VA’s HPACT Program Collaborates to Meet Healthcare, Housing Needs

The nation is nearing the half-way point towards our goal of ending homelessness for Veterans by 2015, and USICH and its partners are focusing on ways to accelerate progress to that goal. The 12% reduction in Veteran homelessness in just one year is proof positive that the goal is achieveable if we focus our interventions in strategic ways, particularly for interventions serving Veterans who regularly use the emergency shelter system.  With the leadership of Secretary Shinseki, the Department of Veterans Affairs (VA) continues to develop Veteran-centric innovations to meet homeless Veterans where they are and help them to improve their health and get off the streets and into housing. In May 2012, USICH detailed the array of VA programs serving Veterans experiencing or at risk of homelessness that provide prevention, assessment, outreach, engagement, treatment, and housing as well as services for Veteran families. VA and its partners in communities continue to engage Veterans and offer them the correct level of service (“the right treatment for the condition”) to improve outcomes while simultaneously containing costs. 

A particular innovation worth exploring in greater detail is the Homeless Patient Aligned Care Team (HPACT), which focuses on the primary healthcare needs of homeless Veterans in coordination with housing programs.  Now up and running in over 30 sites with another eight sites in development or planning, the HPACT is built at the intersection between two successful healthcare models, the Healthcare for the Homeless Primary Care Clinics and the Patient-Centered Medical Home.

The Roots of HPACT: Health Care for the Homeless and Primary Care Medical Homes

Adults experiencing homelessness have greater healthcare needs and are higher users of crisis services than virtually any other sub-population of people living with poverty.  For people who have concurrent substance use disorders, mental illness, chronic medical conditions, and extensive histories of homelessness, medical care is critical to help stabilize individuals as they transition into housing as well as success in remaining housed.  Recognition of the need for specialists serving the homeless population began with the Robert Wood Johnson pilot project of healthcare for the homeless clinics in the mid-1980s, and resulted in the development of over 200 healthcare for the homeless clinics supported by the McKinney-Vento Act

More recently, primary care policy experts recommend that vulnerable individuals with complex needs who have high levels of health services utilization be served in Primary Care Medical Homes.  Some of the components of the medical home include open access appointments so that patients can be seen by their provider upon request, as well as integrated substance use, mental health services, nursing care, and case management in one location, preferably in a primary care setting. Many high performing healthcare for the homeless clinics such as Boston’s Healthcare for the Homeless and the Colorado Coalition for the Homeless have embraced the medical home model to improve quality, efficiency, and integration of services across their system of care. 

Fundamentals of HPACT

The VA’s new Homeless Patient Aligned Care Teams (HPACT) is modeled after both of these successful interventions, yet is tailored to the needs of homeless Veterans by creating a hub in primary care so that Veterans can access housing and stabilization services that have recently been developed and expanded across the VA system.  In addition, the HPACT program has a robust evaluation component so that the intervention can be assessed for quality and cost-effectiveness. It is expected that the evaluation will show that participating Veterans will have a marked decrease in utilization of expensive healthcare crisis services such as avoidable emergency department visits and inpatient admissions, in favor of increased utilization of primary care and preventive services.

Beginning around 2005, the Providence VA Medical Center developed a Homeless Oriented Primary Care Clinic.  Evaluation of the Providence program showed that participants had improved health outcomes as well as a 30% reduction in emergency department use and a 50% reduction in inpatient days.  Building on these successful results, the HPACT model was developed and has now spread to most areas of the country. 

There are three distinct types of HPACT clinics:  (1) a clinic co-located within a VA Medical Center or CBOC (Community Based Outpatient Clinic); (2) a service built on an outreach model in which HPACT staff arrange for and accompany homeless Veterans to a primary care clinic visits; and (3) services that are integrated into a CRRC (Community Resource and Referral Center) where Veterans can receive a wide range of services including job training, access to benefits, and health services.  All HPACT clinics are structured as multidisciplinary teams (i.e., medical and behavioral health providers, peer advocates, benefits managers, nurses, and nurse care mangers) with regular case management.  In addition, all HPACTs are mandated to:  

  1. Provide accessible, just-in-time primary care;
  2. Engage Veterans during a “treatable moment” where Veterans are engaged where they are and partner with providers to improve healthcare outcomes;
  3. Create a care setting that is built on mutual trust and respect between the Veteran and the care provider; and
  4. Provide integrated, coordinated care on site, that includes rapid re-housing and Housing First permanent supportive housing options. 

The HPACT Experience in Providence, Rhode Island

The Providence HPACT is part of the Providence VAMC located in downtown Providence.  Now serving over 300 homeless Veterans, the clinic is open five days a week and provides primary care, behavioral health, and nursing services.  Next month, the clinic will move to a newly renovated, free-standing building on the VA Medical Center campus.  The staff for the Housing and Urban Development VA Supportive Housing program (HUD-VASH) is co-located with the HPACT so that Veterans can have medical care as part of the services offered to them as they are being assessed for housing. 

The co-location of the HUD-VASH staff and the HPACT staff has been one of the factors that has led to a high proportion (71%) of VASH vouchers being offered to people who have had extensive homeless histories and meet the Federal definition for chronic homelessness. This targeting is an important way for this intervention to be right-sized for Veterans with highest needs that would not be as successful with another intervention. Kerrin Charpentier, the HUD-VASH lead social worker in Providence noted, “it sometimes breaks my heart to hold off on giving a VASH voucher to a recently homeless Veteran who is clearly ill.  However, I know that they can be served by our local GPD (Grant and Per Diem) program to get off the street and have their health care needs taken care of by the clinic. Hopefully, they will be able to leave homelessness without a voucher and I will be able to use the voucher for someone who can’t get off the street without it.” 

Dr. Thomas O’Toole, who is the Medical Director of the Providence clinic as well as Medical Director of the national HPACT program, points out that the intersection of chronic pain and addiction can often be an underlying issue that can lead to failure in permanent supportive housing. The HPACT model connected to permanent supportive housing can address this issue. He says that,

by providing continuity in primary care for Veterans with chronic pain and addiction, we can stick with them as the symptoms of their illness wax and wane, and we can intervene before the behavior that is sometime associated with their illness results in housing loss. The primary care relationship and supportive housing are both designed to last a lifetime.  Having the same time frame makes primary care and supportive housing a good fit when providing care to homeless Veterans.  

The experience in Providence has shown that the HPACT model can provide an excellent quality of primary care for Veterans, reduce healthcare costs and utilization, and help Veterans do something that has an even a greater positive impact on their health than primary care: leaving the streets and becoming housed. 

A Focus on Evaluation

As with any new intervention, sustainability is dependent on documenting success and cost efficiency.  Dr. O’Toole and his team have at their disposal a powerful opportunity for evaluation with the electronic medical record (EMR) that is in place throughout the VA system.  Over ten years ago, the VA invested in an EMR so that VA Medical Centers across the country could document services using the same platform.  Dr. O’Toole has capitalized on this powerful tool to assess healthcare utilization as well as disease-specific outcomes (such as glucose control for diabetics and blood pressure for people with hypertension).  EMRs are also used to assess severity of illness across patients in HPACTs so that appropriate utilization at each site can be weighted by severity of diagnosis.  Because the program is a little more than a year old, system-wide results are not yet available, but going forward HPACT’s success will be able to be assessed using some of the most sophisticated and powerful measures in healthcare delivery systems available. 

With the development of the Homeless Patient Aligned Care Team, the Veterans Administration health delivery system is taking another innovative step forward to be Veteran-centric in its service model.  Over the next year or two, this sensible, cost-effective system of care promises to make a strong contribution toward achieving the goal of ending homelessness among Veterans by 2015.

Dr. Josh Bamberger, MD, MPH, is the Medical Director of the San Francisco Department of Housing and Urban Health and the medical director of the Housing and Urban Health Clinic. He is serving as a Special Advisor to the Executive Director at USICH on a short-term assignment.