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Homeless PACT (PCMH)
David I. Rosenthal MD
Medical Director – Homeless PACT, VA Asst
Prof, Section of General Internal Medicine,
Yale School of Medicine
2010 HUD Report on Homelessness

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9. • http://maketheconnection.net/stories-of-connecti

10. Background
• On a typical night in 2010, more than 400,000
homeless individuals in the US (1)
• ~10% experienced chronic homelessness
– Defined as homelessness >1 year or 4 episodes in
the past 3 years
(1) The 2010 Annual Homeless Assessment Report to Congress. Department of Housing and Urban Development
(US), Office of Community Planning and Development.
Available at http://www.hudhre.info/documents/2010HomelessAssessmentReport.pdf

11. http://www.pathwaystohousing.org/content/our_model
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Housing Services OverviewHousing Services Overview

12. Housing First - Core Principles
 Consumer choice and empowerment
 Separation of services and housing
 Services are voluntary and flexible
Community integration
Harm reduction and recovery oriented
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Housing Services OverviewHousing Services Overview

13. Homeless
Shelter
placement
Transitional
housing
Permanent
housing
Levelofindependence
Treatment compliance + psychiatric stability + abstinence
Underlying theory and values:
•Transitional placements provide
for stabilization and learning.
•Individual change is required
through treatment.
•Consumers must ‘earn’
permanent housing
Treatment First Model
Tsemberis slide, 2010
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Housing Services OverviewHousing Services Overview

14. Homeless
Shelter
placement
Transitional
housing
Permanent
housing
Ongoing, flexible
supports
Housing First Model
Tsemberis slide,
2010
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15. Community Housing
15

16. The Eleanor and Franklin
Formerly Park City--Bridgeport, CT
Permanent Supportive Housing
55 Elderly & 49 Homeless Mentally Ill
Legion Woods, New Haven,
CT
Permanent Supportive
Housing- 20 Units
Transitional—14 Beds
Harkness House, West Haven, CT
Kossuth Street—New Haven, CT
Yale School
of Architecture
Homeownership
Community
Partnerships
16

17. Jewett City/American Legion
2010
Opened
June 2012

18. Jewett City/American Legion
18
Street View
Interior View

19. Why Housing First?
1. It ends homelessness
2. Housing First eliminates the need for costly shelter care,
transitional and short term treatment services aimed at
preparing Veterans to be housing ready.
3. Studies demonstrate the Housing First reduces ER visits,
unscheduled mental health and medical hospitalization
4. Decreases the frequency and duration of homelessness
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20. VA Housing Programs
Domiciliary Care for Homeless Veterans
The Domiciliary Care Program is a clinical rehabilitation and
treatment program for male and female Veterans. The Domiciliary
Care Program addresses goals of rehabilitation, recovery, health
maintenance, improved quality of life, and community integration in
addition to specific treatment of medical conditions, mental
illnesses, addictive disorders, and homelessness.
Department of Housing and Urban Development/Department of
Veterans Affairs Supportive Housing (HUD-VASH)
Through the HUD-VASH Program, HUD and VA, through a
cooperative partnership, provide long-term case management,
supportive services and permanent housing support for Veterans
who require these supports in order to live independently.
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21. VA Housing Programs, cont.
Grant and Per Diem (GPD)
The Grant and Per Diem (GPD) Program funds community-based
agencies providing transitional housing or service centers for
homeless Veterans. A Veteran can typically reside in a GPD Program
for up to 2 years.
Supportive Services for Veteran Families Program
The Supportive Services for Veteran Families (SSVF) Program is a
new VA program that will provide supportive services to very low-
income Veterans and their families who are in or transitioning to
permanent housing. VA awards grants to private non-profit
organizations and consumer cooperatives that assist very low-
income Veterans and their families by providing a range of
supportive services designed to promote housing stability.
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22. The challenge of keeping homeless people
in housing
• High rate of recidivism from grant per diem housing
• Substance abuse relapse is the most commonly cited reason
– Chart review of 50 “early departure” veterans found secondary
reasons of pain management, untreated mental illnesses, and
relationship problems involved
– Participation in a Homeless-Oriented Primary Care model (Providence
VA) reduced GPD “early departure” rate to 16%
Used with permission from Dr. O’Toole, from HPACT Cyberseminar
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23. Health impact of homelessness
Barrow SM, Herman DB, Córdova P,
Struening EL. Mortality among homeless
shelter residents in New York City. Am J
Public Health. 1999 Apr;89(4):529-34
1260 NYC
homeless
Shelter
residents

24. Health impact of homelessness
Barrow SM, Herman DB, Córdova P,
Struening EL. Mortality among homeless
shelter residents in New York City. Am J
Public Health. 1999 Apr;89(4):529-34
In a 7 year follow up period
~2-4x increased risk of mortality

25. Years of potential life lost
3-3.5x to matched controls

26. BMJ 2009, Oct 26;339

27. • Large, nationwide, prospective, register-based
cohort study 1999-2009 in Demark
• 32,711 in study population
• Overall SMR (Standardized Mortality Ratio)
5-6x in Men, 6-7x in Women
Highest in Substance abuse disorder, higher than dual
diagnosisNielsen SF, Hjorthøj CR, Erlangsen A, Nordentoft M. Psychiatric disorders and mortality
among people in homeless shelters in Denmark: a nationwide register-based cohort
study. Lancet. 2011 Jun 25;377(9784):2205-14

28. • Boston Health Care for the Homeless:
Case control study of 558 deaths 1988-1993

29. Homeless Vulnerability Index
• For individuals who have been homeless for at least six months, one or more following
markers place them at heightened risk of mortality:
– more than three hospitalizations or emergency room visits in a year
– more than three emergency room visits in the previous three months
– aged 60 or older
– cirrhosis of the liver
– end-stage renal disease
– history of frostbite, immersion foot, or hypothermia
– HIV+/AIDS
– tri-morbidity: co-occurring psychiatric, substance abuse, and chronic medical
condition
In Boston, 40% of those with these conditions died prematurely, underscoring the need
for housing and appropriate support for this group.
Developed by Jim O’Connell, Boston Health Care for the Homeless
used in practice by Common Ground, NYC

30. Salit SA, Kuhn EM, Hartz AJ, Vu JM, Mosso AL. Hospitalization costs associated
with homelessness in New York City. N Engl J Med 1998; 338: 1734-1740
•Hospital discharge data from public hospital system of NYC
1992-1993, and private hospital data of medicaid admissions
•Of 354,494 persons discharges, identified 18,864 patients as
homeless

31. Salit SA, Kuhn EM, Hartz AJ, Vu JM, Mosso AL. Hospitalization costs associated with
homelessness in New York City. N Engl J Med 1998; 338: 1734-1740

32. Salit SA, Kuhn EM, Hartz AJ, Vu JM, Mosso AL. Hospitalization costs associated with homelessness in
New York City. N Engl J Med 1998; 338: 1734-1740
•Average LOS
3.1 -5.1 days longer
•∆Cost in 1997 $s
$4094 per discharge
for psychiatric
primary diagnosis
$3370 per pt with
AIDS as primary
diagnosis
$2414 per pt of
all causes
~rough cost of
monthly NYC
apt

33. 3x
$$
x
Courtesy O’Toole, VA Providence Data

34. VERA Sustainability Capacity
• New Multiple Medical and Chronic Mental Illness classes
specifically for homeless Veterans
• Homelessness diagnosis (V.60) in combination with medical
conditions managed utilizing at least 7 RVUs qualify for Class
5 Price Group (Multiple Problems) VERA
• No RVU credit for ER or inpatient encounters
• Price Group Differential:
– Non-reliant care: $813
– Multiple Problem care: $27,686

35. Ku BS, Scott KC, Kertesz SG, Pitts SR. Factors associated with use of urban emergency departments by the U.S. homeless
population. Public Health Rep. 2010 May-Jun;125(3):398-405

37. “First Stops” when becoming
homeless
• Community-based survey of 230 homeless adults
• Question: “Where do you go first after becoming homeless
and for what?”
• Top 5 sites:
– Soup kitchen
– Welfare office
– Detox center
– Homeless outreach team
– Emergency Department
• 62.6% of individuals with a chronic medical/mental health
condition went to a health care site
• 46.4% of individuals with alcohol abuse went to a health care
site
O’Toole, et al. Health Soc Care Community. 2007

38. Physical health concerns, homelessness and
behavior change
• N=370 adults presenting to an emergency department (266
homeless; 104 housed)
• 80% of homeless adults seeking substance abuse treatment
reported physical health concerns as a major reason.
• More homeless were in an action stage for wanting substance
abuse treatment
• Homeless adults were almost 2.5 times more likely to report
their living arrangement as a major motivation for seeking
treatment
O’Toole et al. JSAT. 2008

39. “I’m just a doctor, how can I fix this?”

40. “The painfully obvious lesson for me has been the
futility of solving this complex social problem solely
with new approaches to medical or mental health
care...I dream of writing a prescription for an
apartment, a studio, an SRO, or any safe housing
program, good for one month, with 12 refills.”
-Dr. Jim O’Connell
Boston Health Care
for the Homeless

41. •Large Health Survey 1999 with
N=559,985
•Serious mental illnesses (schizophrenia,
bipolar d/o) is associated
with lower utilization of primary care.

42. Co-located Primary Care?
Adm Policy Ment Health. 2009 Jul;36(4):255-64. Epub 2009 Mar 12.
In Los Angeles VA, usual VA care (n=130) vs. integrated care group (n=130),
received more prevention services, primary care visits, fewer ED visits, but no
difference in inpatient utilization or health status at 18 months.

43. December 2010, Vol 100, No. 12 | American Journal of Public Health O’Toole et al. | Peer Reviewed | Research
and Practice | 2493
•Providence VA System
• retrospective cohort study of 177 Vets in Specialized homeless-
oriented primary clinic (79) vs. traditional primary care Model (98)

48. Why a PACT model?

49. TODAY’S CARE MEDICAL HOME CARE
My patients are those who make
appointments to see me
Our patients are those who are
registered in our medical home
Patients’ chief complaints or reasons
for visit determines care
We systematically assess all our
patients’ health needs to plan care
Care is determined by today’s
problem and time available today
Care is determined by a proactive plan
to meet patient needs without visits
Care varies by scheduled time and
memory or skill of the doctor
Care is standardized according to
evidence-based guidelines
Patients are responsible for
coordinating their own care
A prepared team of professionals
coordinates all patients’ care
I know I deliver high quality care
because I’m well trained
We measure our quality and make
rapid changes to improve it
It’s up to the patient to tell us what
happened to them
We track tests & consultations, and
follow-up after ED & hospital
Clinic operations center on meeting
the doctor’s needs
A multidisciplinary team works at the
top of our licenses to serve patients
Acute care is delivered in the next
available appointment and walk-ins
Acute care is delivered by open access
and non-visit contacts
Used with Permission; Daniel Duffy, MD, MACP, School of Community Medicine, Tulsa, Oklahoma.

50. 7 Core elements of
Patient Aligned Care Teams
• Patient-driven – focus on the patient rather than the disease
• Team-based - care delivered by interdisciplinary team
• Efficient – deliver care the patient needs when they need it
• Comprehensive – delivering while person-oriented care
• Continuous – long-term, longitudinal relationship between pt & team
• Communication – honest, respectful, reliable, culturally sensitive
• Coordination – across all elements of the health care system
Used with permission from Dr. O’Toole, from HPACT Cyberseminar

51. Key features of Special Population
PACTs
• Access - Accommodates barriers, challenges to routine
care
• Care tailored to specific needs of a population
– Readiness to respond to “treatable moments”
• Case management/Care coordination
– Expanded team members/communities
– Capacity to address competing needs
• Care team equipped with specialized
knowledge and skills
O’Toole, et al. Journal Gen Intern Med 2011
Used with permission from Dr. O’Toole, from HPACT Cyberseminar

52. Homeless PACT goals: PACT-PLUS
• To provide comprehensive, continuity care to a
population of patients (Homeless Veterans) who
have multiple deferred care needs complicated by
their living arrangements
• To integrate housing objectives with clinical care
objectives in care planning and delivery
• To build knowledgeable compassionate teams
equipped and prepared to provide care needed by
this population of patients
Used with permission from Dr. O’Toole, from HPACT Cyberseminar