Records for 6 months preceding the index visit were used to identify the presence or absence of common medical conditions, psychiatric diagnoses, and ATOD abuse or dependence. Medical conditions were identified from a list of common outpatient diagnoses from the National Ambulatory Medical Care Survey, supplemented by common conditions among homeless men.16-18 The EHR problem list (a list of diagnoses, by patient) was used to obtain diagnoses, supplemented by notes from inpatient admissions/discharges, as well as ED, primary care, and subspecialty consultations within 6 months preceding the index visit. Prior VA health care use was ascertained from the EHR review of the same 6-month window, reflecting ED visits, inpatient admissions, primary care visits, subspecialty visits, and individual/group therapy for ATOD or other mental health problems. Data were used to generate site-specific descriptive statistics.
RESULTS
Like all VA hospital-based clinics, a universal EHR captured all medical and social service notes, orders, medications, and administrative records. All facilities had on-site EDs, medical/mental health specialty care, and pharmacies. Social services, including benefits counseling and housing services, were available on site. Table 1 summarizes the HPACT structures at BIR, WLA, and PIT.
Birmingham
The BIR HPACT was devised as a new homeless-focused team located within a VA primary care clinic where other providers continued to see primary care patients. Staff and space were reallocated for this HPACT, which recruited patients in 4 ways: (1) the facility’s primary homeless program, Healthcare for Homeless Veterans, referred patients who previously sought VA housing but who required primary care; (2) an outreach specialist sought homeless veterans in shelters and on the streets; (3) HPACT staff marketed the clinic with presentations and flyers to other VA services and non-VA community agencies; and (4) a referral mechanism within the EHR.
A nurse practitioner was the PCP at this site, supervised by an academic internist experienced in the care of underserved populations, and the HPACT director, a physician certified in internal and addiction medicine. Patients at the BIR HPACT also received care from a social worker, registered nurse, licensed practical nurse, and psychiatrist who received all or a portion of their salaries from this demonstration project. This clinic accommodated walk-in appointments during business hours. Clinicians discussed clinical cases daily, and the full clinical and administrative team met weekly. To promote service integration, HPACT staff attended meetings of the BIR general primary care and Healthcare for Homeless Veterans programs, and vice versa.
West Los Angeles
At WLA, a previously established Homeless Screening Clinic that offered integrated social and medical services for homeless veterans with mental illness was already available during business hours and located within the site’s mental health program.11 However, because ED use for homeless veterans peaked after hours, the new WLA HPACT was established within the WLA ED.
During WLA HPACT hours (3 weekday evenings/week), routine nursing triage occurred for all patients who presented to the ED. However, distinct from other times of day, veterans who were triaged with low-acuity and who were appropriate for outpatient care were given a self-administered, 4-item questionnaire to identify patients who were homeless or at risk for becoming homeless. Veterans who were identified with this screening tool were offered the choice of an ED or HPACT visit. Veterans who chose the latter were assigned to the queue for an HPACT primary care visit instead of the ED.
A physician led the clinical team, with additional services from a mental health clinical nurse specialist and clerks who worked with homeless and/or mental health patients during business hours and provided part-time HPACT coverage. When needed, additional services were provided from colocated ED nurses and social workers. Providers were chosen for their aptitude in culturally responsive communication.
Patients who chose to be seen in HPACT received a primary care visit that also addressed the reason for ED presentation. HPACT staff worked collaboratively, with interdisciplinary team huddles that preceded each clinic session and ended each patient visit. Referrals and social service needs were tracked and monitored by the PCP. Specialty care referrals were also tracked and facilitated when possible with direct communication between HPACT providers and specialty services. Meetings with daytime Homeless Screening Clinic and ED staff facilitated cross-departmental collaborations that helped veterans prepare for and retain housing.
Pittsburgh
The HPACT at PIT evolved from an existing PACT that provided primary care-based addiction services.2 That team included an internist credentialed in addiction medicine and experienced in homeless health care, nurse practitioner, nurse care manager, nursing assistant, and clerks. At this site, HPACT providers had subspecialty expertise in the assessment and treatment of ATOD use, certification to prescribe buprenorphine for outpatient opioid detoxification and/or maintenance, and experience engaging homeless and other vulnerable veterans. The existing colocated clinic included 2 additional addiction medicine clinicians and a physician assistant experienced in ATOD use. The PIT HPACT was not restricted to patients with ATOD use.