**Transcript of Cyberseminar**

**Patient Aligned Care Teams (PACT) Demonstration Labs**

**Housing is Health: Promoting Residential and Medical Homes for Homeless Veterans**

**Presenter: Dr. Lillian Gellberg**

**September 19, 2012**

**Patient Aligned Care Teams (PACT) Demonstration Labs**

**September 19, 2012**

Moderator:  First we have Dr. Lillian Gelberg.

Dr. Lillian Gelberg:We are from the Homeless Workgroup, a VISN22 PACT Demonstration Lab, which we will be telling you a little bit more about, and from the VA Greater Los Angeles Healthcare System. We are going to be speaking about housing as health, promoting residential and medical homes for homeless veterans. You can advance Molly.  

Dr. Gelberg:     Thank you. Today we are going to be speaking about several agenda items. One is that we are going to talk a little bit about homelessness and veterans. We are going to talk about the mission, goals, and philosophy of our Homeless Workgroup of the VISN22 PACT Demo Lab. We are going to talk about a needs assessment that is guiding some of our quality improvement efforts. We are going to talk about our quality improvement innovation of our Homeless Patient Aligned Care Team, oor HPACT. We will be having several of us that will be presenting during this webinar. We will be introducing them as they come on. 

First I wanted to talk about homelessness and veterans. How do we define homelessness? Veterans who lack a fixed, regular, and adequate night time residence, or who identify a primary night time residence that is a shelter, a public or private place that provides temporary residence for individuals intended to be institutionalized, or a public or private place not designed for ordinary use as a sleeping accommodation for human beings. This is based on the Stewart McKinney Act, the Homeless Assistance Act of 1987. Next slide? 

Persons at risk for homelessness we also include in our definition. This is based on the US Department of Housing and Urban Development expanded definition, which includes individuals and families who expect to be imminently losing their primary night time residence or are worried about it. Next slide? 

The VA aims to end homelessness. President Obama and VA Secretary Shinseki are committed to ending homelessness among U.S. veterans by 2015. This is among their top three priorities for the VA. Innovative programs for homeless veterans are a current VA priority. Next slide?

How many veterans are homeless? We have two ways right now of counting them. One is at the top of the slide, which is the Point-In-Time Prevalence, which is on a single night. Then we have an Annual Prevalence. This is based on 2010 data. The Point-In-Time Prevalence includes sheltered and unsheltered veterans. There we have got about 76,000 homeless veterans per night, meaning that 37% of veterans have been homeless. The Annual Prevalence includes only sheltered, so emergency sheltered or transitional housing veterans. This would exclude veterans who have only been in outdoor areas or are living in public spaces or in their cars. Here we get up to about 145,000 homeless veterans per year. Next slide?

Where do homeless veterans live? One-half of homeless veterans are located in four states, California, Florida, New York and Texas. Nearly half of homeless veterans are unsheltered, meaning they have been living on the streets, in an abandoned building, in an outdoor area, or in another place not meant for human habitation. Next slide?

How many veterans are homeless in Greater Los Angeles? There are about 8,600 veterans who are homeless in the VA-GLA catchment area on any given night. That is in one night, not necessarily for a whole year. In fiscal year 2010, VA-GLA provided homeless services to about 8,700 veterans. Next slide?

What housing services does GLA offer? We have got about 4,700 beds for homeless veterans in GLA. Most of these are Housing First, which is a HUD/VA Supportive Housing Program, or HUD-VASH. Then we also have 1,970 beds in the Continuum of Care program, which is emergency shelter and transitional housing, including the Grant Per Diem and Domiciliary programs. Next slide? 

In terms of the clinical services that GLA offers for homeless veterans, we have got the Mental Health Screening and Treatment Clinic. We have got a Mental Health Primary Care Clinic, which is the primary care clinic co-located with mental health services, where care is tailored for patients who are homeless or who are diagnosed with mental illness. We have street and jail outreach programs that are extensive and vocational rehab programs. We have several Homeless Assertive Community Treatment ACT teams, which go out to the less affiliated veterans who may be living in distant transitional housing, or in outdoor areas, or in isolated apartments or vehicles. We have our Homeless-PACT Demonstration Clinic, which we will be telling you more about later. 

Next we want to talk to you about our mission, goals, and philosophy of our VISN22 PACT Demo Lab Homelessness Workgroup. Next slide?

Our Workgroup is the VISN22 Veterans Assessment and Improvement Laboratory for Patient Centered Care, or VAIL-PCC. It is a PACT Demo Laboratory that supports quality improvement innovations on PACT. We represent the Homeless Workgroup of VAIL-PCC, which develops and evaluates innovations that aim to improve access and quality of care for veterans who are homeless or are at risk for becoming homeless. This is located at GLA. Next slide?

I would now like to turn the presentation over to Dr. Ronald Andersen, who will be telling you about our mission and philosophy. 

Dr. Ronald Andersen:     We believe that mission does make a difference, to promote residential and medical homes for homeless veterans through health services research and program evaluation. Next slide?

The goals that we have to reach this mission are to understand and to assist. To understand factors associated with homeless veterans' residential status and use of health services. To understand the associations between residential status and use of services with homeless veterans' health status, quality of life and satisfaction, and to assist service programs intended to improve the residential and medical homes of homeless veterans in program planning, implementation, and outcome assessment. Next slide please? 

The mission will be best accomplished, it is our philosophy, by understanding the factors associated

with improved residential and medical homes, and using that understanding to assist service

programs in effective implementation. Good research and evaluation assumes that reaching the truth will make us well and free. Next slide please? 

The conceptual model that we are using for our work is based on a version of the behavioral model for vulnerable populations developed by Dr. Gelberg and her colleagues. What we are assuming here is that health behavior and outcomes are a function of a number of characteristics. Predisposing characteristics, and we will be stressing housing status in our work. Enabling factors include case management for veterans, their income level, and of particular interest to us is clinic type and services provided and the way they are provided by clinics. We have our HPACT demonstration clinic for this purpose. And needs of veterans. Next please?

Turning to needs assessment, we will be having Dr. Sonya Gabrielian. Dr. Gabrielian is a psychiatrist at the Veteran's Administration at GLA. She is a fellow in the Mental Health Research and Education Clinical Center. She is also a co-principal and investigator for our homeless teams. She will discuss the needs assessment of homeless veterans in the GLA, which is one of our major activities. 

Dr. Sonya Gabrielian:     Thank you Dr. Andersen. I will be talking a little bit about a needs assessment that we use with the overarching aim to understand the health problems of homeless veterans and to learn more about how their health problems differ from veterans who are low income and housed and from other housed veterans as a larger group. For this database driven needs assessment, we defined health problems as diagnoses for which veterans receive VA ambulatory care. 

Our needs assessment is really framed with the behavioral model that Dr. Gelberg and Dr. Andersen and their colleagues developed, and with the overarching presumption that diagnoses in veterans receiving ambulatory care may differ in vulnerable populations. And here on this slide you can see a variety of variables that would indicate why this is the case. Housing status is a predisposing factor that has major roles in whether or not patients access care, particularly in the vulnerable low income or homeless population. Factors like case management, income level and clinic specialty type can be enabling factors that have huge impacts on health service utilization. We also all know that perceived need and evaluated needs can differ by vulnerable sub-populations and impact health behaviors and health service utilization quite significantly in the ambulatory care setting. 

With this needs assessment we had a few core aims. First, we aimed to learn the rates and types of medical and psychiatric diagnoses for which veterans within the GLA service area receive ambulatory care. Perhaps more importantly, how these diagnoses rates vary by housing and income status. With these goals in mind, our more practical next step was to inform the development of innovative programs for vulnerable sub-groups, particularly homeless sub-groups and looking at our Homeless PACT program that you will hear about in just a few moments. 

As a side note, with the  push toward Supported Housing and the Housing First model of care, and the HUD-VASH program being a priority in terms of housing homeless veterans, we had particular interest in looking at the HUD-VASH group and thinking about how HUD-VASH patients differ from other homeless veterans, as well as some other low income housed veterans. 

Our needs assessment was a database driven assessment. We used the VHA Medical SAS Outpatient data set, looking within an arbitrary calendar year of data from October 2010 to September 2011, within the GLA service area. Next slide?

Our analytic sample was individuals at least 18 years of age. We used a variety of variables to make sure that these were veterans who had received ambulatory care at the VA-GLA within the calendar year we mentioned. Next slide?

For our analysis, because we had that particular focus on HUD-VASH as well as the focus of looking at homeless versus low income housed veterans, we found about 78,000 unique patients who sought care within GLA during that calendar year and subdivided it into four mutually exclusive groups. About 2,000 veterans in HUD-VASH were one of our groups, compared to about 2,600, so a little bit more, in terms of other homeless veterans. 27,000 veterans were low income but housed. Here we used a means test, looking at co-pay exempt veterans who are not service connected to categorize this low income group. Our fourth group was of course all other veterans, which is the largest group at around 46,000 patients total. 

One of our initial challenges in developing this needs assessment was how to identify which veterans were homeless. This is a particular challenge because we do not, as of yet, have a particular designation in our encounter data that identifies homeless persons. We have to use service utilization as a surrogate measure of homelessness. In particular, we were met with the challenge of identifying the veterans in HUD-VASH but because of the focus on Supportive Housing in today's administration and VA climate, it was something of great importance to us. Though HUD-VASH has a stop code, in VA encounter data it is impossible to identify veterans who have actually enrolled in HUD-VASH. What you can identify by database queries are which veterans inquired about the program, had ongoing case management or had some sort of contact with HUD-VASH staff, but an actual automated mechanism to figure out what veterans actually receive ongoing case management was very difficult. 

Our HUD-VASH staff fortunately was able to develop an internal list of veterans who were case managed as of a static point in January 2012, giving us the names and SSNs so that we could pull this list of about 2,000 veterans. 

For the other homeless veterans it was a little less challenging. There is a nationally accepted list of stop codes that are a surrogate measure for homelessness in large database analyses. Essentially what these are are use of homeless services. So things like the HDAC programs, certain CWTs or vocational rehabilitation programs and the Domiciliary program, programs that cater to homeless veterans and allow us to have a surrogate measure of which patients are actually homeless. 

HUD-VASH stop codes are traditionally in this list. What we did was pull our list of other homeless veterans using this list of stop codes and excluded the social security numbers of veterans who were in our first group of veterans in HUD-VASH. 

Our next step after identifying which patients in our data were actually homeless or part of HUD-VASH, was to select ambulatory care diagnoses of interest. We were particularly interested in chronic conditions. We looked at both chronic conditions which were common in general populations, diabetes, hypertension and dyslipidemia, things along those lines, as well as chronic conditions that have high rates in homeless populations. Things like HIV/AIDS, hepatitis C, chronic pain, mental illness, and substance use disorders. 

Unidentified Female:     Thank you, Sonya. Can I ask you just to speak up a little bit? 

Dr. Sonya Gabrielian:     Sure. 

With homeless veterans, our hypotheses were that homeless veterans both in the HUD-VASH group and other homeless veterans would have greater health needs than other veterans. This would be measured by higher rates of medical, psychiatric, and substance abuse diagnoses seen in ambulatory care. Our specific interest in looking at the HUD-VASH group was to think through if independent housing and case management that work in VASH together would enable the diagnosis and treatment for a higher number of diagnoses in the HUD-VASH sub-group, in comparison to other homeless veterans. 

I will present some of our preliminary data. You can see our four columns. You have the HUD-VASH group of about 2,000 veterans, the other homeless group, our low income housed group that we identified with the means test, and all other veterans as our four columns. In the rows you can see some of our key demographic variables, age, gender, race and ethnicity here. I will just point out a few interesting points. 

Our HUD-VASH and homeless veterans were a bit younger than our housed veterans. They were in their early fifties as opposed to their early sixties. The male/female breakdown was very similar across all four groups. In terms of race and ethnicity, we did see higher rates of Caucasians among the housed groups and higher rates of African-Americans in the HUD-VASH and homeless groups. 

We have some data also about a few of our diagnoses of interest. This first slide goes through general medical diagnoses. Just to clarify how we got these percentages, in this table you will see that a veteran is counted as having a diagnosis if he or she sought ambulatory care for the diagnosis at least once over the calendar year. Looking at the encounter data, we looked at the primary diagnosis that a provider gave that is associated with the given encounter. With that, if a patient received a diagnosis one or more times over the calendar year of interest, they are counted as having the diagnosis. 

Here in our rows you can see some of our conditions that we know have high rates in homeless populations, hepatitis C, HIV/AIDS, and chronic pain. You can actually see markedly higher rates in the HUD-VASH group versus the other homeless group, as well as our housed groups. For diabetes and hypertension, some of the chronic conditions seen in ambulatory care overall, you interestingly note that other homeless veterans have lower rates and that the HUD-VASH rates actually parallel that which you see in housed populations. 

This slide goes through some common mental health diagnoses, all of which we thought would have high rates in homeless and HUD-VASH, and actually low income populations as well. You see our mood disorders, both unipolar depression and bipolar disorder, PTSD and other anxiety disorders, and psychotic spectrum disorders in the lowest row. The HUD-VASH group really had strikingly higher rates of those mental health diagnoses than our other groups. We also do know that the other homeless veterans have a significantly higher rate of psychotic disorders than the housed groups, 8% versus 3% or 4%. 

Our last slide talks about some of the addictive disorders. You can see alcohol use disorder, illicit drug use disorder; these could be polydrug disorders or other specific illicit drug disorders and nicotine dependence. Here you can really see a parallel between these diagnoses, with the lowest rates being found in the housed group that did not meet low income criteria and the highest rates being seen in HUD-VASH, with the other homeless and low income falling in between. 

What we took away from this data is really that the HUD-VASH group was strikingly different from our other groups. We had higher rates of many diagnoses seen in the ambulatory care setting, across general medical, mental health and addictive disorders. In particular, the rates were considerably higher in HIV/AIDS, hepatitis C, chronic pain, mood disorders and substance abuse disorders, which we know are particularly common in homeless populations. A few other interesting points were that the other homeless group, the non HUD-VASH homeless group, had intermediate rates of psychotic disorders and that the low income veterans and other housed veterans had the lowest rates of conditions seen in ambulatory care. 

We make these statements with acknowledgement of a few very key limitations. The first and foremost is that data is cross sectional. It really cannot speak to causality. When we think about factors like housing and income, we cannot say the role of housing and income in terms of causing the sorts of diagnoses seen. We also recognize that this is utilization data, which lies very distinct from disease burden, particularly when we are limited to VA service utilization and we are not able to capture data about service utilization in the community. Last but also important is that our identification system of homeless veterans was really limited to those who were seeking VA housing services. Our stop codes that indicate use of VA housing services are really a surrogate measure for homelessness. They do not capture our homeless veterans who are not seeking housing services through the VA, either who are not seeking housing services at all or who are seeking housing services from community agencies. 

Regardless, our needs assessment raised a few key questions, particularly about our HUD-VASH group. Really our thoughts are, are the HUD-VASH veterans sicker than other veterans? Or are they simply more affiliated with other veterans and therefore more likely to seek care for their illnesses? As we also think through next steps, we think about how we can use our needs assessment data to inform current service provision for homeless veterans, particularly with innovative programs like the HPACT, which you will hear about in a moment. We are also thinking through what other needs assessments do we need to help us inform the development of services tailored for the homeless. 

Next I will turn the presentation over to Dr. Rishi Manchanda, who is the lead clinician at our Homeless PACT here at GLA, to talk about the specific quality improvement innovations. 

Dr. Rishi Manchanda:     Thanks Sonya. My name is Dr. Rishi Manchanda. It is a pleasure to be here with you guys today. Thanks to Molly and everybody for organizing this. HPACT, as you heard, is obviously informed by the studies and the data that Sonya and Dr. Gelberg had just mentioned, as well as a lot of experiences that many of you who are listening in have had. It is really geared to provide a medical home for homeless veterans. Let's get into the specifics. 

HPACT is a Demonstration Project that is part of a national effort that has funded 32 sites across the country. HPACT, like other sites, is an 18 month program. Our goal again is to provide a medical home that is tailored to veterans who are homeless, or veterans who are at risk of becoming homeless. When I say medical home, I think it is worth reinforcing what this means from the perspective of a clinician and for anybody who has dealt with the challenges of taking care of veterans who are experiencing homelessness. What it means is a place that not only provides the comprehensive health services that we have come to think of in terms of medical homes, but also speaks to the largest driver for this population of disease, and that is the lack of housing. To put a point to it, a medical home for homeless veterans needs to not only look at their health issues, but realize housing is health, as our title alludes to. Next slide?

How does it work here in Los Angeles at GLA? It is like other programs, but certainly here with us we are very much guided by a culture of continuous quality improvement. As you have seen demonstrated in this presentation today, it is a team that includes equal parts operations and evaluations, with a keen eye to making sure that we use rapid cycle improvement to improve our performance and to meet our objectives which you will hear about in a minute. I think we are really privileged, by design, to be working together with researchers and with boots on the ground operations folks who know how to tackle problems from a medical and social services perspective. Our target population is the sickest of the sick and the high utilizers of the VA-GLA emergency department. This is specific to our program. Other HPACT sites around the country have tailored their interventions somewhat differently. 

Our initial model here is a model that involves setting up a PACT clinic, or Patient Aligned Care Team or Patient Centered Medical Home model, if you will, adjacent to the emergency room, to co-locate primary care services in the urgent care backtrack area of our emergency room, and to set up that clinic is an important distinction that I think is worth reflecting on. We set this clinic up in the evening. As many of you know, veterans who are experiencing homelessness and have complex chronic diseases are often challenged in terms of meeting their daily needs, food, shelter, and medical issues. They often will present in the evenings. That is what we are finding here in L.A. They have been presenting in the evenings to the emergency room. Our goal was to co-locate services to divert them into a primary care setting and provide them that high standard of medical home. 

We screen for homelessness using the screening tool that was developed by the National Center on Homelessness. It is adapted from that actually. It is a much shorter version of the screening tool that you will hear about in a second. We are pilot testing that now. We’re proud to say that we are now part of a GLA wide effort to screen for homelessness in general. We can talk more about that in the Q&A section. Essentially, the process is that our triage nurses and the staff in the emergency room will go ahead and screen those low acuity patients who present. Next slide please? 

Here are the questions from the screening tool. First is simply asking are you currently receiving housing or other services from a VA Homeless program? Do you have a home of your own that is safe and where you have lived for the past 90 days? Third, are you worried that you may not have a home of your own that is safe and where you can live for the next 90 days? Those first three questions are ones that came directly from that larger screening tool from the national office. We included a fourth question here, which comes informed by our service providers on the community care side here at GLA and basically asks where did you sleep last night? Those are the four items in our screening tool. 

After the patient presents to the emergency room in the triage area, a veteran is screened using the questions I mentioned. Then they are referred to HPACT if he or she meets those criteria for homelessness or at risk for homelessness and also has a non-urgent medical complaint. In other words, is a low acuity patient. In our world a low acuity patient means level four or five. 

HPACT provides, when they come into our care, wrap around services. They are comprehensive medical, mental health, social needs and interventions. I will reflect a bit later on what this really means in terms of our experience so far to date, but suffice to say this is a population that requires complex chronic care management. We have developed tracking tools to be able to provide ongoing case management, above and beyond what we are already documenting in our EHR system. We have a very explicit and robust focus on connecting these patients to community care services and we are currently staffed with me, an MD, an LPN, a mental health clinical nurse specialist and a clerk. We also work really closely with the emergency room social workers. Our goal, as we expand is to include social workers and an RN case manager on the [inaudible] team. Next slide?

We are going to try to show a story of one of our clerks, Louis Wilder, who is the medical support assistant with us. He has been serving as our clerk from the get-go, about four months ago when we started. Since the file itself, the video is not open, I will fill in right now and just tell Louis' story. Later on we will try to provide a link to a video that will allow you to hear his story directly. 

Louis is a pretty incredible person and colleague. Here is his video. Can you go ahead and scroll to minute eight? 

Molly:     Yes. Give me just one second. 

Dr. Rishi Manchanda:     Wonderful. That is the miracle of technology here, 8:04. Let's cross our fingers for audio. 

Molly:     Are you receiving audio there? 

Dr. Rishi Manchanda:     No. we are not receiving audio 

Molly:     I apologize. We are just not going to have that function at this time. 

Dr. Rishi Manchanda:     No problem. Thanks for trying. For those interested, please contact us and Molly. We will try to provide a link to the video that you can view. 

This is Louis' story. Let me give you the summation of this. You see Louis there and he deserves as much attention as we can give him. He is a pretty incredible guy. His story is... Molly, go ahead and press play. To the audience out there, thank you for being patient with us. Let me go ahead and just ask you to press play Molly. I am going to play the audio from our side here. 

Molly:     Okay. Would you like me to start back at 8:04?

Dr. Rishi Manchanda:     Yes, 8:04. I will give you the cue. We will start on my cue. Give me a second here. 

Molly:     We really want you to be able to hear Louis and if the voice and the picture are not quite synchronized, bear with us audience. His story is quite compelling. We would love for you to be able to hear it. 

Dr. Rishi Manchanda:     Okay. Molly, you are at 8:03. Let's go ahead and start now. 

Louis Wilder:     Good afternoon. My name is Louis Wilder. I am currently an MSA for primary care at HPACT and for [inaudible]. I work here at the West LA VA hospital. I was also, at one time a homeless man. I became homeless in 2009. I was a nursing home administrator. I went to work Monday and the doors were closed so I was unemployed. This led to the separation of my family. I was out looking for jobs and was applying at city, federal, state and I was lucky to secure an interview here at West LA VA . I was hired as a medical assistant August 2, 2010. August 2, 2012 was two years I’m proud to say. I just want to talk to you about the HPACT clinic that was started here in West LA Hospital. We’re into the pilot program. The feedback we are getting is tremendous from the veterans that we are able to help. They are appreciative that they have somewhere to go and they have somebody who cares about their care. The doctors and the nurses, they all came together as one team. The professionalism is something to be proud of. The services we are giving our veterans are something to be proud of because it is a needed clinic. There is a large population of veterans downtown that we have not even tapped yet. I imagine when the clinic goes full time that it will grow and that will get better. We will be able to serve more of our veterans. And basically this is it, what HPACT is all about, helping those who served our country. 

Dr. Rishi Manchanda:     Thank you Molly. 

Let's go back to the presentation. Louis' story is really compelling. For those who were able to follow along on that audio, it is clear that not only does Louis bring skills as a clerk and as peer support for HPACT, but his own story is telling, and I think he has been part of the reason we have been so successful in reaching out to veterans there. 

Molly:     My apologies for that. 

Dr. Rishi Manchanda:     You heard earlier from Dr. Andersen a review of the model that Dr. Gelberg and colleagues have put together. Here is an updated one that clearly speaks to the interrelated nature of characteristics that really define what the experience is for our homeless veterans. From the left side you will see that clearly contextual characteristics in terms of services provided, individual characteristics in terms of where they are from and their social determinants of health, their perceived and evaluated needs, all the way to the right column in terms of their own engagement, all of these factors. The bottom line is that the behavioral model clearly informs a lot of our thinking of how to relate to individuals and their upstream determinants. Next slide please? 

In a nutshell, here are some statistics, just to give you some more quantitative flavor to what we are doing. In the past four months, we have had 256 patients present to the emergency room who are eligible for screening. Of those ,70% were screened. It is worth noting that the reason for that gap is primarily because those 30% who were not screened were not present in the emergency room and we hypothesize that many of those patients are actually homeless and sometimes come into the emergency room for temporary shelter. That said, of the 70% who were screened, nearly 2/3, 61.5% were homeless or at risk for becoming homeless. Let me stress that point again. For those patients who were screened, nearly 2/3 of low acuity patients presenting to the emergency room identified themselves as either homeless or at risk of becoming homeless. That is a pretty compelling number for us. What is also compelling is that we have been able to see nearly all of them, 90.9% of those who screened positive for becoming homeless are seen that day in HPACT. For those that we do not see, we enter them into our tracking system and through our case management process we are able to track them down and try to help them with services. 

Another important point on the right side of the screen here is underneath that graphic. This is a very sick population. What Dr. Gabrielian and Dr. Gelberg talked about earlier, is really alluding to the fact that this is a patient population that experiences a higher burden of disease. As important is the fact that with HPACT, we are not only taking care of these patients but we have designed our model to be able to address the complexities of those issues during those visits. As compared to some other clinical scenarios where perhaps two or three diagnoses are addressed, we are on average addressing 6.3 diagnoses per visit. Our patients have complex diseases and we are addressing them. 

The outcomes that we’re interested in following and have been collecting data on include health services utilization, patterns among these veterans, rates of adherence to medications, their own satisfaction with the process, acceptance and feasibility of our model among staff, perceived social support and loneliness among veterans and as importantly, the status of housing for these veterans, whether or not they have received and maintain permanent housing due to our intervention. Next slide please? 

Going forward, our evaluation model really seeks to address whether or not these outcomes are improved by virtue of being enrolled in HPACT. We are exploring various comparison group options, including the ones stated there, comparing veterans to patients who are receiving care in Building 206, which is a much more robust model of co-located primary and mental health care. Another comparison group is those veterans who are not willing to be enrolled in HPACT who do present to the emergency room, and veterans who present to the emergency room during hours when HPACT is closed. The other comparison group option or evaluation option that we have is to compare data for veterans in the year prior to enrollment versus a year after, so a time period. Next slide please? 

What is clear in our work so far with the incredible team that we have here is that our process and evaluation efforts will and are already improving quality improvement efforts here at GLA. We are already starting to realize that the lessons we’re learning, the notes from the field that we are bringing back are informing system wide care delivery for veterans. The point that I want to stress here with you guys today is that homelessness itself, as we propose, is a complex chronic condition. As such, it should receive the same kind of attention that other chronic conditions like diabetes or congestive heart failure receive. Therefore, homelessness itself requires complex chronic care management. The last important contribution that I think we are making is that, as you have seen today, we are helping to advance operational research and really how to meet the challenges for homeless veterans. Next slide please? 

Let me put a special thanks out to a lot of individuals who represent a lot of different arms of the VA system, on the medical and community care sides. I will start with our clerks, who staff our clinic every day, those champions in the emergency room who have been with us at the table, including Dr. Jennifer Chen and the nursing staff including Joan Brosnan and others who have been with us and supportive of HPACT. On the mental health and community care side, represented by Bill Daniels and Michelle Wildy specifically. Susan Rosenberg is our mental health clinical specialist. From social work, we have incredible contributions of social work resources that are at the table, and in primary care as well. 

For the next slide I will hand it over to Lillian to round us out. 

Dr. Lillian Gelberg:     What makes our special team go is that our team consists of, as you heard, the operations side and the research and evaluation side. We meet together every single week. We discuss with the people who are on the prior slide as well as on this slide, how we are going forward and how we are modifying things, how we are moving forward and what our next steps are, what research questions are bubbling up from the patients, the providers and the staff. I want to acknowledge our Demo Lab Homeless Workgroup, who all contributed to this presentation. They are all in this room, even though they did not present, they are part of the presentation and contributed to the slides. We have myself, Ron Andersen, Sonya Gabrielian, Anita Yuan who is here, Lisa Rubinstein, Jim McGuire, Lisa Altman, Rishi Manchanda who you heard, Beena Patel, J'ai Michel and Negar Sapir. Next slide? 

We want to share with you a little bit about the presentations that we have made regarding our work with HPACT and the Homeless Workgroup, and various different projects we have been working on, and two of our manuscripts that are now under revise and re-submit. We are hopeful that they will be published soon. Next slide? 

Here is the contact information of the presenters. Thank you very much to the audience for bearing with us and being on the call today. Thank you for Molly and all of your technical cyber seminar expertise. 

Molly:     Thank you all for sharing your expertise. We do appreciate our audience's patience. For those of you that joined us after the top of the hour, I want to explain to you how you can submit any questions or comments today. Just go to the question pane, which is located on the right hand side of the dashboard on the right hand side of your screen. Click under questions and then you can submit your question or comment. We will be able to answer those in the order that they are received. You can have more than one pending at a time. 

I have gotten a lot of questions asking if the slides are available for download. They are. You have the link to them located in the reminder e-mail you received two hours ago. There is a hyperlink directly to the slides. You can also e-mail cyberseminar@va.gov and I can shoot you a copy right now. 

Finally, when we send the follow-up e-mail tomorrow, we will also include a link to the archive video where the slides are available and we will include the link to the YouTube video, so that you can hear the story and the audio as well. 

The first question has come in. Do you all have any measures of which programs are more cost effective, HUD-VASH versus Grant and Per Diem programs, as an example, cost comparison?

Dr. Lillian Gelberg:     This is Lillian speaking. No, we currently do not have measures but we would love to develop measures. If you would like to partner with us, drop us a line. It is an important area that we believe we will, as a nation, need to move into. 

Molly:     Thank you for that reply. We do have another one. We are interested in whether you have a breakdown of the number or percentage of HPACT attendees, who are not yet linked to a primary care provider in some regular way, potentially transfers from within other greater Los Angeles primary care, versus new to PC patients? 

Dr. Rishi Manchanda:     Thank you for the question. I will take it. We have some of that data. The gist of it is that about...

Molly:     I am sorry. I am going to interrupt. There was an error in writing that in. they are interested in the breakdown of numbers between people that are linked to primary care providers in the regular way versus new to primary care patients. 

Dr. Rishi Manchanda:     Sure. We can share that data. For that person, please e-mail me. We will share that data. The gist is that roughly 70% of veterans who screened positive were actually assigned to a primary care provider, but we found that the rates of engagement, even though they were assigned, were not even optimal at all. Some of them had not seen a provider, even though they were assigned, in quite a while. It is worth stating at this point that what we have routinely provided to these veterans is the option to assign themselves to us as a primary care home, or to choose among any other options. Beyond the services we provide that day and ongoing, we also try to very specifically engage them in a medical home, whether it is with us or somebody else. 

Molly:     Thank you for that reply. The next question we have: Are there any health outcomes of HPACT attendees? 

Dr. Rishi Manchanda:     Right now we are in the process of tracking those outcomes. Stay tuned. Please e-mail us. We will be sure to communicate back with the audience about those outcomes. I am presuming that the questioner is asking about health outcomes related to our interventions. The slide presentation that you heard earlier clearly speaks to the burden of disease among many of the homeless veterans. We are certainly seeing that. If it is data regarding the complexity of chronic diseases and other issues that the veterans are experiencing, we do have that data. If it is regarding our intervention loaded outcomes, we are tracking that now with our evaluation team. 

Molly:     Thank you for that reply. That is the last pending question we have at this time. We do have a few minutes left. I encourage our attendees to write any last minute questions for this team that we are lucky enough to have on the call, and also while we wait you guys can feel free to give any concluding comments you would like to. 

 Dr. Rishi Manchanda:     Let me take it back to that last question. While we are collecting health outcomes and quantitative data, which is so critical, it is also worth noting that what we are seeing already is impact that [inaudible] on the ground. There are veterans who have been coming in and have been bouncing in and out of inappropriate utilization of the emergency room, and even in-patient admission. One veteran that comes to mind, alcohol-dependent veteran, recent OIF vet who continuously engaged with care after relocating to Los Angeles homeless. We stayed engaged with him, even whether he came in for a low acuity issue or presented to the emergency room with acute intoxication. We stayed engaged and continued to offer our services and support him as he tried to establish care and get into housing. After about six weeks of intervening and connecting him, we are proud to say now that he is at this point, about 56 or 57 days sober. He is staying in a transitional housing program. He has substance abuse treatment going on currently. This work is not only challenging, but incredibly rewarding. I think it speaks to the fact that the interventions required by definition have to be a combination of medical and social services. Having that capacity to provide that complex chronic care management and allowing the veterans to leverage their own resources while we leverage resources at the VA is the right thing to do. We hope to see that collected in our data, but certainly know that is being reflected in our day to day experiences. 

Dr. Lillian Gelberg:     We would like to acknowledge Vince Kane, from the National Center on Homelessness, who has been very supportive of us and our work. Also Tom O'Toole, who leads the National HPACT program, who has also been very supportive of our work and encouraging us to dream and think about outcomes research in this area. 

Molly:     Thank you all very much. No further questions have come in. We are nearing the top of the hour. Once again, I would like to remind our attendees that I will send a follow-up e-mail tomorrow. It will have the link to the YouTube video. With this presentation in particular, we will not be able to upload it to our archive catalog until the end of next week. Our web team is out of town. We will get that out to you by the end of next week. You can always check our archive catalog. I invite you to join us for our next PACT session, which is October 17, also at noon eastern. It is on integrating mental health into PACT for OEF/OIF veterans and for primary care populations. This will be presented by representatives from VISN4 and VISN22. You can always register for our cyber seminars by going to our catalog. The link is on the HSR&D home page. Thank you to our attendees who joined us and thank you very much to all of our speakers. Unless anyone has any further comments, this does conclude today's HSR&D presentation. Thank you very much. 

Dr. Ronald Andersen:     Thanks Molly. 

Molly:     Thank you Dr. Andersen. 

Dr. Lillian Gelberg:     Thank you Molly. 

Molly:     Happy to help. 

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