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Homeless Veterans Patient Aligned Care Team

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1Homeless Veterans Patient Aligned Care 9mental health, and substance abuse
Team (H-PACT). Office of Homeless Programs treatment. Ending Veteran homelessness
Office of Primary Care Operations. Housing placement/stabilization –
December 2012. Integrate clinical care with housing
2Background. Homeless Veterans have objectives; partner with housing staff and
more chronic medical, mental health and community agencies.
substance abuse needs that are more 10H-PACT Model for Treatment Engagement
difficult to treat in traditional care of Homeless Veteran
models and to coordinate within fragmented Disengaged/Disenfranchised from Care ?
delivery systems. Transportation and Treatment Engagement ? Stabilization
scheduling challenges, competing Unstable sheltering Housing First Chronic
priorities, and services not aligned with disease management Significant barriers to
their needs keep many homeless Veterans treatment engagement Facilitated
from accessing primary care and receiving access/population tailored care Prevent
services necessary to exit homelessness. recidivism Health Care low among Maslow
Homeless Veterans end up relying on Hierarchy of needs Care management of
emergency departments for care and are conditions Early identification new needs
hospitalized at much higher rates than High rates of ED and inpatient care
their housed counterparts. Homeless Leading to homelessness Premature
Veterans are three to six times more morbidity/mortality Perpetuating
likely to become ill than housed people homelessness Delayed and deferred because
and cost three times more to care for than of homelessness Address competing needs.
non-homeless Veterans. Intervention. Disposition. Identification
3Background. Integrated Primary and Referral. Homeless PACT Enhanced, open
Care-Homeless Services care models access Intensive case management Care
tailored to the needs and specific tailored to population
challenges of homeless Veterans have been needs/de-stigmatizing care One-stop care –
able to: Reduce emergency department use On-site addressing of competing sustenance
by up to 40% Reduce hospitalizations by needs. Homeless situation stabilized;
30-50% Improve chronic disease management transferred to general population PACT
outcomes Expedite housing placement and team w/ specialty care access. Emergency
retention. Departments. Inpatient Wards. Community
4The Need for a Paradigm Shift. How do outreach/ Agency referrals. Homeless
we take advantage of health care seeking situation stabilized; transferred to
behavior and the “treatable moment” Special Population PACT based on patient
embedded in a health care episode? How can need: SMI PACT Women’s Health PACT HIV
the resources and “safe haven” of the PACT. Homeless situation not stabilized:
health care setting be used to break the Patient stays in Homeless PACT due to
cycle of homelessness and poor health? ongoing homelessness, imminent risk of
5Homeless Patient Aligned Care Team. return to homelessness.
Program goal is creating a collaborative 11H-PACT Program. Implementation Update
Homeless Programs-Primary Care model that 37 sites funded to develop H-PACTs 19
eliminates barriers to quality health care VISNs, 24 states, 20 in high impact/high
and improves health and housing outcomes volume cities, 7 in rural communities
of Veterans that are homeless or at Active engagement from Primary Care,
imminent risk of homelessness. Not Homeless and Mental Health programs.
intended to replace care being provided or 12Data Snapshot. 30 H-PACT sites are
alter ongoing care relationships for those actively seeing homeless Veterans. Over
homeless Veterans engaged in treatment 4000 patients enrolled to date.
models (e.g. Severe Mental Illness (SMI), Anticipated approximately 10,000 will be
HIV care). enrolled by end of FY 2013. H-PACT
6H-PACT Model. Three different enrollment increasing by approximately 400
homeless-oriented primary care PACT models Veterans per month. Most Veterans will
will be supported by this initiative for stay in the H-PACT 12 to 18 months,
local station implementation. Model depending on individual circumstances,
adoption will be based on site-specific preferences. 21 August 2015.
need, capacity, geography and targeted 13VISN. Station. VISN. Station. VISN.
focus: Co-located, integrated Homeless Station. VISN. Station. 1. Providence
PACT. PACT team enhanced with homeless VAMC. 4. Philadelphia VAMC. 10. Chalmers
case management. Community Resource and P. Wylie VAMC (Columbus). 20. VA Puget
Referral Center (CRRC)-based Homeless Sound HCS (Seattle). 1. VA Connecticut
outreach/PACT. Healthcare System (West Haven). 4. VA
7Health and Homelessness. Housing Pittsburgh HCS. 11. Battle Creek VAMC. 20.
Security for Homeless Persons. Health Care Portland VAMC. 1. VA Maine HCS (Togus). 5.
sites as “First Stops” for newly homeless. VA Maryland HCS (Baltimore). 11. John D.
The health encounter as a “treatable Dingell VAMC (Detroit). 21. VA Northern
moment” for behavior change and treatment California HCS. 1. VA Boston HCS (Causeway
engagement. Health maintenance and support Street CBOC). 5. Washington DC VAMC. 12.
as a means of keeping people in housing. Jesse Brown VAMC (Chicago). 21. VA Pacific
8H-PACT Program. H-PACT’s must be able Islands HCS (Honolulu). 1. Leeds VA
to: Provide Accessible, Just-in-Time Primary Care Center (New Bedford). 6.
Continuity Care to homeless Veterans when Hampton VAMC. 16. Micheal E. DeBakey VAMC
and where they need it. Respond to the (Houston). 21. San Francisco VAMC. 2.
“Treatable Moment” with staff trained and Canandiagua VAMC. 7. Ralph H. Johnson VAMC
prepared to engage patients in behavior (Charleston). 16. Southeast Louisiana
change, and with resources in place to act Veterans HCS (New Orleans). 22. VA San
on patient motivation. Create a care Diego HCS. 3. Northport VAMC. 7.
setting that promotes trust and Birmingham VAMC. 17. South Texas Veterans
relationship building necessary for HCS (San Antonio). 22. VA Greater Los
longitudinal primary care and care Angeles HCS. 3. James J. Peters VAMC
coordination. Address competing social and (Bronx). 8. James A. Haley VAMC (Tampa).
sustenance needs of the Veteran trying to 18. Phoenix VA HCS. 22. VA Southern Nevada
access health services. Employ a Rapid HCS. 3. VA Hudson Valley HCS (Montrose).
Engagement/Housing-First approach. 9. Lexington VAMC. 19. VA Eastern Colorado
9H-PACT Goals. Deliverables: Systems HCS (Denver). 23. Minneapolis VA HCS. .
redesign – Population-Centered Homeless . . . . . 23. Iowa City VA HCS. 13.
PACTs: Rapid Access – Reduce barriers and 14Anticipated outcomes. Reduced
obstacles to receiving care; bring emergency department visits, hospital
homeless into care earlier in their admissions Increased ambulatory care use
homelessness. Sustained Engagement – (primary care, specialty, mental health,
Provide ongoing, longitudinal care that addictions) Expedited housing/reduced
responds to changing needs, interests and recidivism Improved chronic disease
readiness of the Veteran. Improved monitoring/management Enhanced care,
Clinical Outcomes for multi-morbid cost-efficiencies. 21 August 2015.
homeless Veterans Improved Quality of Life 15H-PACT and Community Partners.
– Provide comprehensive chronic disease Referral source Development of
and preventive care to a traditionally partnerships Collaborative effort to serve
disenfranchised group Greater Efficiencies homeless Veterans. 15.
in our care delivery system Care Offsets – 16Questions? For more information please
Reduce emergency department and hospital contact: Rico Aiello, H-PACT Project
use; increase primary care, outpatient Coordinator Riccardo.aiello@va.gov. 16.
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Homeless Veterans Patient Aligned Care Team

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