Building medical homes for homeless veterans: A comparison of organizational processes and patient characteristics at three veterans affairs facilities

BACKGROUND: Ending Veteran homelessness is a priority of the Veterans Administration (VA). Homeless Veterans have high rates of illness, low primary care utilization, and priorities that compete with healthcare. As a result, the VA launched an 18-month demonstration project to create Homeless-Patient Aligned Care Teams (HPACTs) – patient-centered medical homes (PCMH) for homeless Veterans – at 32 VA facilities. We compared the organizational and patient characteristics of newly implemented VA HPACTs in Birmingham, Los Angeles and Pittsburgh to facilitate quality improvement and inform other PCMH for vulnerable populations. METHODS: Clinic directors characterized their HPACTs along organizational parameters common to all PCMH and features particularly relevant to homeless Veterans. Demographic, diagnostic, and healthcare utilization information was abstracted from the medical record for all enrolled patients from May-September 2012. RESULTS: Each HPACT had distinct organizational features. Los Angeles' HPACT operated after-hours, was co-located with the Emergency Department, and had the highest percentage of unsheltered patients (26%). Birmingham's HPACT was co-located with primary care, outreached to community shelters, and attained the highest percentage of shelter-residing homeless patients (14%). Pittsburgh's HPACT developed from an existing PCMH for persons with addictive disorders, offered buprenorphine, and saw the highest percentage of patients with opioid misuse (21%). CONCLUSIONS: This comparison highlights how HPACT organizational differences impact the characteristics of patients served and suggests ways that primary care operations can be tailored for differing groups of homeless or persons with substance abuse, to improve care for this population.