VA Homelessness: Homeless Patient Aligned Care Teams
In 2016, nearly 40,000 veterans were homeless on a given night in January, with 13,000 living in the streets.1
Homelessness often has a direct impact on physical, emotional, and mental health status, and further exacerbates pre-existing health problems.2,3 Many people experiencing homelessness suffer from other pre-existing conditions, such as post-traumatic stress disorder, mental illness, alcohol and/or substance abuse, or have co-occurring disorders.4 Veterans who are homeless are more likely to have complex medical conditions and more likely to have limited access to care, which compounds the issue.
Many of those that experience homelessness rely on fragmented, costly care from emergency departments or through hospital admittance. Although urgent care may triage an immediate need, the absence of primary care and the lack of followup create care management problems, leading to increased reliance on the emergency department. Therefore, this care model often proves ineffective, with about 20 percent of veterans treated in urgent care settings returning to the emergency department or hospitalized within 30 days.5
About Homeless Patient Aligned Care Teams
In 2010, the United States Interagency Council on Homelessness (USICH) launched Opening Doors, a Federal strategic plan to prevent and end homelessness, a key provision of which was the implementation of a Five Year Plan to End Homelessness Among Veterans. In response to this national effort, the Department of Veterans Affairs (VA) founded the National Center on Homelessness among Veterans, which, among other functions, is responsible for piloting new and innovative models within VA. The VA Homeless Patient Aligned Care Team (H-PACT) began as a 32-site pilot project in the VA National Center on Homelessness. The H-PACT is similar to the Health Care for the Homeless program sponsored by the Health Resources and Service Administration, and is an adaptation of the VA patient-centered medical home framework, enhanced by various elements of this specific to the VA. Various elements include the VA’s integrated national care model, electronic medical record as well as inclusion of housing and benefits within a health care delivery model.
The goal of H-PACT is to create a collaborative homeless medical home model eliminating barriers and obstacles to accessing quality health care by incorporating social determinants of health into care delivery, and to fast-track permanent housing placement. H-PACT measures its outcomes and results through ongoing data tracking and evaluation. Results show improved health access, patient engagement, and housing outcomes for veterans who are homeless or at imminent risk of homelessness. Veterans enrolled in H-PACT gained housing 81.1 days faster than those not enrolled in an H-PACT.6 Additionally, the H-PACT program contributed to reducing costs to the health system providing care for veterans. Care at an H-PACT costs almost $10,000 less per veteran per year, compared to a homeless veteran enrolled in a VA general population primary care clinic, driven largely by fewer hospitalizations in the VA and the community.7
There are currently 61 active H-PACT teams around the country with plans to expand imminently.
Overview of Activities
H-PACTs co-locate medical staff, social workers, mental health and substance use counselors, and other staff equipped to deal with homelessness in order to create a comprehensive “one-stop shop” to serve the complex set of health care and social needs of homeless and vulnerable veterans. Located at VA medical centers, community-based outpatient clinics, and community resource and referral centers around the country, H-PACT staff demonstrate special cultural competencies to understand homelessness, appreciate the background of veterans who are homeless, and contextualize their unique care needs.
Each H-PACT is person-centered and tailored to meet the needs of the local community of homeless veterans it serves. H-PACTs provide co-located, wraparound health care and social services ranging from onsite addiction treatment and integrated mental health care, street outreach to community shelters, and coordination with local emergency departments to engage veterans in care. Many H-PACTs also provide donation-based food and clothing pantries, hygiene kits, showers, and onsite laundry facilities, allowing Veterans to address multiple needs in one location. This “open-access” model allows homeless and at-risk veterans to receive primary care and housing services with no appointment needed. To be truly comprehensive, H-PACTs also actively engage and work with VA housing specialists, community partners, agencies, and shelters where homeless veterans stay. For example, veterans treated at the H-PACT in Philadelphia, Pennsylvania, receive public transportation tokens donated by a local church in addition to housing placement assistance and meals. Another H-PACT in Providence, Rhode Island, co-hosts a coat giveaway each winter with a local community organization.
Care teams at each site consist of a primary care provider, a registered nurse, social workers, and VA homeless program staff. This team integrates and coordinates care with mental health and substance abuse treatment providers, as well as an array of other programs and disciplines from nutrition to podiatry to assist veterans in navigating a complex health care system. A 23-item checklist of core elements is provided to H-PACT teams by the national office to ensure fidelity across the diverse VA settings. H-PACT teams receive significant national support from the VA program office, including technical assistance, monitoring of outcomes and performance, and assistance in developing quality improvement efforts.
Though H-PACT services are intended for the most challenging and complex cases and patients that are most difficult to engage in care—such as those who have multiple morbidities, have difficulty keeping scheduled appointments, make multiple visits to the emergency department, or have underlying mental health or substance abuse needs—not all veterans experiencing homelessness need this level of care. All H-PACT teams are expected to develop a locally defined strategy to determine which veterans they are going to seek out and engage in care within an H-PACT and how they can effectively engage them into care. This is intentionally a locally determined process meant to be adaptable to and reflect the dynamics and needs at each site.
By recognizing that the complexity of homelessness requires an integrated, individualized care delivery system, the H-PACT program can deliver comprehensive care specifically tailored to the needs of these veterans with complex, multifaceted health care needs. The goal is to provide a care alternative to the emergency department that is more suited to meet the unique health needs of a veteran experiencing homelessness, while addressing root-causes for why they are homeless. The result is a care model that increases both efficiency and quality of care, and decreases reliance on the emergency room or hospital for care.8
In 2016, roughly 25,000 veterans used H-PACT’s services, and more than 96 percent of those veterans currently enrolled in an H-PACT also received VA homeless services. A study published in Preventing Chronic Disease of 33 H-PACT sites with at least 3 years of operating experience found that 82 percent provided hygiene care (onsite showers, hygiene kits, and laundry); 76 percent provided transportation; 55 percent had an onsite clothes pantry; and 42 percent had a food pantry and provided onsite meals or other food assistance—allowing H-PACT to provide all-encompassing, tailored health and health care services.9
Over the last 7 years, roughly 70 percent of H-PACT enrollees graduated from the program into a regular primary care setting once their situation stabilized and they were able to find permanent housing.
Through 2015, the program also reduced both emergency department use and hospitalizations by 25 percent among its target population.10
The care H-PACTs provide helps veterans who are homeless to obtain and maintain permanent housing, which is a major factor in reduction of emergency department use and hospitalizations and improvement of chronic disease management among the population.11 Ensuring this housing stability means that the program helped contribute to the significant strides toward meeting the goals of the VA’s Five Year Plan to End Veteran Homelessness; the number of veterans experiencing homelessness has been cut nearly in half since 2010.12 Additionally, HUD’s annual estimate of America’s homeless population found that the number of homeless veterans dropped by more than 8,000 people, a decrease of 17 percent, from just January 2015 to January 2016.13
The H-PACT program represents one of several innovations and efforts within VA to address veteran homelessness. Together, they have contributed to the substantial drop in veteran homelessness since 2010. In 2010, veterans comprised 13 percent of sheltered homeless adults and 16 percent of homeless adults,14 and an estimated 144,842 veterans spent at least one night homeless, living in emergency shelters or transitional housing units. On just one night in January 2010, a survey of the homeless population identified 76,329 veterans who were homeless.15 The 2016 Annual Homeless Assessment Report to Congress found that homelessness among veterans had been reduced by an estimated 47 percent, or nearly 35,000 people, since 2010.16 USICH also stated that unsheltered homelessness has fallen by 56 percent since 2010.17
Alignment to the National Quality Strategy
The H-PACT program promotes care coordination, effective prevention and treatment, and care affordability through the levers of learning and technical assistance and workforce development.
For more information about the VA National Center on Homelessness Among Veterans’ Homeless Patient Aligned Care Teams (H-PACT), contact Thomas O’Toole, the Director of VA National Center on Homelessness among Veterans and the National Director of H-PACT, at Thomas.O’Toole@va.gov, or Erin Johnson, the H-PACT Program Coordinator, at Erin.Johnson4@va.gov.
2 Goodman, L. A., Saxe, L., & Harvey, M. (1991). Homelessness as psychological trauma: Broadening perspectives. American psychologist, 46(11), 1219.
5 Hastings, S. N., Smith, V. A., Weinberger, M., Schmader, K. E., Olsen, M. K., & Oddone, E. Z. (2011). Emergency department visits in Veterans Affairs medical facilities. The American journal of managed care, 17(6 Spec No.), e215-23.
9 O’Toole TP, Johnson EE, Aiello R, Kane V, Pape L. Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: the Veterans Health Administration’s “Homeless Patient Aligned Care Team” Program. Prev Chronic Dis 2016;13:150567.
12 U.S. Department of Housing and Urban Development (2016). Obama Administration Announces Nearly 50 Percent Decline In Veteran Homelessness [Press release]
13 U.S. Department of Housing and Urban Development (2016). Obama Administration Announces Nearly 50 Percent Decline In Veteran Homelessness [Press release]
14 Khadduri, J., Culhane, D., Cortes, A., & Henry, M. (2010). Veteran homelessness: A supplemental report to the 2009 Annual Homeless Assessment Report to Congress. Washington, DC: Abt. Associates and the US Department of Veterans Affairs National Center on Homelessness Among Veterans.
15 Khadduri, J., Culhane, D., Cortes, A., & Henry, M. (2010). Veteran homelessness: A supplemental report to the 2009 Annual Homeless Assessment Report to Congress. Washington, DC: Abt. Associates and the US Department of Veterans Affairs National Center on Homelessness Among Veterans.