BUILDING PRIMARY CARE 

MEDICAL HOMES FOR 

HOMELESS VETERANS: A CASE 

STUDY OF THREE VA FACILITIES

Sonya Gabrielian, MD, MPH, Adam J. Gordon, MD, MPH, Lillian Gelberg, MD, MSPH, 

Beena Patel, DrPH, Rishi Manchanda, MD, MPH, Lisa Altman, MD, 

Ronald M. Andersen, PhD, Robert A. Campbell, BA, 

Lauren M. Broyles, PhD, RN, James Conley, BA, Stefan Kertesz, MD, MSc

VA Greater Los Angeles, University of California, Los Angeles 

VA Pittsburgh Healthcare System, University of Pittsburgh 

Birmingham VA Medical Center, University of Alabama at Birmingham

VA PACT Cyberseminar: November 20, 2013

1 
Agenda

• Homeless adults and primary care

• Homeless Patient-Aligned Care Teams (HPACTs) 

• Case study of three HPACTs

• Clinic structures

• Patient characteristics

• Utilization patterns

• Conclusions and Implications

2 
POLL QUESTION

Which of the following best describes your work with 

homeless Veterans?

1) I am a clinician who sees homeless Veterans in 

practice.

2) I am a researcher who studies homeless Veterans.

3) I am a policymaker/administrator involved in services for 

homeless Veterans.

4) I work with homeless Veterans in some other capacity.

5) I do not work with homeless Veterans.

3 
The VA aims to end Veteran homelessness

• On a single night in 2012, 62,619 Veterans 

were homeless (13% of all homeless adults)

• Veterans may be at higher risk for becoming 

homeless than the civilian population

• Combat exposure, military sexual trauma

• Homeless Veterans are a vulnerable 

population

• High rates of medical/mental illness, alcohol, 

tobacco, and other drug (ATOD) use

• Fragmented health and social services

• Age-adjusted mortality is 2-10 times that of housed 

peers

4 

Cortes A, et al. The 2012 Point-in-Time Estimates of Homelessness: Volume I of the 2012 Annual Homeless Assessment Report. 

Balshem H, et al. A Critical Review of the Literature Regarding Homelessness Among Veterans. VA-ESP Project #05-225. 2011.

O'Toole TP, et al. Building care systems to improve access for high-risk and vulnerable veteran populations. JGIM. 2011
Little is known about best practices in 

homeless-focused primary care

• Primary care needs are complicated by poor 

social support and competing priorities 

• Co-located VA primary care, mental health, 

and homeless services in Los Angeles, CA

• Higher rates of primary and preventive care 

• Homeless-focused VA primary care in 

Providence, RI

• Greater improvements in chronic disease 

outcomes compared to a historical cohort of 

homeless Veterans in traditional VA primary care 

clinics

• Fewer non-acute Emergency Department and 

inpatient admissions for general medical conditions

5 

McGuire J, et al. Access to Primary Care for Homeless Veterans with Serious Mental Illness or Substance Abuse: A Follow-up 

Evaluation of Co-Located Primary Care and Homeless Social Services. Adm Policy Ment Health. 2009.

O'Toole TP, et al. Applying the chronic care model to homeless veterans: effect of a population approach to primary care on utilization 

and clinical outcomes. Am J Public Health. 2010.
The VA lacked a homeless-focused 

primary care initiative

• The Health Care for Homeless Veterans (HCHV) program 

already offered a host of services for homeless Veterans

6 

VA Office of 

Homeless Programs

VA Office of 

Primary Care 

Operations

2012: Homeless Patient-Aligned Care Teams 

(HPACTs) funded at 32 VA facilities
HPACTs are patient-centered medical 

homes for homeless Veterans

• Three features guided HPACT implementation nationwide:

• Tailor clinical/social services to homeless Veterans

• Establish processes to identify/refer appropriate Veterans

• Integrate distinct services

• New programs must fit local contextual factors

• Space, personnel, infrastructure, institutional/community resources

• Different models of homeless-focused primary care 

evolved nationwide

7 

Each new HPACT affords an opportunity to explore how 

variations in initial service design may influence the types 

of patients seen and services delivered
Case study of three newly implemented 

HPACTs

• Convenience sample of 

HPACTs with contrasting 

clinic structures and 

geographic diversity

• Compared demographic, 

housing, medical, and 

health service utilization 

of initial patient cohorts

• Aimed to facilitate HPACT 

quality improvement and 

add to the paucity of 

literature about homelessfocused primary care

8 

Los 

Angeles

Birmingham

Pittsburgh
Methods

9 

• Clinic Structures

• Authors at each site independently developed 

a list of organizational domains by which to 

describe HPACTs, along the 3 guiding 

principles

• Patient Characteristics (enrolled in 

HPACTs from 4/30/12 – 9/30/12) 

abstracted from the electronic medical 

record

• Baseline data: demographics, housing status, 

diagnostic information, VA healthcare utilization

• After 6 months: housing status and VA 

healthcare utilization 
HPACT Clinic Structure: Los Angeles

• Evening clinic, co-located with the Emergency 

Department (ED)

10

Not appropriate for 

outpatient care

ED RN triages Veteran by 

clinical acuity

Appropriate for 

outpatient care

Patients are screened for 

homelessness

ED

Patients who screen “positive” are

offered an HPACT visit

Patient Declines

Patient Accepts

Homeless-PACT
HPACT Clinic Structure: Pittsburgh

11

Team that provided 

primary-care based 

addiction services

Adopted additional role of 

Homeless-PACT

• The existing addiction-focused primary care team 

referred empanelled Veterans who were homeless 

or at-risk for homelessness

• Other VA providers referred Veterans who were 

homeless or at-risk for homelessness who did not 

have a primary care provider
HPACT Clinic Structure: Birmingham

12

• New homeless-focused team physically located within a 

traditional VA primary care clinic

Patient 

recruitment

Health Care for Homeless Veterans 

program refers Veterans seeking housing 

who need primary care

Street- and shelter-based outreach

HPACT staff market the clinic to VA and 

non-VA services that work with 

homeless persons
Additional Clinic Characteristics

13

Los Angeles Pittsburgh Birmingham

Mental Health 

and 

Alcohol, Tobacco, 

and Other Drug 

(ATOD) Services

• Mental health 

clinical nurse 

specialist on team

• Specialty care 

referrals 

• PCPs with

addiction 

expertise and 

buprenorphine 

certification 

• Specialty care 

referrals 

• Psychiatrist 

within HPACT 

• Specialty care 

referrals 

• All clinics employed a mix of open-access (drop-in) and 

scheduled appointments

• Across sites, primary care providers (PCPs) were 

chosen for their expertise in homeless populations
Demographics

14

Los Angeles 

(n = 47)

Pittsburgh 

(n = 43)

Birmingham 

(n = 35)

Males 94% 95% 94%

Age (mean) 53 years 53 years 52 years

White 49% 53% 34%

African 

American

45% 42% 66%

Hispanic 17% 0% 2%

Other or 

Unknown

4% 5% 0%
Housing Status (Baseline  6 months)

15

Los Angeles 

(n = 47)

Pittsburgh 

(n = 43)

Birmingham 

(n = 35)

Unsheltered 

Homeless 

26%  9% 2%  2% 6%  6%

Sheltered 

Homeless

68%  85% 72%  77% 88%  77%

Housed 6%  6% 26%  21% 6%  17%

• Los Angeles had high numbers of unsheltered homeless

patients, many became sheltered homeless patients

• Pittsburgh had many patients at-risk for homelessness

who lost their housing but obtained other shelter

• Birmingham saw gains in the number of housed patients
Selected Chronic Medical Conditions

16

Los Angeles 

(n = 47)

Pittsburgh 

(n = 43)

Birmingham 

(n = 35)

Chronic Pain 30% 12% 51%

Diabetes 20% 5% 20%

Dyslipidemia 29% 9% 29%

Hepatitis C 17% 33% 17%

Hypertension 46% 51% 46%
Selected Mental Health and ATOD 

Diagnoses

Los Angeles 

(n = 47)

Pittsburgh 

(n = 43)

Birmingham 

(n = 35)

Mood 

disorders 

55% 42% 49%

Psychotic 

disorders 

19% 7% 0%

Alcohol use 

disorder 

35% 44% 60%

Cocaine use 

disorder 

19% 23% 37%

Opioid use 

disorder 

6% 21% 9%

17
VA Healthcare Utilization (6 Months Before 

HPACT  First 6 Months of HPACT)

Los Angeles 

(n = 47)

Pittsburgh 

(n = 43)

Birmingham 

(n = 35)

Emergency 

Department / 

Urgent Care

62%  70% 47%  26% 46%  29%

Mental health

medication 

management

39%  56% 56%  64% 60%  60%

ATOD

treatment

9%  37% 47%  19% 34%  34%

18

• At Pittsburgh and Birmingham there was a decrease in

ED/Urgent Care use

• At Los Angeles and Pittsburgh, more patients grew

engaged in mental health care
Limitations

• Limited longitudinal outcome data on a

small sample size (ongoing)

• Reliance on VA medical record review

• Differences in community context

(available non-VA resources, size of

homeless population) are important

but not included in this initial

exploration of data

19
Conclusions 

•Contrasting organizational structures were 

reflected in patient characteristics and changes in 

housing/VA health service use

. Los Angeles • Co-located with Emergency Department (ED) 

Highest rates of unsheltered patients, persons with 

psychotic disorders, prior ED use

Many patients became sheltered and engaged in 

substance abuse/mental health care

Grew from an addiction-focused team

Highest rates of opioid use disorder, Hepatitis C

Saw decrease in ED use

When patients lost housing, they stayed sheltered

Employed community-based outreach

Highest number of patients from emergency shelters

Many patients became housed and used the ED less 2 

•

•

Pittsburgh •

•

•

•

Birmingham •

•

•
Acknowledgements

• Special thanks to the many dedicated HPACT clinicians

and support staff at Los Angeles, Pittsburgh, and

Birmingham

• This work was supported by the VA Office of Patient Care

Services and the use of facilities at the Birmingham VA

Medical Center; the VA Greater Los Angeles; and the VA

Pittsburgh Healthcare System

21
Women Veterans’ Experience 

With Intimate Partner Violence

Melissa E. Dichter, PhD, MSW

Center for Health Equity Research and Promotion

Philadelphia VA Medical Center

HSR&D Cyber Seminar

November 20, 2013

Funding: CEPACT #12-005; HSR&D CDA #10-202
Earlier cyber seminars addressing IPV (SoWH) 

The Complex Dynamics of Intimate Partner Violence in the 

Lives of Veterans

April Gerlock, 11/17/2011

Intimate Partner Violence: An Overview for the VA Clinician

Megan Gerber, 11/27/2012

Clinical Utility of an Intimate Partner Violence Screening Tool 

for Female VA Patients

Kate Iverson, 2/13/2013

All available at: http://www.hsrd.research.va.gov/cyberseminars/catalog-search.cfm
Poll Question #1

How knowledgeable do you feel you are about IPV?

 I am an expert in this area

 I have extensive knowledge in this area but am not an expert

 I have a pretty good awareness of the issues

 I know a little bit about IPV

 I do not know much about IPV

 I do not know anything about IPV
Background: Intimate partner violence (IPV)

• IPV includes:

• Physical violence (hitting, punching, stabbing)

• Psychological violence (threatening, belittling)

• Social violence (isolating, alienating, economically restricting)

• Sexual violence (forced or coerced sexual behavior)

• Stalking or harassment (following, spying, sending repeated unwanted messages, refusing

to stay away)

• IPV can be perpetrated by a current or former romantic or sexual partner

• More than 1 in 3 women in the United States experience physical violence, rape, or stalking by

an intimate partner in their lifetimes; women Veterans are at particular risk

• IPV is a major source of morbidity and mortality for women and is associated with:

• A wide variety of acute and chronic physical and mental health problems

• Social/economic impacts (financial insecurity, homelessness, unemployment)

• Social/health risks (suicide/suicidal ideation, homicide, substance misuse, unplanned

pregnancies)
“IPV assessment and response within the PACT 

model: Needs, barriers, and opportunities”

Funding: VISN 4 Center for Evaluation of Patient Aligned Care Teams (CEPACT 12-005) 

Aims 

1) To identify the scope of IPV experiences, and associated healthcare needs, among

women Veterans receiving VHA care

2) To identify the opportunities and options for IPV assessment and care in the VHA

setting under the PACT model

Methods

• Phase I: face-to-face surveys with women Veteran patients at Philadelphia VA Medical

Center (N = 249)

• Phase II: face-to-face qualitative interviews with 10% of Phase I participants (N = 25)

• Phase III: telephone qualitative interviews with VISN 4 clinicians (PCPs, GYNs, WVPMs,

MST Coordinators, MH providers, SWs)
Sample demographics – patients

Demographic Characteristics Survey (Phase I)

(N = 249)

Interview (Phase II)

(N = 25)

Age: Range (Mean) 22-64 (46.6) 22-58 (42.8)

Race/Ethnicity: % Black/African American 69.4 54.2

White/Caucasian 13.3 19.0

Hispanic/Latina 8.1 19.0

Other/Mixed 9.3 9.5

Education: % No College 19.0 23.8

Some College (No Degree) 37.9 38.1

Associates or Bachelors Degree 43.1 38.1

Employment: % Full-time 23.3 14.3

Part-time 14.9 14.3

Not Employed 61.8 71.4

Financial Situation: % Can’t make ends meet 29.8 33.3

Have just enough to get by 46.4 52.4

Are comfortable 23.8 14.3
IPV Experience (%)

*IPV questions taken from CTS2S (Straus & Douglas, 2004)
Timing of IPV Experience Relative to Military Service

Before During After

Any 40.5 58.9 67.2

Psychological 36.7 54.4 60.7

Physical 16.9 26.5 37.3

Sexual 11.2 18.1 20.9

0

10

20

30

40

50

60

70

80
Poll Question #2

For clinicians (current or former), have you ever asked a patient 

about experiences with IPV?

 Yes, I routinely screen patients for experience of IPV

 Yes, I have asked patients about IPV but do not routinely screen

 No, I have never asked a patient about IPV

 I have never worked as a clinician
Has a healthcare provider ever asked you about safety, 

violence, or stress in your relationship or with an intimate 

partner?

Yes: 55%

No: 45%

36 

14 

30 

0

20

40

60

80

100

PCP Gynecologist Mental Health

Percent who had been asked, by 

provider type (not mutually 

exclusive)
Have you ever told a healthcare provider about violence or 

safety concerns you were having in an intimate relationship?

12 

3 

21 

0

20

40

60

80

100

PCP Gynecologist Mental Health

Percent who had told,

by provider type (not mutually 

exclusive) Yes: 27%

No: 73%
Do you feel that healthcare providers should ask about 

safety, violence, or stress in intimate relationships?

Yes: 83%

No: 6%

Not Sure / Don’t Know / Depends: 11%

• Reason for visit

• Patient signs of violence or abuse (“red flags”)

• Patient-provider relationship, provider sensitivity
ASKING AND DISCLOSING:

PATIENT AND PROVIDER PERSPECTIVES
Ask!

Asking facilitates disclosure

No one ever asked me about it. You know, I was walking around 

with a black eye and not a single question. So I may have talked 

about it if I had been given the chance, but I wasn’t going to bring 

it up on my own.
Ask again!

Patients may not be ready to disclose the first 

(or second) time they are asked

I said “no” because I didn’t feel 

like talking about it. At that time, 

I wasn’t ready to talk about it or 

get in to it with anybody. There 

were a lot of things I didn’t tell 

her when I first started seeing 

her. But once you get to know a 

person and you know the doctor, 

you can start opening up and 

saying different stuff.

What I always feel is that by 

asking the questions each time, 

that the patient will know that 

this is a safe environment in 

which they can discuss these 

types of things. And they may 

not do it the first five times, but 

they might do it the sixth time.
Make it safe to disclose

Decisions to disclose may depend on comfort with provider

If you feel comfortable with 

your doctors, you can pretty 

much talk to them about 

anything. But if you don’t feel 

comfortable with a certain 

doctor that you have, you’ll 

never tell them anything.

I’ve had people disclose to me 

and they said they’ve never 

told anybody else. And if I look 

back and say, “Why is that?” I 

think it’s because they know 

I’m listening.
Even if a patient doesn’t disclose...

Asking shows you care

If you’re not ready to tell, but you see that question, you know 

that they care and they’re interested, and they may be able to 

help. It’s like a signal that this is something we care about here.

It’s nice that somebody actually cares about stuff other than your 

blood pressure. 
Benefits of disclosure

Disclosure, itself, may be a therapeutic intervention

If I could have spilled my beans a long time ago when I started 

coming here, I definitely would have, and I think that would have 

made me feel so much better. Just to be able to talk, it probably 

would have prevented me from, you know, wanting to harm 

myself, if I felt like I had somebody to talk to. And I know I guess 

they're busy and they got to hurry up and see us and hurry up and 

get us out, but just that little talk, just the, you know – to speak 

with someone, it helps. It goes a long way. 
RESPONDING TO DISCLOSURE:

PROVIDER PERSPECTIVES ON THE VHA/PACT MODEL
What to do when they say “yes”?

I think the scariest things is, if I ask the question, she says ‘yes’ 

and then we don’t have anything to offer her, well, how horrible is 

that for both of us? 

You know, there’s not really back-up systems in place if somebody 

is seeing their primary care provider and they disclose, “Yes, my 

boyfriend is actively beating me up,” you know, do they have 

somebody to call? Do they have resources at their fingertips to 

say, “Hey, help me with figuring out what to do here”? Do they 

know resources within the VA who they can call and send them 

to? I don’t know. 
VA-specific considerations: Barriers

• Policies of permitting family members/others in exam rooms

• Concern about attributing PTSD/other conditions to non-military IPV 

(C&P exams)

• Utilization of community-based services

In the private sector you’re kind-of in the community so you’re referring 

naturally into the community immediately. But in VA, you know, we kind-of 

only refer to ourselves. There are several restrictions, or bureaucracy. 

Getting through that sometimes can be a mine field. You know, and then we 

may lose that opportunity to effect change for that female that has 

expressed the need or at least showed us that she has a need.
Opportunities with the PACT model

• Holistic, patient-centered care

• Team-based approach

• Strength: availability of SW and MH

• Potential limitation: less confidentiality for the patient (multiple team members)

• Integration of care

A good social worker or a well-trained RN, at that level of their license, 

should be able to more effectively either talk to [the patients] about a 

screening or to really do some in-depth counseling work with them. So 

the social worker perhaps more on the counseling intervention side, 

or, you know, a good RN with good training can do more of a little bit 

of an in-depth screening.”
VA PACT Model: Integration of care
Conclusions

• WV VHA patients experience high rates of IPV – before, during, and after 

military service

• Healthcare providers can help patients through asking about IPV and 

connecting patients with services

• Inquiry about IPV should be repeated and conducted in a sensitive manner, 

in a setting safe for a patient to disclose

• Resources, protocols, and education needed to support providers 

encountering patients who have experienced IPV

• The PACT model may be used to facilitate IPV inquiry and support
Reading and Resources

National survey data: Black, M., Basile, K. C., Breiding, M. J., Smith, S. G., Walters, M. L., Merrick, M. T., Chen, J., & Stevens, 

M. R. (2011). The National Intimate Partner and Sexual Violence Survey: 2010 summary report. Atlanta, GA: National Center 

for Injury Prevention and Control, Centers for Disease Control and Prevention.

Recent VA-based literature on experience of IPV

• Dichter, M. E., Cerulli, C., & Bossarte, R. M. (2011). Intimate partner violence victimization among women veterans and 

associated heart health risks. Women’s Health Issues, 21, S190-S194.

• Dichter. M. E., & Marcus, S. C. (2013). Intimate partner violence victimization among women veterans: Health, healthcare 

services use, and opportunities for intervention. Military Behavioral Health, 1: 107-113.

• Dichter, M. E., True, J. G., Marcus, S. C., Gerlock, A. A., & Yano, E. M. (2013). Documentation of intimate partner violence 

in women veterans’ medical records: An in-depth analysis. Military Behavioral Health, 1: 114-120.

• Iverson, K. M., King, M. W., Resick, P., Gerber, M. R., Kimerling, R., & Vogt, D. (2013). Clinical utility of an intimate partner 

violence screening tool for female VHA patients. Journal of General Internal Medicine, 28, 1288-1293.

• Iverson, K. M., Wells, S. Y., Wiltsey-Stirman, S., Vaughn, R., & Gerber, M. R. (2013). VHA primary care providers’ 

perspectives on screening female veterans for intimate partner violence: A preliminary assessment. Journal of Family 

Violence, 28, 823-831.

• Latta, R. E., & Horner-Johnson, W. (2013). Violence in the veteran home: Risk factors and implications for clinical care. 

Federal Practitioner: 10S-15S.

• Sweeney, A. C., Weitlauf, J. C., Manning, E. A., Sze, J. A., Waldrop, A. E., & Hasser, C. (2013). Intimate partner violence: 

Perspectives on universal screening for women in VHA primary care. Women’s Health Issues, 23: e73-e76.

Web-based resources

• IPV Screening and Counseling Toolkit from Futures without Violence: http://www.healthcaresaboutipv.org

• VA National Center for PTSD: http://www.ptsd.va.gov/public/pages/domestic-violence.asp

• VA Women’s Health: http://www.womenshealth.va.gov/WOMENSHEALTH/intimatepartnerviolence.asp

National Domestic Violence Hotline: 800-799-SAFE
THANK YOU!
Contact Information

Sonya Gabrielian, MD, MPH 

Sonya.Gabrielian@va.gov

Melissa Dichter, PhD, MSW

Melissa.Dichter@va.gov