te be 0

Lillian Gelberg, MD, MSPH; Ronald Andersen, PhD; SonMD, MPH; Rishi Manchanda, MD, MPH; Louis Wilder; BAnita Yuan, PhD, MPH; Lisa Altman, MD

HOUSING IS HEALTH

Promoting Promoting Residential Residential and Medical Medical Hom

Homeless Veterans

• The Homelessness Homelessness Workgroup Workgroup of the

VISN22 PACT Demonstration Lab

• VA Greater Los Angeles (GLA) Healthca

System

September 19, 2012
2

Agenda

• Homelessness and Veterans• Mission, Goals, and Philosophy of the V

PACT Demo Lab Homelessness Homelessness Workgro

Workgro

• Needs Assessment

• Quality Improvement Innovation

– Homeless‐Patient Aligned Care Team (HPA
3

Agenda

• Homelessness Homelessness and Veterans Veterans
4

How do we define homelessn

homelessn

Veterans who:Lack a fixed, regular, and adequate nightti

residence

Identify Identify a primary primary nighttime nighttime residence residence tha

A supervised publicly or privately operated sh

designed to provide temporary living accommodations

A public or private place that provides tempo

residence for individuals intended to be

institutionalized

A public or private place not designed for, or 

used as, regular sleeping accommodations fo

beings

Stewart B. McKinney Homeless Assistance Act of 1987 
5

Persons Persons at‐risk for homelessn

homelessn

• The U S. . Department Department of Housing Housing and Ur

Development expands this definition to

include include persons persons at‐risk for homelessnes

homelessnes

– Individuals and families who will imminent

their primary primary nighttime nighttime residence residence

Homeless Emergency Assistance and Rapid Transition to Housing (HEARTH Act): Defining “Homeless.” Federal 

No. 233/Dec. 5, 2011 
6

The VA aims to end homeless

homeless

• President President Obama and VA Secretary Secretary Shin

Shin

– Committed to ending homelessness amon

Veterans Veterans by 2015 (among the top three pr

pr

of the VA)

• Innovative Innovative programs programs for homeless homeless Vete

Vete

are a current VA priority

Balshem H, et al. A Critical Review of the Literature Regarding Homelessness Among Veterans. VA-ESP Project 

2011.
–

–

7

How many Veterans Veterans are home

home

• Point‐in‐Time Prevalence Prevalence

– Single night, January 2010– Sheltered and Unsheltered

• 76,329 homeless Veterans/ night• 0.37% of Veterans Veterans are homeless homeless

• Annual Prevalence (2010)

Sheltered only

• Emergency shelter/transitional housing

– 144,842 144,842 homeless homeless Veterans/ Veterans/ year

2010 Annual Homeless Assessment Report to Congress, Veteran Homelessness Supplement (Veteran 
8

Where do homeless homeless Veterans Veterans 

• One‐half of homeless Veterans are loca

states

– California = 25%– Florida = 10%

– New York = 8%

– Texas = 7%

• Nearly half (43%) of homeless Veterans 

unsheltered

– On the street, in an abandoned building, o

another place not meant for human habita

2010 Annual Homeless Assessment Report to Congress, Veteran Homelessness Supplement (Vetera
9

How many Veterans are homele

Greater Los Angeles?

8,600 Veterans Veterans are homeless homeless in the VA 

catchment area on any given night*

In FY 2010, VA GLA provided homeless

services to approximately 8 700 , Veteran

*Los Angeles Homeless Services Authority 2011 and the U.S. DepaHousing and Urban Development (HUD) 2009 point‐in‐time enum
10

Context: What housing services 

GLA offer?

y4703 beds for homeless homeless Veterans Veterans in 

(FY 2011)

yHousing Housing First (2733 beds)

{HUD‐VA Supportive Housing Program (H

VASH)

• Continuum of Care (1970 beds)

{Emergency shelter{Transitional housing, including Grant Per 

and Domiciliary programs
11

Context: What clinical services d

GLA offer?

y Mental Health Screening Screening and Treatment Treatment Clinicy Mental Health Primary Care Clinic

y Primary care clinic co‐located with mental health sy Care is tailored for patients who are homeless and

are diagnosed with mental illness

y Street and jail outreach

y Vocational rehabilitation programsy Homeless‐Assertive Community Treatment (AC

y Homeless‐PACT demonstration clinic
12

Agenda

• Homelessness and Veterans• Mission, Goals, and Philosophy of the V

PACT Demo Lab Homelessness Homelessness Workgro

Workgro
13

The VISN22 PACT Demo Lab Homele

Workgroup: Overview

• The VISN 22 Veterans Veterans Assessment Assessment and

Improvement Laboratory for Patient‐Ce

Care (VAIL‐PCC) is a PACT demonstratio

laboratory that supports quality improvinnovations

– The Homelessness Workgroup develops an

evaluates innovations that aim to improve 

and quality quality of care for Veterans Veterans who are h

h

or at‐risk for becoming homeless

• Located at GLA
14

The VISN22 PACT Demo Lab Homele

Workgroup: Mi i ss on

• To promote resident

and medical medical homes 

homeless Veterans

through health serv

research and progra

evaluation
15

The VISN22 PACT Demo Lab Homele

Workgroup : Goals

• To understand factors associated with hom

Veterans' residential status and use of hea

services

• To understand understand the associations associations between between

residential status and use of services with

homeless Veterans' health status, quality o

and satisfaction

• To assist service programs intended to imp

the residential residential and medical medical homes of hom

hom

Veterans in program planning, implement

and outcome assessment
•

16

The VISN22 PACT Demo Lab Homele

Workgroup : Philosophy

The mission mission will be best accomplished accomplished 

better understanding the factors associ

with improved improved residential residential and medical medical 

and using that understanding to assist s

programs programs in effective effective implementation implementation
17

Operationalizing the Mission, Goal

Philosophy

• Conduct Conduct a needs assessment assessment to identif

identif

health problems in Veterans by housin

income status

• Help implement and evaluate a Home

PACT demonstration demonstration clinic which bega

GLA in April 2012

• G id u ed by our conceptual mod l e
18

Conceptual Model:

Behavioral Behavioral Model for Vulnerable Vulnerable Popula

Popula

Predisposing Enabling 

Need 

Health 

Behavior 

• Demographics • H lth B li f Health Beliefs 

• Social Structure 

Housing

• Mental Illness • Substance Use 

g

Status

• Substance Use • Criminal History 

• Source of care 

Case

Management

• Insurance • Competing 

needs 

Clinic type

( C

Income

(HPACT vs.

other)

• Perceived 

h lth ea 

Evaluated

Health

• Personal 

h lth ea practices 

Health

Service

Utilization

• 

• S 

S

w

Gelberg, L., Andersen, R., and Leake, B, 2000 
19

Agenda

• Homelessness and Veterans• Mission, Goals, and Philosophy of the V

PACT Demo Lab Homelessness Homelessness Workgro

Workgro

• Needs Assessment
o u de sta d t e ea t

20

Needs Assessment

• To understand the health

problems of homelessVeterans, and how their

h l ea th problems d ff i er fromlow‐income and otherhoused veterans

• We defined health problems

as diagnoses diagnoses for whichVeterans received VA

ambulatory care
21

( g )

Diagnoses seen in VA Ambulatory 

May Differ in Vulnerable Popul i at 

Predisposing

(Housing Status)

Enabling

(Case managem

income, clinic t

Need

(Perceived a

Health Behaviors (Perceived a

Evaluated Hea

(Health service utilization)

Gelberg, L., Andersen, R., and Leake, B, 2000 
am for homeless Veterans

22

Diagnoses seen in VA Ambulatory 

May Differ in Vulnerable Popul i at 

• We aimed to learn more about:

– The rates and types of medical and psychiatric dia

for which Veterans in GLA receive ambulatory car

– H th ow ese diagnosis rates vary b h i y ous ng and in

status

• Goal – to inform the development of innovat

programs for vulnerable subgroups of Veteraespecially our new H‐PACT Program

• P i art cular interest in the popul i at on of HUD‐V

Veterans, since HUD‐VASH is a top priority fe

program progr for housing housing homeless Veterans
23

Needs Assessment: Assessment: Datase

Datase

• VHA Medical Medical SAS Outpatient Outpatient Da

Da

–GLA service area

– Encounter data

• October 2010 to September 2011
24

Needs Assessment: Assessment: Analytic Analytic Sam

• Individuals Individuals at least 18 yea

age

• Veteran Veteran status identified identified 

VHA Vital Status Master F

– Have enrolled enrolled in the VHA– Received benefits or comp

from the VBA since 2002

– Veterans who received ca

VHA since 1992
25

Needs Assessment:

Subgroups Subgroups for Analyses Analyses

• Four mutually exclusive groups (N = 

– Veterans in HUD‐VASH (n = 2007)– Other homeless homeless Veterans Veterans (n = 2,636)– Low‐income Veterans who are housed 

27,217)

• Identified by Means Test, co‐pay exempt 

are not service‐connected

– All other Veterans (n = 46,237)
26

Identifying Identifying Homeless Homeless Vetera

Vetera

 HUD‐VASH

 In VA encounter data, we can identify Veteran

had contact with HUD‐VASH staff, for p g ro ram 

or ongoing case‐management

 However, there is no automated mechanism 

encounter data to identify Veterans who are enrolled in HUD‐VASH

 Therefore Therefore, internal internal staff developed developed a list of th

Veterans in HUD‐VASH at GLA (names and SSJanuary 2012)
27

Identifying Homeless Vetera

 Other homeless homeless Veter

Veter

 Nationally accepted l

codes that are surrog

measure for homelesi.e., use of homeless 

 Excluded SSNs of Vet

HUD‐VASH at GLA
Coc co d t o s co o e a

–

28

Selecting Selecting Ambulatory Ambulatory Care Diagn

Diagn

• Chronic conditions common in general

populations such as:

– Diabetes– Hypertension

• Chronic conditions more uniquely commo

homeless p po ulations such as:

– HIV– Hepatitis C– Chronic Pain– Mental Illness

– Substance Use Disorders
‐

29

Hypotheses

 Homeless Homeless Veterans Veterans (HUD‐VASH group and oth

homeless) will have greater health needs than 

veterans, as measured by higher rates of med

psychiatric, and substance use diagnoses seen ambulatory care

 HUD‐VASH (housing and case management) w

enable the diagnosis and treatment for a highnumber of diagnoses diagnoses, in comparison comparison to other

homeless Veterans
30

,

Veteran Demographics

Variable HUD-VASH Other Homeless Low-Income, A

(n = 2,007) (n = 2,636) Housed 

(n = 27,217) 

V(

Mean Age 53 years 54 years 62 years Male* 91% 95.% 95% 

Race/Ethnicity* 

White 26% 35% 45% 

Black 57% 43% 23% 

Hi ispan c 9% 10% 13 % Other 7% 12% 19% 

*Chi-square tests of differences by housing/income status are significant at p<0.001 
31

g ,

Physical Health Diagnoses in Ambul

Care

Diagnosis HUD-VASH Other Homeless Low-Income, A

(n = 2,007) (n = 2,631) Housed 

(n = 27,007) 

Ve(n 

Hepatitis C* 10% 5% 3% 

HIV/AIDS* 2% 1% 1% 

Chronic Spinal Pain* 23% 10 % 11% 

Chronic Non-Spinal Pain* 

29% 10 % 14% 

Diabetes* 14% 8% 14% 

Hypertension* 24% 13% 21% 

*Chi-square tests of differences by housing/income status are significant at p<0.001 
32

g ,

Mental Health Diagnoses in Amb

Care

Diagnosis HUD-VASH Other Homeless Low-Income, All O

(n = 2,007) (n = 2,631) Housed 

(n = 27,007) 

Veter(n = 

Depression* 26% 11% 10% 

Bipolar Disorders* 10% 5% 3% 

PTSD* 20% 8% 5% 

Anxiety Disorders* 7% 3% 4% Schizophrenia and Other Psychotic Disorders* 

12% 8% 4% 

*Chi-square tests of differences by housing/income status are significant at p<0.001 
33

g ,

Substance Use Disorder Diagno

Ambulatory Care

Diagnosis HUD-VASH Other Homeless Low-Income, 

(n = 2,007) (n = 2,631) Housed 

(n = 27,007) 

Alcohol Use Disorders* 16% 8% 3% 

Drug Use Disorders* 30% 18% 5% 

Nicotine Dependence* 10% 5% 3% 

*Chi-square tests of differences by housing/income status are significant at p<0.001 
–

34

Summary: Diagnoses in Ambulatory 

by Housing and Income Status

• HUD‐VASH Veterans Veterans, compared compared to othe

Veterans:

– Higher rates of many diagnoses diagnoses seen in am

am

care, across general medical, mental healtsubstance use disorders

– Strikingly higher rates of:

• HIV/AIDS; Hepatitis C; Chronic Pain• Mood Disorders; PTSD

• Substance Use Disorders
35

Summary: Diagnoses in Ambula

Care, by Housing and Income St

• Other Homeless Homeless Veterans Veterans had intermediate intermediate r

schizophrenia and other psychotic disorders as substance use

• Low‐income Veterans and other housed Vete

had lowest rates of conditions seen in ambul

care.
36

Limitations

• Data are cross

‐section

cannot spea

k to causa

• Utilization data do not 

t

o commen

t on diseas

• Limited to VA service u• Identifi ti tification

o

f

home

persons was limited to 

who seek VA housing housing s

s

– Stop codes that indicat

housing services are

a 

measure for homeless
37

Needs Assessment Raises Sev

Questions

• Are HUD‐VASH Veterans Veterans sicker than othe

• Are HUD‐VASH Veterans more affiliated t

Veterans and therefore, more likely to see

their illnesses?

• How can we use needs assessment data t

current service provision for homeless Ve

• What additional needs assessments can h

the development of services tailored for h

Veterans?
38

Agenda

• Homelessness and Veterans• Mission, Goals, and Philosophy of the V

PACT Demo Lab Homelessness Homelessness Workgro

Workgro

• Needs Assessment

• Quality Improvement Innovations

– Homeless‐Patient Aligned Care Team (HPA
at o de t e O ce o o e ess

39

What is HPACT?

• Nationwide, the VHA Office of Homeless

Programs and the Office of Primary Care f32 sites for an 18‐month HPACT demonstrproject

• Provides a medical home tailored to Veter

who are homeless or at‐ri ks for becominghomeless

– Comprehensive Comprehensive health services services crossing crossing tradi

tradi

service lines

– Tailored social services for homeless Veterans
40

How does HPACT Work at G

Guided by Continuous Continuous Quality Quality Improve

Improve

the team components include:

OperationsEvaluation

Target popul ti a on

 High‐utilizers of the VA GLA Emergency Depart

 Initial model

 Evening PACT clinic adjacent to ED
41

Homelessness screening

• Screening Screening tool (4 item

developed by the Na

Center on Homelessamong Veterans is p

tested at the point‐o

identify Veterans wh

homeless or at‐risk f

becoming homeless
42

Homelessness Homelessness screening screening to

1. Are you currently currently receiving receiving housing housing or othe

services from a VA Homeless Program? (Yes

2. Do you have a home of your own that is safe 

where you have lived for the past 90 days? (

3. Are you worried that you may not have a ho

your own that is safe and where you can live 

next 90 days? (Yes/No)

4. Where did you sleep last night?
43

How does HPACT work at G

• After ED triage, a Veteran Veteran is referre

referre

HPACT if he/she:

– Meets screening cri i ter a f h or omelessness 

risk for homelessness, and

– Has a non‐urgent medi l ca complit a n

• Low acuity level (acuity level = 4 or 5)
–

44

How does HPACT work at G

• HPACT provides provides comprehensive comprehensive medica

medica

mental health, and social needs assessm

and intervention

– Complex chronic care management: tracki

Link with community community care services services

– Staffing: MD, LVN, MH‐CNS, Clerk...ED SW

• Goal to include include SW, RN Case Manager Manager
45

Personal Story: Louis Wild

• Louis Wilder, Medical

Support Assistant, HPACT

Clinic

• Serves as clerk and peer

support for HPACT

• Marine Corps Veteran Veteran,

homeless from April 2009‐

August 2010
46

GLA HPACT’s Comprehensive Eval

Mdl o e Andersen R. and Davidson P, 200

Contextual 

Ch t i ti 

Individual 

Ch t i ti 

Health 

B h i 

O

Characteristics Characteristics Behaviors 

Predisposing D hi 

Predisposing D hi 

Personal Health P ti 

Pe

Demographics, 

Social, Beliefs Enabling 

H lth P li Health Policy, 

Financing, Organization: VHA/HPACT 

Characteristics Need Environmental, Population Indices 

Practices Process of M di l C 

Ev

Medical Care Use of Personal H lth S i 

CoSa

Need Perceived and Evaluated 

Health Services 

Qu

Demographics, Social, Beliefs, Genetics Enabling Enabling Financing, Organization Need 
47

GLA HPACT to date

• 256 ED patients eligible

for homelessnessscreening

– 70% were screened

• Of patientsscreened,

61.5% were homeless or

at risk for becoming

h l ome essness  An average o

– 90.9% seen in HPACT diagnoses w

add d 

ddressed pe
48

GLA HPACT helps us understan

homeless homeless medical medical home

• Outcomes:

– Health services utilization– M di e cation adherence

– Patient satisfaction

– Staff acceptance and feasibility

– Perceived social support, loneliness– Housing status (e.g., receipt and mainte

permanent housing)
49

GLA HPACT Evaluation

• Are outcomes outcomes improved improved for Veterans Veterans e

e

in HPACT?

– Exploring Exploring Comparison Comparison Group Options Options

• Veterans in co‐located primary care/mental h

care clinic in WLA Bldg 206

• Veterans in ED not willing to be enrolled in H

• Veterans in ED during hours when HPACT is c

– Compare data for Veterans in the year prio

HPACT enrollment vs. a year after enrollme
–

50

GLA HPACT Next Steps

• Implementation process and

evaluation efforts will:

– Improve ongoing quality improveme– Inform system‐wide care delivery for

Veterans who are homeless or at risk 

becoming homeless

• Complex chronic care management

Advance operational research
51

Special Thanks to GLA HPACT Tea

Members:

• HPACT Clerks: Louis Wilder, Wilder, Kenny Wasson• ED: Dr. Jennifer Chen and James Webb• Nursing: Nursing: Joan Brosnan Brosnan, Tazmin Bolanos Bolanos, LaTre

LaTre

Hamilton, Eva Rush

• MH and Community Community Care: Bill Daniels, Daniels, Miche

Miche

Wildy, Bob Friedman, Susan Rosenberg

• SW: Florence Long, Flinda Behring , er Kathlee

Chronley, Andrea Giese‐Sweat, Todd Ramsay

• PC: Danielle Kehler, Chara Cordova
VISN22 PACT Demo Lab Homelessne

W k or group

• Led by Lillian Lillian Gelberg Gelberg • Lisa Altman

and Ron Andersen • Rishi Manchand

• Sonya Gabrielian • Beena Patel

• Anita Yuan • J’ai Michel

• Lisa Rubenstein • Negar Sapir

• Jim McGuire
Homelessness Workgrou

Present ti a ons and Manuscr

• PRESENTATIONS

– National Institute on Drug Abuse (NIDA) International Forum, Ju

– College on Problems of Drug Dependence (CPDD), June 2012

– 40th American Public Health Association (APHA) Annual meetin

2012

– 2012 North American Primary Care Research Group (NAPCRG) 4

meeting, December 2012

• MANUSCRIPTS

– Gabrielian S, Yuan A, Andersen RM, Gelberg L. Serving homeles

the VA Desert Pacific Healthcare Network: A needs assessment 

quality improvement endeavors. Revise and resubmit from Jour

Care for the Poor and Underserved.

– Gabrielian S, Yuan A, Andersen RM, McGuire J, Rubenstein L, Sa

L. Chronic disease management for recently homeless Veterans

improvement p g ro ram to adapt home telehealth technology for 

population. Revise and resubmit from Medical Care.
54

Contact Information

• Lillian Lillian Gelberg Gelberg, LGelberg@mednet LGelberg@mednet.ucla• Ronald Andersen, randerse@ucla.edu

• Sonya G ba rielian, sonya.gab ir elian@va.

• Rishi Manchanda, rishi.manchanda@va• Louis Wilder, louis.wilder@va.gov

• Beena Patel, beena.patel2@va patel2@va.gov

• Anita Yuan, anita.yuan@va.gov

• Lisa Altman, lisa.altman@va.gov