 14.4% *Research data from “Engaging homeless veterans in care” study HSR&D IIR 07-184. Principal Investigator: O’Toole; Community sample of 215 homeless veterans not receiving primary care

15. Homeless Veteran Patient Aligned Care Teams (HPACT)

16. Homeless PACT Enhanced Team Model H-PACT Team Primary Care Provider RN Case manager Homeless Program Staff Social Worker Mental health staff Community partners

17. Health and HomelessnessInstitute of Medicine, 1988 Health conditions made worse by homelessness Health conditions causing homelessness Traditional model for providing Health care to Homeless Health conditions caused by homelessness

18. Health and Homelessness Health Care sites as “First Stops” for newly homeless The health encounter as a “treatable moment” for behavior change and treatment engagement The Homeless Medical Home Health maintenance and support as a means of keeping people in housing

19. Homeless PACT Model • Evidence-based (Health Resources and Services Administration (HRSA): Health Care for the Homeless; VA: O’Toole, et al. AJPH, 2010). • 4 key elements that distinguish H-PACT from traditional healthcare models: • Open access – Care on-demand: not reliant on mail/telephone based scheduling, limited appointments; • Homeless tailored care with wrap-around, integrated services (Primary Care, Housing, Mental Health, Substance Abuse); • Intensive case management/high frequency care (ambulatory-Intensive Care Unit (ICU) approach) with high frequency care; and • Staff competency/sensitivity to homelessness – critical to longitudinal care, staff trained to work with homeless Veterans with attention to engagement of this population. • Core team staffing: Primary Care Provider (PCP), Registered Nurse (RN), Social Worker (SW), Homeless staff, Mental Health (MH), clerk

20. H-PACT Model for Treatment Engagement of Homeless Veteran Disengaged/Disenfranchised from CareTreatment Engagement  Stabilization Unstable sheltering Housing First Chronic disease management Significant barriers to treatment engagement Facilitated access Prevent recidivism Health Care low among Maslow Hierarchy of needs Care management of conditions Early identification new needs High rates of ED and inpatient care Leading to homelessness Premature morbidity/mortality Perpetuating homelessness Delayed and deferred Address competing needs Identification and Referral Intervention Disposition 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 Emergency Departments Inpatient Wards Homeless situation not stabilized: Patient stays in Homeless PACT due to ongoing homelessness, imminent risk of return to homelessness Community outreach/ Agency referrals Homeless situation stabilized; transferred to Special Population PACT based on patient need: SMI PACT Women’s Health PACT HIV PACT

21. H-PACT Project Benchmarks • Project launched in January, 2012 – 2 year pilot program based at the National Center on Homelessness among Veterans 2 models: • Medical Center/Community-Based Outpatient Clinic (CBOC) co-located integrated care • Community Resource and Referral Center (CRRC)-based community outreach model • 36 sites actively enrolling patients • 5,800 enrolled patients as of May 22, 2013 • Approximately 350 new patients/month • 86 percent Retention rate • High rates of ambulatory care (Primary care, MH, Specialty Care engagement)

22. Pilot Sites

23. Key Outcomes • 36.7 percent reduction in emergency department use; 1,101 fewer ED visits* • 34.4 percent reduction in hospitalizations; 240 fewer admissions* • Annualized systems savings : $5.8-7.2 million (AHRQ(Agency for Healthcare Quality and Research) /MEPS (Medical Expenditure Panel Survey) cost estimates) • Enhanced VERA estimate: $25-75 million (Group 5 Homeless Multiple Problem) • 80.7 percent moved into stable housing within 6 months of enrollment (Providence VA data) • Significant improvements in chronic disease monitoring and management * Based on 6 month pre- post- H-PACT enrollment utilization comparisons using Primary Care Management Module (PCMM) data for the H-PACT enrollment (4/12-10/12).

24. What we are learning:Using the care model to reduce ER visits Factors associated with a net decrease in ER use during the first 6 month of care* > 5 Primary Care encounters (PCP or RN) OR: 1.46 (95% CI: 1.11-1.92) > 5 Specialty Care visits OR 10.95 (95% CI: 1.58-75.78) Stable sheltering at baseline (transitional housing, doubled-up) OR 3.41 (95% CI: 1.24-9.42) *Independent variables included: primary care, specialty care, mental health care, substance abuse treatment, new chronic illness, new MH illness, new SUDS dx, chronic homelessness

25. What we are learning: Clinical Risk Factors for Homelessness Recidivism Cross-sectional and prospective f/u of Veterans enrolled in an HPACT (N=352) Key question: What clinical factors are associated with chronic/recurrent homelessness? • Substance abuse, ETOH abuse (OR: 2.11) • Sciatica and low back pain (OR: 3.25) • Bipolar disorder (OR 2.13) There is a clinical role for both treating and preventing homelessness (Homelessness as a chronic disease?)

26. Summary • Homeless PACTs provide team-based, population-tailored, comprehensive care to a high-risk population. • Directly incorporates Social Determinants of Health into care delivery – goal is to facilitate transition to stable housing • New processes, skills, and models are needed for the Homeless PACT to be effective • Evolving process; steep learning curve • Done right, it can be an important piece in the equation to ending homelessness among Veterans

27. We’re not there yet… • How do we operationalize the adage: Housing is Health Care • Making housing a health care outcome (building the care model around housing objectives - Taking on recidivism) • Moving beyond the minimum “entry physical” to a medical home and longitudinal continuity • Who is on the team (it can’t/shouldn’t be purely clinical) • How do we talk to each other? • When? (creating space and time is key) • How and to whom? • Sharing a common language