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Homeless Veterans Patient Aligned Care Team (H-PACT)

Homeless Veterans Patient Aligned Care Team (H-PACT). Office of Homeless Programs Office of Primary Care Operations. December 2012. Background.

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Homeless Veterans Patient Aligned Care Team (H-PACT)

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  1. Homeless Veterans Patient Aligned Care Team (H-PACT) Office of Homeless Programs Office of Primary Care Operations December 2012

  2. 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.

  3. 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

  4. 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? The Need for a Paradigm Shift

  5. 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).

  6. 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.

  7. 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 Housing Security for Homeless Persons Health maintenance and support as a means of keeping people in housing

  8. H-PACT Program • H-PACT’s must be able to: • Provide Accessible, Just-in-Time Continuity Care to homeless Veterans when 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.

  9. 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.

  10. 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/population tailored care 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 because of homelessness Address competing needs Intervention Disposition Identification and Referral 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

  11. 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

  12. 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.

  13. 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

  14. H-PACT and Community Partners • Referral source • Development of partnerships • Collaborative effort to serve homeless Veterans

  15. Questions? For more information please contact: Rico Aiello, H-PACT Project Coordinator Riccardo.aiello@va.gov

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