title: Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans Health Administration's "Homeless Patient Aligned Care Team" Program.
abstract: BACKGROUND
  Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a "homeless medical home" initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites.
  
  
  METHODS
  We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services.
  
  
  RESULTS
  More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies.
  
  
  CONCLUSIONS
  Integrating social determinants of health into clinical care can be effective for high-risk homeless veterans.
authors.affiliation: National Center on Homelessness Among Veterans, Providence VA Medical Center, 830 Chalkstone Ave, Providence, RI 02909. Email: Thomas.OToole@va.gov.
authors.forename: Thomas P
authors.initials: TP
authors.lastname: O'Toole
authors.affiliation: The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island.
authors.forename: Erin E
authors.initials: EE
authors.lastname: Johnson
authors.affiliation: The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Aiello
authors.affiliation: The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island and Lebanon VA Medical Center, Lebanon, Pennsylvania.
authors.forename: Vincent
authors.initials: V
authors.lastname: Kane
authors.affiliation: The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island.
authors.forename: Lisa
authors.initials: L
authors.lastname: Pape
mesh_terms: D000368:Aged; D000553:Ambulatory Care / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006703:Ill-Housed Persons / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D018802:Patient-Centered Care / Q000706:statistics & numerical data; D064890:Social Determinants of Health; D014481:United States; D014493:United States Department of Veterans Affairs / Q000458:organization & administration*; D014728:Veterans / Q000706:statistics & numerical data*; D058014:Veterans Health / Q000592:standards*; D035862:Vulnerable Populations