Health Care Interventions

HOMELESS PATIENT ALIGNED CARE TEAMS (H-PACT)

The Homeless Patient Aligned Care Team (H-PACT) program is a coordinated “medical home” specifically tailored to the needs of Veterans experiencing homelessness. Staffed by interdisciplinary teams of doctors, nurses and case managers, the program serves as a conduit for treatment engagement and involvement in VA Homeless Programs and VA clinical services and supports through a “no wrong door” policy. H-PACT care teams provide medical care, case management, housing and social services assistance to help Veterans obtain and stay in permanent housing, thereby reducing emergency department use and hospitalizations and improving chronic disease management.

NCHAV first piloted the H-PACT model in 2012. By 2015, nearly 16,000 patients were enrolled in an H-PACT at one of 51 sites across the country. The initiative was subsequently incorporated into program operations and has successfully engaged some of the most challenging, complex and chronically disenfranchised patients with the VA health system, reflected in very high rates of primary care, specialty care, mental health, and homeless program use. As a result, the program has reduced emergency department use and hospitalizations by 25 percent. It has also helped Veterans secure and maintain housing, contributing in a very important way to meeting the goal of ending Veteran homelessness.

Relevant journal articles attesting to H-PACT’s effectiveness are listed below.

Dual Use and Hospital Admissions among Veterans Enrolled in the VA's Homeless Patient Aligned Care Team. Trivedi AN, Jiang L, Johnson EE, Lima JC, Flores M, O'Toole TP., Health Serv Res. 2018 Dec;53 Suppl 3:5219-5237. doi: 10.1111/1475-6773.13034. Epub 2018 Aug 27.

Population-Tailored Care for Homeless Veterans and Acute Care Use, Cost, and Satisfaction: A Prospective Quasi-Experimental Trial. O'Toole TP, Johnson EE, Borgia M, Noack A, Yoon J, Gehlert E, Lo J. Prev Chronic Dis. 2018 Feb 15;15:E23. doi: 10.5888/pcd15.170311.

Patient-aligned Care Team Engagement to Connect Veterans Experiencing Homelessness With Appropriate Health Care. Gundlapalli AV, Redd A, Bolton D, Vanneman ME, Carter ME, Johnson E, Samore MH, Fargo JD, O'Toole TP. Med Care. 2017 Sep;55 Suppl 9 Suppl 2:S104-S110. doi: 10.1097/MLR.0000000000000770.

Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans Health Administration's "Homeless Patient Aligned Care Team" Program. O'Toole TP, Johnson EE, Aiello R, Kane V, Pape L., Prev Chronic Dis. 2016 Mar 31;13:E44. doi: 10.5888/pcd13.150567.

For additional information on H-PACTs, please visit Homeless Patient Aligned Care Teams - VA Homeless Programs

TRAUMA-INFORMED CARE

Pilot to integrate trauma-informed approach to care in medical center homeless programs and replicate an intervention for high-need/high risk Veterans

Across VA homeless programs, there is an emphasis on engaging and providing services to vulnerable Veterans who are chronically homeless or at risk of homelessness with serious health and mental health diagnoses. There is also ongoing concern to address the needs of Veterans who have high rates of emergency department/urgent care (ED/UC) use and hospitalization. It is in this context that NCHAV and the National Health Care for Homeless Veterans (HCHV) Program in the VA Homeless Programs Office (HPO) are collaborating to replicate two linked promising practice models that are operating in the VA Boston HCHV Program – the Care Coordination, Advocacy, Treatment, and Connections to Housing (CATCH) program and the Trauma-Informed Care (TIC) Integration Initiative. Lessons learned from Boston HCHV’s experience in working to adopt a trauma-informed approach will be used to develop an enhanced model to pilot at two VA medical centers.

CATCH – a model intervention for our most vulnerable Veterans experiencing homelessness

Established in 2013 CATCH serves Veterans experiencing homelessness who have high needs and treatment costs and face complex challenges in obtaining and retaining housing, often due to chronic serious mental illness and/or substance use. CATCH is a three-year program that devotes the first two years to moving the Veteran to stable housing and the third to ensuring the Veteran can live independently with strong connections to VA and community resources and supports. Longitudinal analyses of emergency department/urgent care (ED/UC) visits and admissions costs for Veterans enrolled in CATCH between fiscal years 2014 and 2019 showed a 48% decrease in ED/UC visits and a 41% decrease in admissions costs after the first year of enrollment. Five years after enrollment average admissions costs had fallen by 81%, from $156,856 to $29,392. CATCH not only offers a pathway to hope for Veterans who have fallen by the wayside but also, as these results clearly show, pays for itself over time. CATCH will be replicated at two medical centers beginning in fiscal year 2023.

Trauma-Informed Care Integration Initiative – a model for incorporating trauma-informed care principles into homeless programs

CATCH uses a trauma-informed approach to care that aligns with the Trauma-informed Care (TIC) Integration Initiative launched in 2017 to incorporate trauma-informed care principles into programming and policy across the Boston Medical Center’s homeless programs. This work is guided by a multi-disciplinary, multi-level TIC Task Force and a plan developed through a trauma-informed organizational capacity assessment. The overall goal is to make a trauma-informed approach a common thread across programs, while allowing each program to “customize” the approach for their particular missions and goals. This model will be replicated along with the CATCH program at the two medical center site.

OCCUPATIONAL THERAPY IN HUD-VASH

Pilot to Standardize Occupational Therapy Workflow, Intake Screening, Referral and Workload Capture

A major area of focus for the VA Homeless Programs Office (HPO) is to enhance targeted services to address the needs of high-acuity and vulnerable populations, including Veterans who are older. Adults experiencing homelessness are at increased risk for geriatric syndromes, making a 55 year-year-old likely to present with the age-related functional difficulties of a person 20 years older. Early identification of age-related housing barriers can enable appropriate housing placement and the initiation of housing supports, modifications, treatment and other interventions to circumvent future crises. For this reason, some HUD-VASH teams have added occupational therapists (OTs) to their staff. As of February 2022, HPO funded 49 full- and part-time OT positions across 35 of the 139 HUD-VASH parent facilities. However, identification of an appropriate scope and depth of OT activity is critical, considering the limited number and capacity of OT providers and the multitude of valuable services they can provide.

Starting in 2020, NCHAV partnered with VA Rehabilitation and Prosthetic Services and HUD-VASH to examine the status of OT in HUD-VASH and conduct a needs assessment. During 2021 and 2022 we developed a stepwise model to standardize the OT workflow within the program. The initial phase of the model involves intake screening for early recognition of factors compromising housing success and timely referral to OT evaluation and treatment. We piloted the screen at two sites with well-integrated OT services. We collected qualitative and quantitative data and compared them to baseline screening and OT referral methods. While site staff viewed the pilot screen favorably, the data suggest refinement of the tool might be required for maximum effectiveness and efficiency in capturing OT referrals at HUD-VASH intake. We initiated additional projects to address concerns related to workload capture and further standardization of OT services.

For more information about the pilot, lessons learned, and considerations for next steps, please contact Roger Casey, NCHAV Director of Education and Dissemination, to request the full or summary reports.