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Homeless Veterans Patient Aligned Care Team (H-PACT)
Homeless Veterans Patient Aligned Care Team (H-PACT)
Background
Background
Background
Background
The Need for a Paradigm Shift
The Need for a Paradigm Shift
Homeless Patient Aligned Care Team
Homeless Patient Aligned Care Team
H-PACT Model
H-PACT Model
Health and Homelessness
Health and Homelessness
H-PACT Program
H-PACT Program
H-PACT Goals
H-PACT Goals
H-PACT Model for Treatment Engagement of Homeless Veteran
H-PACT Model for Treatment Engagement of Homeless Veteran
H-PACT Program
H-PACT Program
Data Snapshot
Data Snapshot
VISN
VISN
Anticipated outcomes
Anticipated outcomes
H-PACT and Community Partners
H-PACT and Community Partners
Questions
Questions

Презентация на тему: «Homeless Veterans Patient Aligned Care Team». Автор: Your User Name. Файл: «Homeless Veterans Patient Aligned Care Team.ppt». Размер zip-архива: 160 КБ.

Homeless Veterans Patient Aligned Care Team

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1 Homeless Veterans Patient Aligned Care Team (H-PACT)

Homeless Veterans Patient Aligned Care Team (H-PACT)

Office of Homeless Programs Office of Primary Care Operations

December 2012

2 Background

Background

Homeless Veterans have more chronic medical, mental health and substance abuse needs that are more difficult to treat in traditional care models and to coordinate within fragmented delivery systems. Transportation and scheduling challenges, competing priorities, and services not aligned with their needs keep many homeless Veterans from accessing primary care and receiving services necessary to exit homelessness. Homeless Veterans end up relying on emergency departments for care and are hospitalized at much higher rates than their housed counterparts. Homeless Veterans are three to six times more likely to become ill than housed people and cost three times more to care for than non-homeless Veterans.

3 Background

Background

Integrated Primary Care-Homeless Services care models tailored to the needs and specific challenges of homeless Veterans have been able to: Reduce emergency department use by up to 40% Reduce hospitalizations by 30-50% Improve chronic disease management outcomes Expedite housing placement and retention

4 The Need for a Paradigm Shift

The Need for a Paradigm Shift

How do we take advantage of health care seeking behavior and the “treatable moment” embedded in a health care episode? How can the resources and “safe haven” of the health care setting be used to break the cycle of homelessness and poor health?

5 Homeless Patient Aligned Care Team

Homeless Patient Aligned Care Team

Program goal is creating a collaborative Homeless Programs-Primary Care model that eliminates barriers to quality health care and improves health and housing outcomes of Veterans that are homeless or at imminent risk of homelessness. Not intended to replace care being provided or alter ongoing care relationships for those homeless Veterans engaged in treatment models (e.g. Severe Mental Illness (SMI), HIV care).

6 H-PACT Model

H-PACT Model

Three different homeless-oriented primary care PACT models will be supported by this initiative for local station implementation. Model adoption will be based on site-specific need, capacity, geography and targeted focus: Co-located, integrated Homeless PACT. PACT team enhanced with homeless case management. Community Resource and Referral Center (CRRC)-based Homeless outreach/PACT.

7 Health and Homelessness

Health and Homelessness

Housing Security for Homeless Persons

Health Care sites as “First Stops” for newly homeless

The health encounter as a “treatable moment” for behavior change and treatment engagement

Health maintenance and support as a means of keeping people in housing

8 H-PACT Program

H-PACT Program

H-PACT’s must be able to: Provide Accessible, Just-in-Time Continuity Care to homeless Veterans when and where they need it. Respond to the “Treatable Moment” with staff trained and prepared to engage patients in behavior change, and with resources in place to act on patient motivation. Create a care setting that promotes trust and relationship building necessary for longitudinal primary care and care coordination. Address competing social and sustenance needs of the Veteran trying to access health services. Employ a Rapid Engagement/Housing-First approach.

9 H-PACT Goals

H-PACT Goals

Deliverables: Systems redesign – Population-Centered Homeless PACTs: Rapid Access – Reduce barriers and obstacles to receiving care; bring homeless into care earlier in their homelessness. Sustained Engagement – Provide ongoing, longitudinal care that responds to changing needs, interests and readiness of the Veteran. Improved Clinical Outcomes for multi-morbid homeless Veterans Improved Quality of Life – Provide comprehensive chronic disease and preventive care to a traditionally disenfranchised group Greater Efficiencies in our care delivery system Care Offsets – Reduce emergency department and hospital use; increase primary care, outpatient mental health, and substance abuse treatment. Ending Veteran homelessness Housing placement/stabilization – Integrate clinical care with housing objectives; partner with housing staff and community agencies.

10 H-PACT Model for Treatment Engagement of Homeless Veteran

H-PACT Model for Treatment Engagement of Homeless Veteran

Disengaged/Disenfranchised from Care ? Treatment Engagement ? Stabilization Unstable sheltering Housing First Chronic disease management Significant barriers to treatment engagement Facilitated access/population tailored care Prevent recidivism Health Care low among Maslow Hierarchy of needs Care management of conditions Early identification new needs High rates of ED and inpatient care Leading to homelessness Premature morbidity/mortality Perpetuating homelessness Delayed and deferred because of homelessness Address competing needs

Intervention

Disposition

Identification and Referral

Homeless PACT Enhanced, open access Intensive case management Care tailored to population needs/de-stigmatizing care One-stop care – On-site addressing of competing sustenance needs

Homeless situation stabilized; transferred to general population PACT team w/ specialty care access

Emergency Departments

Inpatient Wards

Community outreach/ Agency referrals

Homeless situation stabilized; transferred to Special Population PACT based on patient need: SMI PACT Women’s Health PACT HIV PACT

Homeless situation not stabilized: Patient stays in Homeless PACT due to ongoing homelessness, imminent risk of return to homelessness

11 H-PACT Program

H-PACT Program

Implementation Update 37 sites funded to develop H-PACTs 19 VISNs, 24 states, 20 in high impact/high volume cities, 7 in rural communities Active engagement from Primary Care, Homeless and Mental Health programs

12 Data Snapshot

Data Snapshot

30 H-PACT sites are actively seeing homeless Veterans. Over 4000 patients enrolled to date. Anticipated approximately 10,000 will be enrolled by end of FY 2013. H-PACT enrollment increasing by approximately 400 Veterans per month. Most Veterans will stay in the H-PACT 12 to 18 months, depending on individual circumstances, preferences.

21 August 2015

13 VISN

VISN

Station

VISN

Station

VISN

Station

VISN

Station

1

Providence VAMC

4

Philadelphia VAMC

10

Chalmers P. Wylie VAMC (Columbus)

20

VA Puget Sound HCS (Seattle)

1

VA Connecticut Healthcare System (West Haven)

4

VA Pittsburgh HCS

11

Battle Creek VAMC

20

Portland VAMC

1

VA Maine HCS (Togus)

5

VA Maryland HCS (Baltimore)

11

John D. Dingell VAMC (Detroit)

21

VA Northern California HCS

1

VA Boston HCS (Causeway Street CBOC)

5

Washington DC VAMC

12

Jesse Brown VAMC (Chicago)

21

VA Pacific Islands HCS (Honolulu)

1

Leeds VA Primary Care Center (New Bedford)

6

Hampton VAMC

16

Micheal E. DeBakey VAMC (Houston)

21

San Francisco VAMC

2

Canandiagua VAMC

7

Ralph H. Johnson VAMC (Charleston)

16

Southeast Louisiana Veterans HCS (New Orleans)

22

VA San Diego HCS

3

Northport VAMC

7

Birmingham VAMC

17

South Texas Veterans HCS (San Antonio)

22

VA Greater Los Angeles HCS

3

James J. Peters VAMC (Bronx)

8

James A. Haley VAMC (Tampa)

18

Phoenix VA HCS

22

VA Southern Nevada HCS

3

VA Hudson Valley HCS (Montrose)

9

Lexington VAMC

19

VA Eastern Colorado HCS (Denver)

23

Minneapolis VA HCS

23

Iowa City VA HCS

13

14 Anticipated outcomes

Anticipated outcomes

Reduced emergency department visits, hospital admissions Increased ambulatory care use (primary care, specialty, mental health, addictions) Expedited housing/reduced recidivism Improved chronic disease monitoring/management Enhanced care, cost-efficiencies

21 August 2015

15 H-PACT and Community Partners

H-PACT and Community Partners

Referral source Development of partnerships Collaborative effort to serve homeless Veterans

15

16 Questions

Questions

For more information please contact: Rico Aiello, H-PACT Project Coordinator Riccardo.aiello@va.gov

16

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