Aligning Resources to Care for Homeless Veterans
Condition: Homeless Persons; Primary Health Care
Study type: Interventional

Summary: 
      "Aligning Resources to Care for Homeless Veterans" (ARCH) will study ways to best organize
      and deliver primary care for homeless Veterans. The investigators will assess 4 different
      adaptations of the PACT primary care model in a mixed methods study that includes
      multi-center, randomized-controlled trials of embedded peer-mentoring within different
      iterations of the PACT model, focus groups of study participants assessing satisfaction,
      treatment engagement and self-efficacy within the different care models and a cost-utility
      analysis to determine the most cost-efficient approach to organizing care for this
      population. Findings from this study will help determine optimal care approaches for reducing
      emergency department visits and acute hospitalizations, increasing patient satisfaction, and
      improving chronic disease management. Findings from this study will also substantively add to
      our understanding of health seeking behavior and the care of vulnerable/high-risk Veteran
      populations as well as clinical systems design. This project reflects a true "field-based
      study" to identify optimal and feasible approaches to patient care within our current VHA
      system. Finally, it will help inform pressing policy issues relevant to two identified T-21
      priority areas: Ending Veteran Homelessness in 5 Years and Transforming to a Patient Centered
      Primary Care model.
    

Detailed description: 
      Background:

      Primary care, and specifically primary care directed to homeless Veterans represents an
      opportunity to engage individuals in care, address unmet health needs and facilitate receipt
      of services necessary to exit homelessness. However, it is unclear what the best and most
      cost-efficient approach is to providing this care. Past research suggests two alternative
      approaches to organizing and delivering primary care to homeless Veterans: (1) structurally
      realigned and organized care and (2) embedded peer mentoring. The overall purpose of our
      research is to compare and contrast outcomes from 4 different adaptations and combinations of
      primary care delivery to homeless Veterans within the construct of the Patient Aligned Care
      Team (PACT) model for primary care.

      Objectives:

        1. To test whether a peer mentor intervention embedded in the Patient Aligned Care Team
           (PACT) model will be more effective than usual-care PACT or, in a separate randomized
           controlled trial, within a homeless-oriented PACT (H-PACT) model, in reducing emergency
           department use and hospitalizations, improving chronic disease management, and
           increasing participation in homeless programming.

        2. To compare clinical outcomes, service use, treatment engagement, self-efficacy, and
           patient satisfaction of participants in usual care-PACT with and without peer mentoring
           to H-PACT with and without peer mentoring.

        3. To determine differential costs and cost offsets associated with each PACT model
           adaptation in relation to care outcomes for homeless Veterans.

        4. To determine whether a structurally adapted health care delivery model for homeless
           Veterans (homeless PACT) affects treatment engagement, as measured by utilization of
           services over time, compared with assignment to a general population Patient Aligned
           Care Team or no primary care assignment.

      Methods:

      Substudy #1- Two multi-center Randomized Controlled Trials: The first comparing PACT to
      PACT+Peer Support (PACT+P); and the second comparing Homeless-oriented PACT (H-PACT) to
      H-PACT+Peer Support (H-PACT+P). Within each site we will conduct a 1:1 RCT of embedded peer
      support.

      Substudy #2- A qualitative study using focus groups of study participants from each of the
      intervention arms to assess perceptions of care, treatment engagement, and satisfaction
      within each approach. These findings will be triangulated with survey data and conditional
      logistic regression modeling to address the question of how each model is perceived by those
      receiving care within it and what outcomes can be ascribed to each care approach. This
      submission will occur at the end of Year 2 of the project and be specific for the focus group
      activities.

      Substudy #3- Cost-Utilization Analysis Study: We will conduct a cost-utilization analysis
      assessing cost offsets using CPRS, DSS, and PCMM labor mapping data to develop cost models
      for each care approach.

      Substudy #4- VINCI Data Extraction & Natural Language Processing: Use VINCI to analyze for
      PACT and H-PACT emergency department visits, including diagnosis, whether substance abuse was
      a factor, whether it resulted in a hospital admission, and what type of aftercare occurred
      (primary care follow-up, case manager telephone call note, etc.); hospital admissions
      (diagnosis, length of stay, and aftercare follow-up), ambulatory care utilization (primary
      care, mental health, specialty clinics, outpatient substance abuse treatment, and homeless
      programming - VRRC), including both face-to-face and remote-based care (My HealtheVet,
      telehealth, telephone notes), medication compliance with continuous prescriptions (i.e.
      insulin, antihypertensives), and chronic disease monitoring and management (blood pressure,
      diabetes care, hyperlipidemia in heart disease and diabetic patients). Baseline utilization
      (prior 6 months) of emergency department, inpatient and primary care prior to cohort tracking
      will be conducted to allow for post-hoc stratification of patient subgroups based on
      predicted risk for high use patterning.
    

Intervention name(s): Embedded Peer Mentor
Intervention type(s): Behavioral
Intervention description(s): This intervention/condition consists of a formerly homeless individual embedded in the PACT or H-PACT clinic team. This person is responsible for community-based follow-up for homeless patients randomly assigned to him or her. In addition to structured, scheduled meetings with assigned study subjects, the peer mentor will also participate in PACT/H-PACT team meetings and serve as a liaison between the study subject and his or her primary care team. Peer mentors will be hired as VA term employees in Research.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Care Provider)
Primary purpose: Health Services Research