Social Determinant of Health Clinical Care Implications

NCHV Annual Meeting

June 2016

Veteran Homelessness

Prior history of homelessness

Domestic Violence Unsuccessful Transition

from Military

Family Decompensation

Homeless Veterans Medical and Mental Health Conditions

Depressive Disorder 674 Arthritisjoint pain 533 Alcohol dependence 525 Drug abuse 419 Hypertension up to 452 Anxiety 369 Hepatitis up to 280 COPDEmphysema up to 173 Diabetes up to 93 Heart disease 71

Health and Homelessness Institute of Medicine 1988

Homelessness

Health conditions made

worse

by homelessness

Health conditions

caused by homelessness

Health conditions

causing

homelessness

Health and Homelessness

Homeless-Driven

Adverse Health Outcomes

Biologic

Accelerated AgingPremature Morbidity

Increased Cell Death Stress hormones Micronutrient

Malnutrition

Behavioral

Poor compliance due to

behavioral and substance use issues

competing sustenance needs

Environmental

High Risk

Environment

Inadequate care system

capacity to address

social determinants of health

Am J Public Health 1997 Feb87(2)217-20

Competing priorities as a barrier to medical care among homeless adults in Los Angeles Gelberg L1 Gallagher TC Andersen RM Koegel P Frequent subsistence difficulty appears to be an important nonfinancial barrier to the utilization of health services perceived as discretionary among homeless adults J Health Care Poor Underserved 2015 Aug26(3)1019-31 doi 101353hpu20150077

Needing Primary Care But Not Getting It The Role of Trust Stigma and Organizational Obstacles reported by Homeless Veterans OToole TP Johnson EE Redihan S Borgia M Rose J Reasons for delaying care fell into three domains 1) trust 2) stigma and 3) care processes Our findings support the importance of considering health access within an expanded framework that includes perceived stigma inflexible care systems and trust issues

Veteran Homelessness

Prior history of homelessness

Domestic Violence Unsuccessful Transition

from Military

Family Decompensation

Homeless Veterans Medical and Mental Health Conditions

Depressive Disorder 674 Arthritisjoint pain 533 Alcohol dependence 525 Drug abuse 419 Hypertension up to 452 Anxiety 369 Hepatitis up to 280 COPDEmphysema up to 173 Diabetes up to 93 Heart disease 71

Health and Homelessness Institute of Medicine 1988

Homelessness

Health conditions made

worse

by homelessness

Health conditions

caused by homelessness

Health conditions

causing

homelessness

Health and Homelessness

Homeless-Driven

Adverse Health Outcomes

Biologic

Accelerated AgingPremature Morbidity

Increased Cell Death Stress hormones Micronutrient

Malnutrition

Behavioral

Poor compliance due to

behavioral and substance use issues

competing sustenance needs

Environmental

High Risk

Environment

Inadequate care system

capacity to address

social determinants of health

Am J Public Health 1997 Feb87(2)217-20

Competing priorities as a barrier to medical care among homeless adults in Los Angeles Gelberg L1 Gallagher TC Andersen RM Koegel P Frequent subsistence difficulty appears to be an important nonfinancial barrier to the utilization of health services perceived as discretionary among homeless adults J Health Care Poor Underserved 2015 Aug26(3)1019-31 doi 101353hpu20150077

Needing Primary Care But Not Getting It The Role of Trust Stigma and Organizational Obstacles reported by Homeless Veterans OToole TP Johnson EE Redihan S Borgia M Rose J Reasons for delaying care fell into three domains 1) trust 2) stigma and 3) care processes Our findings support the importance of considering health access within an expanded framework that includes perceived stigma inflexible care systems and trust issues

Homeless Veterans Medical and Mental Health Conditions

Depressive Disorder 674 Arthritisjoint pain 533 Alcohol dependence 525 Drug abuse 419 Hypertension up to 452 Anxiety 369 Hepatitis up to 280 COPDEmphysema up to 173 Diabetes up to 93 Heart disease 71

Health and Homelessness Institute of Medicine 1988

Homelessness

Health conditions made

worse

by homelessness

Health conditions

caused by homelessness

Health conditions

causing

homelessness

Health and Homelessness

Homeless-Driven

Adverse Health Outcomes

Biologic

Accelerated AgingPremature Morbidity

Increased Cell Death Stress hormones Micronutrient

Malnutrition

Behavioral

Poor compliance due to

behavioral and substance use issues

competing sustenance needs

Environmental

High Risk

Environment

Inadequate care system

capacity to address

social determinants of health

Am J Public Health 1997 Feb87(2)217-20

Competing priorities as a barrier to medical care among homeless adults in Los Angeles Gelberg L1 Gallagher TC Andersen RM Koegel P Frequent subsistence difficulty appears to be an important nonfinancial barrier to the utilization of health services perceived as discretionary among homeless adults J Health Care Poor Underserved 2015 Aug26(3)1019-31 doi 101353hpu20150077

Needing Primary Care But Not Getting It The Role of Trust Stigma and Organizational Obstacles reported by Homeless Veterans OToole TP Johnson EE Redihan S Borgia M Rose J Reasons for delaying care fell into three domains 1) trust 2) stigma and 3) care processes Our findings support the importance of considering health access within an expanded framework that includes perceived stigma inflexible care systems and trust issues

Health and Homelessness Institute of Medicine 1988

Homelessness

Health conditions made

worse

by homelessness

Health conditions

caused by homelessness

Health conditions

causing

homelessness

Health and Homelessness

Homeless-Driven

Adverse Health Outcomes

Biologic

Accelerated AgingPremature Morbidity

Increased Cell Death Stress hormones Micronutrient

Malnutrition

Behavioral

Poor compliance due to

behavioral and substance use issues

competing sustenance needs

Environmental

High Risk

Environment

Inadequate care system

capacity to address

social determinants of health

Am J Public Health 1997 Feb87(2)217-20

Competing priorities as a barrier to medical care among homeless adults in Los Angeles Gelberg L1 Gallagher TC Andersen RM Koegel P Frequent subsistence difficulty appears to be an important nonfinancial barrier to the utilization of health services perceived as discretionary among homeless adults J Health Care Poor Underserved 2015 Aug26(3)1019-31 doi 101353hpu20150077

Needing Primary Care But Not Getting It The Role of Trust Stigma and Organizational Obstacles reported by Homeless Veterans OToole TP Johnson EE Redihan S Borgia M Rose J Reasons for delaying care fell into three domains 1) trust 2) stigma and 3) care processes Our findings support the importance of considering health access within an expanded framework that includes perceived stigma inflexible care systems and trust issues

Health and Homelessness

Homeless-Driven

Adverse Health Outcomes

Biologic

Accelerated AgingPremature Morbidity

Increased Cell Death Stress hormones Micronutrient

Malnutrition

Behavioral

Poor compliance due to

behavioral and substance use issues

competing sustenance needs

Environmental

High Risk

Environment

Inadequate care system

capacity to address

social determinants of health

Am J Public Health 1997 Feb87(2)217-20

Competing priorities as a barrier to medical care among homeless adults in Los Angeles Gelberg L1 Gallagher TC Andersen RM Koegel P Frequent subsistence difficulty appears to be an important nonfinancial barrier to the utilization of health services perceived as discretionary among homeless adults J Health Care Poor Underserved 2015 Aug26(3)1019-31 doi 101353hpu20150077

Needing Primary Care But Not Getting It The Role of Trust Stigma and Organizational Obstacles reported by Homeless Veterans OToole TP Johnson EE Redihan S Borgia M Rose J Reasons for delaying care fell into three domains 1) trust 2) stigma and 3) care processes Our findings support the importance of considering health access within an expanded framework that includes perceived stigma inflexible care systems and trust issues

Am J Public Health 1997 Feb87(2)217-20

Competing priorities as a barrier to medical care among homeless adults in Los Angeles Gelberg L1 Gallagher TC Andersen RM Koegel P Frequent subsistence difficulty appears to be an important nonfinancial barrier to the utilization of health services perceived as discretionary among homeless adults J Health Care Poor Underserved 2015 Aug26(3)1019-31 doi 101353hpu20150077

Needing Primary Care But Not Getting It The Role of Trust Stigma and Organizational Obstacles reported by Homeless Veterans OToole TP Johnson EE Redihan S Borgia M Rose J Reasons for delaying care fell into three domains 1) trust 2) stigma and 3) care processes Our findings support the importance of considering health access within an expanded framework that includes perceived stigma inflexible care systems and trust issues

Study Goals and Design

bull Describe characteristics of health care delivery that are associated with high rates of treatment engagement and improved clinic outcomes among homeless Veterans

bull Observational study of 33 VHA ldquoHomeless Medical Homesrdquo (HPACTs) evaluating care use by 3543 Veterans in 2013

VETERANS HEALTH ADMINISTRATION

H-PACT Mission

bull The mission of the HPACT is to identify and engage in care the highest-risk highest-need homeless veterans who are not able to get the care they need through traditional channels and provide high-intensity wrap-around integrated team care that stabilizes them clinically incorporates social determinants of health into their care delivery and expedites their placement in housing

bull Four tenets of the H-PACT model

ndash Open-access care that does not rely on scheduling processes that are not amenable to a homeless personsrsquo circumstances

ndash Wrap-around servicesincorporation of social determinants of health housing into the care modeltreatment plan

ndash Intensive case and care management with pre-emptivepredictive care modeling

ndash Dedicated staff with specific skill sets cultural competency

DisengagedDisenfranchised from Care

Unstable Sheltering Significant Treatment Barriers

Health Care Low Priority High Rate of ED amp Inpatient Care Premature MorbidityMortality

Treatment Engagement

Housing First Facilitated Access

Care Management of Conditions leading to and perpetuating

Homelessness Address Competing Needs

Stabilization

Chronic Disease Management Prevent Recidivism

Early Identification of New Needs

Disposition Intervention Identification

amp Referral

Emergency Departments

Inpatient Wards

Community Outreach amp

Referrals

Homeless PACT

Enhanced Open Access

Intensive Case Management

Designated staff with specialized training

One-Stop CareWrap

around services Addressing Competing

Needs

Homeless Situation Stabilized Transfer to general PACT team

with Specialty Care

Homeless Situation not Stabilized

Remain in H-PACT due to ongoing homelessnessrisk of

homelessness

Homeless Situation Stabilized Transfer to Special Population

PACT SMI PACT

Womens Health PACT HIV PACT

H-PACT MODEL FOR TREATMENT ENGAGEMENT

VETERANS HEALTH ADMINISTRATION

Results (2013)

High-Performing teams

(N-17)

gt30 reduction in ER

use (or)

gt20 reduction in

hospitalizations

Mid-performing

teams (N=9)

0-30 reduction in

ER use (or)

0-20 reduction in

hospitalizations

Low-Performing

teams (N=7)

Increase in ER

visits

hospitalizations

Access

Availability gt 20 hoursweek 765 (13) 625 (5) 500 (3)

After-hours careconsult

capacity

765 (13) 625 (5) 500 (3)

lt14 days to access MH 765 (13) 625 (5) 667 (4)

Multiple ways to access care 941 (16) 750 (6) 833 (5)

VETERANS HEALTH ADMINISTRATION

Results ndash contrsquod

Homeless-specific care

modeling

High-Performing site Mid-performing site Low -performing

site

Clinical protocols

Post ED hosp admission 588 (10) 750 (6) 500 (3)

Disease-specific care 529 (9) 500 (4) 333 (2)

Housing integrated into care

Part of HampP 941 (16) 100 (8) 833 (5)

Housing status tracking 824 (14) 750 (6) 500 (3) P=005

On-site social supports

Transportation 941 (16) 875 (7) 333 (2) Plt001

Food 647 (11) 250 (2) 167 (1) P=003

Clothes 765 (13) 375 (3) 333 (2) P=003

Community Integration

Clinical outreach 941 (16) 625 (5) 667 (4) P=003

Scheduled meetings 647 (11) 375 (3) 333 (2)

Community events 824 (14) 875 (7) 333 (2) P=001

VETERANS HEALTH ADMINISTRATION

Conclusions ndash Rethinking health care delivery beyond the medical model

Value-added elements

bull Incorporating on-site social services such as food clothing and hygiene care is associated with better health care for homeless Veterans

bull Community partnering ndash shared care management community outreach and co-hosting community events improves health outcomes for homeless Veterans

VETERANS HEALTH ADMINISTRATION

Acknowledgements

Project Team

Tom OrsquoToole

Erin Johnson

Riccardo Aiello

Vincent Kane

Lisa Pape

VETERANS HEALTH ADMINISTRATION

H-PACT Mission

bull The mission of the HPACT is to identify and engage in care the highest-risk highest-need homeless veterans who are not able to get the care they need through traditional channels and provide high-intensity wrap-around integrated team care that stabilizes them clinically incorporates social determinants of health into their care delivery and expedites their placement in housing

bull Four tenets of the H-PACT model

ndash Open-access care that does not rely on scheduling processes that are not amenable to a homeless personsrsquo circumstances

ndash Wrap-around servicesincorporation of social determinants of health housing into the care modeltreatment plan

ndash Intensive case and care management with pre-emptivepredictive care modeling

ndash Dedicated staff with specific skill sets cultural competency

DisengagedDisenfranchised from Care

Unstable Sheltering Significant Treatment Barriers

Health Care Low Priority High Rate of ED amp Inpatient Care Premature MorbidityMortality

Treatment Engagement

Housing First Facilitated Access

Care Management of Conditions leading to and perpetuating

Homelessness Address Competing Needs

Stabilization

Chronic Disease Management Prevent Recidivism

Early Identification of New Needs

Disposition Intervention Identification

amp Referral

Emergency Departments

Inpatient Wards

Community Outreach amp

Referrals

Homeless PACT

Enhanced Open Access

Intensive Case Management

Designated staff with specialized training

One-Stop CareWrap

around services Addressing Competing

Needs

Homeless Situation Stabilized Transfer to general PACT team

with Specialty Care

Homeless Situation not Stabilized

Remain in H-PACT due to ongoing homelessnessrisk of

homelessness

Homeless Situation Stabilized Transfer to Special Population

PACT SMI PACT

Womens Health PACT HIV PACT

H-PACT MODEL FOR TREATMENT ENGAGEMENT

VETERANS HEALTH ADMINISTRATION

Results (2013)

High-Performing teams

(N-17)

gt30 reduction in ER

use (or)

gt20 reduction in

hospitalizations

Mid-performing

teams (N=9)

0-30 reduction in

ER use (or)

0-20 reduction in

hospitalizations

Low-Performing

teams (N=7)

Increase in ER

visits

hospitalizations

Access

Availability gt 20 hoursweek 765 (13) 625 (5) 500 (3)

After-hours careconsult

capacity

765 (13) 625 (5) 500 (3)

lt14 days to access MH 765 (13) 625 (5) 667 (4)

Multiple ways to access care 941 (16) 750 (6) 833 (5)

VETERANS HEALTH ADMINISTRATION

Results ndash contrsquod

Homeless-specific care

modeling

High-Performing site Mid-performing site Low -performing

site

Clinical protocols

Post ED hosp admission 588 (10) 750 (6) 500 (3)

Disease-specific care 529 (9) 500 (4) 333 (2)

Housing integrated into care

Part of HampP 941 (16) 100 (8) 833 (5)

Housing status tracking 824 (14) 750 (6) 500 (3) P=005

On-site social supports

Transportation 941 (16) 875 (7) 333 (2) Plt001

Food 647 (11) 250 (2) 167 (1) P=003

Clothes 765 (13) 375 (3) 333 (2) P=003

Community Integration

Clinical outreach 941 (16) 625 (5) 667 (4) P=003

Scheduled meetings 647 (11) 375 (3) 333 (2)

Community events 824 (14) 875 (7) 333 (2) P=001

VETERANS HEALTH ADMINISTRATION

Conclusions ndash Rethinking health care delivery beyond the medical model

Value-added elements

bull Incorporating on-site social services such as food clothing and hygiene care is associated with better health care for homeless Veterans

bull Community partnering ndash shared care management community outreach and co-hosting community events improves health outcomes for homeless Veterans

VETERANS HEALTH ADMINISTRATION

Acknowledgements

Project Team

Tom OrsquoToole

Erin Johnson

Riccardo Aiello

Vincent Kane

Lisa Pape

DisengagedDisenfranchised from Care

Unstable Sheltering Significant Treatment Barriers

Health Care Low Priority High Rate of ED amp Inpatient Care Premature MorbidityMortality

Treatment Engagement

Housing First Facilitated Access

Care Management of Conditions leading to and perpetuating

Homelessness Address Competing Needs

Stabilization

Chronic Disease Management Prevent Recidivism

Early Identification of New Needs

Disposition Intervention Identification

amp Referral

Emergency Departments

Inpatient Wards

Community Outreach amp

Referrals

Homeless PACT

Enhanced Open Access

Intensive Case Management

Designated staff with specialized training

One-Stop CareWrap

around services Addressing Competing

Needs

Homeless Situation Stabilized Transfer to general PACT team

with Specialty Care

Homeless Situation not Stabilized

Remain in H-PACT due to ongoing homelessnessrisk of

homelessness

Homeless Situation Stabilized Transfer to Special Population

PACT SMI PACT

Womens Health PACT HIV PACT

H-PACT MODEL FOR TREATMENT ENGAGEMENT

VETERANS HEALTH ADMINISTRATION

Results (2013)

High-Performing teams

(N-17)

gt30 reduction in ER

use (or)

gt20 reduction in

hospitalizations

Mid-performing

teams (N=9)

0-30 reduction in

ER use (or)

0-20 reduction in

hospitalizations

Low-Performing

teams (N=7)

Increase in ER

visits

hospitalizations

Access

Availability gt 20 hoursweek 765 (13) 625 (5) 500 (3)

After-hours careconsult

capacity

765 (13) 625 (5) 500 (3)

lt14 days to access MH 765 (13) 625 (5) 667 (4)

Multiple ways to access care 941 (16) 750 (6) 833 (5)

VETERANS HEALTH ADMINISTRATION

Results ndash contrsquod

Homeless-specific care

modeling

High-Performing site Mid-performing site Low -performing

site

Clinical protocols

Post ED hosp admission 588 (10) 750 (6) 500 (3)

Disease-specific care 529 (9) 500 (4) 333 (2)

Housing integrated into care

Part of HampP 941 (16) 100 (8) 833 (5)

Housing status tracking 824 (14) 750 (6) 500 (3) P=005

On-site social supports

Transportation 941 (16) 875 (7) 333 (2) Plt001

Food 647 (11) 250 (2) 167 (1) P=003

Clothes 765 (13) 375 (3) 333 (2) P=003

Community Integration

Clinical outreach 941 (16) 625 (5) 667 (4) P=003

Scheduled meetings 647 (11) 375 (3) 333 (2)

Community events 824 (14) 875 (7) 333 (2) P=001

VETERANS HEALTH ADMINISTRATION

Conclusions ndash Rethinking health care delivery beyond the medical model

Value-added elements

bull Incorporating on-site social services such as food clothing and hygiene care is associated with better health care for homeless Veterans

bull Community partnering ndash shared care management community outreach and co-hosting community events improves health outcomes for homeless Veterans

VETERANS HEALTH ADMINISTRATION

Acknowledgements

Project Team

Tom OrsquoToole

Erin Johnson

Riccardo Aiello

Vincent Kane

Lisa Pape

VETERANS HEALTH ADMINISTRATION

Results (2013)

High-Performing teams

(N-17)

gt30 reduction in ER

use (or)

gt20 reduction in

hospitalizations

Mid-performing

teams (N=9)

0-30 reduction in

ER use (or)

0-20 reduction in

hospitalizations

Low-Performing

teams (N=7)

Increase in ER

visits

hospitalizations

Access

Availability gt 20 hoursweek 765 (13) 625 (5) 500 (3)

After-hours careconsult

capacity

765 (13) 625 (5) 500 (3)

lt14 days to access MH 765 (13) 625 (5) 667 (4)

Multiple ways to access care 941 (16) 750 (6) 833 (5)

VETERANS HEALTH ADMINISTRATION

Results ndash contrsquod

Homeless-specific care

modeling

High-Performing site Mid-performing site Low -performing

site

Clinical protocols

Post ED hosp admission 588 (10) 750 (6) 500 (3)

Disease-specific care 529 (9) 500 (4) 333 (2)

Housing integrated into care

Part of HampP 941 (16) 100 (8) 833 (5)

Housing status tracking 824 (14) 750 (6) 500 (3) P=005

On-site social supports

Transportation 941 (16) 875 (7) 333 (2) Plt001

Food 647 (11) 250 (2) 167 (1) P=003

Clothes 765 (13) 375 (3) 333 (2) P=003

Community Integration

Clinical outreach 941 (16) 625 (5) 667 (4) P=003

Scheduled meetings 647 (11) 375 (3) 333 (2)

Community events 824 (14) 875 (7) 333 (2) P=001

VETERANS HEALTH ADMINISTRATION

Conclusions ndash Rethinking health care delivery beyond the medical model

Value-added elements

bull Incorporating on-site social services such as food clothing and hygiene care is associated with better health care for homeless Veterans

bull Community partnering ndash shared care management community outreach and co-hosting community events improves health outcomes for homeless Veterans

VETERANS HEALTH ADMINISTRATION

Acknowledgements

Project Team

Tom OrsquoToole

Erin Johnson

Riccardo Aiello

Vincent Kane

Lisa Pape

VETERANS HEALTH ADMINISTRATION

Results ndash contrsquod

Homeless-specific care

modeling

High-Performing site Mid-performing site Low -performing

site

Clinical protocols

Post ED hosp admission 588 (10) 750 (6) 500 (3)

Disease-specific care 529 (9) 500 (4) 333 (2)

Housing integrated into care

Part of HampP 941 (16) 100 (8) 833 (5)

Housing status tracking 824 (14) 750 (6) 500 (3) P=005

On-site social supports

Transportation 941 (16) 875 (7) 333 (2) Plt001

Food 647 (11) 250 (2) 167 (1) P=003

Clothes 765 (13) 375 (3) 333 (2) P=003

Community Integration

Clinical outreach 941 (16) 625 (5) 667 (4) P=003

Scheduled meetings 647 (11) 375 (3) 333 (2)

Community events 824 (14) 875 (7) 333 (2) P=001

VETERANS HEALTH ADMINISTRATION

Conclusions ndash Rethinking health care delivery beyond the medical model

Value-added elements

bull Incorporating on-site social services such as food clothing and hygiene care is associated with better health care for homeless Veterans

bull Community partnering ndash shared care management community outreach and co-hosting community events improves health outcomes for homeless Veterans

VETERANS HEALTH ADMINISTRATION

Acknowledgements

Project Team

Tom OrsquoToole

Erin Johnson

Riccardo Aiello

Vincent Kane

Lisa Pape

VETERANS HEALTH ADMINISTRATION

Conclusions ndash Rethinking health care delivery beyond the medical model

Value-added elements

bull Incorporating on-site social services such as food clothing and hygiene care is associated with better health care for homeless Veterans

bull Community partnering ndash shared care management community outreach and co-hosting community events improves health outcomes for homeless Veterans

VETERANS HEALTH ADMINISTRATION

Acknowledgements

Project Team

Tom OrsquoToole

Erin Johnson

Riccardo Aiello

Vincent Kane

Lisa Pape

VETERANS HEALTH ADMINISTRATION

Acknowledgements

Project Team

Tom OrsquoToole

Erin Johnson

Riccardo Aiello

Vincent Kane

Lisa Pape