Studies seek best ways to draw homeless veterans into primary care
Stefan Kertesz, MD, MSc, vividly recalls a patient he saw at a homeless shelter in the
1990s. The man had a mood disorder and hypertension. Clinical guidelines and
performance measures called for aggressively managing the blood pressure. But Kertesz
sensed that if he were to go that route during their initial meetings, it would drive the
man away and stifle their budding patient-doctor relationship.
"I felt if I pushed my agenda—treating his blood pressure—I would have to not focus
on the problems that he was presenting to me," says Kertesz. "I would have to minimize
the time and energy we put into his mood issues and the concerns he was having about
his ability to reside in that shelter."
Kertesz followed his instincts: He held off on attacking the blood pressure issue. As a
result, he was gently reprimanded by his medical director. Looking back, though, he
doesn't regret his action. In fact, he sees the episode as a cautionary tale about why
standard approaches to primary care may not work well for patients who are homeless.
Now a physician-investigator at the Birmingham (Ala.) VA, Kertesz was inspired by the
encounter—and many similar ones—to study what primary care for the homeless should
look like. What do patients need and want most? What will draw
them into a VA clinic, keep them coming back, and improve their
health and social outcomes? Do standard guidelines and quality
measures—which often focus narrowly on managing a single
disease—work for this population?
His findings so far—from scores of interviews with homeless
patients and clinicians and managers involved in their care, both in
and outside VA—confirm that one critical factor is trust. Without
it, he says, primary care for the homeless is a non-starter.
Veterans and homelessness
Roughly one in three U.S. homeless adults is a veteran. Some
131,000 veterans, about 97 percent male, are estimated to be
homeless on any given night.
- Many other veterans are considered at risk for homelessness
because of poverty, lack of social support, and dismal living conditions
in cheap hotels or substandard or overcrowded housing.
- About 45 percent of homeless veterans have mental illness, and
more than 70 percent suffer from drug or alcohol abuse. There is
considerable overlap between the two groups.
Kertesz: "Homeless patients are very experienced with stigma,
and they are accustomed to finding that doctors, social workers and
other authority figures tend to discount their concerns and agenda
in favor of what the expert clinician judges to be the problem that
merits attention. This fosters distrust. We stand a better chance of
achieving our clinical goals over the long term if we can first
establish a durable and sustainable relationship."
He is collecting data to guide the design of a survey for
homeless veterans about their experiences with VA primary care.
He has a "heavy emphasis," he says, on enlisting homeless patients
to help define quality. Eventually, he hopes to compare existing
models within the VA system and learn which features work best.
Lack of chronic-disease care shortens lives
An estimated 131,000 veterans are homeless on any given night.
Perhaps twice as many are homeless at some point during the
course of a year. Many are coping with mental illness or substance
abuse, although Robert Rosenheck, MD, who has studied homeless
programs for VA for more than 20 years, asserts that "homelessness
is clearly a function of two things: low incomes and high rents."
VA has been a national leader in homeless programs overall since
the 1980s, including efforts spanning housing, work rehabilitation,
substance abuse treatment, and mental health. But the agency has
been less successful at engaging homeless veterans in primary care.
That is crucial, because chronic diseases typically managed in
primary care—diabetes, hypertension, heart disease—are widespread
among the homeless. And they account, in large part, for a sharp rise
in mortality. Life expectancy for homeless
people is 30 years less than average.
The VA health system as a whole is
working toward a care model to brighten
that picture. As of today, most VA medical
centers still deliver primary care to
homeless veterans through mainstream
primary care clinics. Veterans are usually
referred from other VA homeless programs.
Some VA sites have added primary care
providers to their mental health clinics, to
speed up access to primary care.
Meshing primary care with
other homeless services
Several VA medical centers have gone
further. Their goal is to integrate primary
care with a fuller network of homeless
services. Rather than having to navigate
through a maze of various services at
different locations on different days,
homeless veterans can see an internist,
social worker and psychologist, for
example, all in one morning. Missed
appointments—a particular problem for the
homeless—are minimized. Primary care
becomes the hub of treatment, rather than
one element to be coordinated with others.
One of the best-known examples of this
approach is the Mental Health Outpatient
Treatment Center on the VA campus in Los
Angeles—a city sometimes called the
homeless capital of America. The center
was funded by VA in 2002 as a
demonstration project. An 18-month study
published last year by a team including
Rosenheck and James McGuire, PhD, of the
Los Angeles VA showed the clinic has
increased access to primary care and curbed
emergency-room use. The researchers are
continuing to study the benefits on patients'
Thomas O'Toole, MD, runs a similar
clinic at the Providence (R.I.) VA. Homeless
veterans are welcome without an
appointment. They can see primary care
doctors as well as mental health providers,
social workers, and benefits and housing
counselors. Referrals to VA substance abuse
programs are made as necessary. It's onestop
service for people with multiple,
complex health and social needs. "We try to
have open-access and sensitive care," says
His research focus is motivating veterans
to visit the clinic in the first place. "They
are a treatment-resistant population," he
says. "But if we can somehow increase their
motivation, they will seek out care."
O'Toole has designed a protocol to
complement existing outreach efforts. A
nurse will accompany the clinic's social
worker, who does outreach in a mobile van
and at local shelters and soup kitchens. The
nurse will do personalized health
assessments for homeless veterans, identify
issues of concern, and then conduct a
motivational interview. This counseling
technique honors patients' autonomy and
elicits and builds on their own internal
motivation to make positive changes.
Claire Bourgault, RN, describes one of the
initial encounters she had as part of the study,
which is just now getting under way. "I
talked with the veteran about what I found—
the potential problem he may face in regard
to his health. I said to him, it's your choice,
but it may be in your best interests to
continue to see us. He said OK, but we didn't
know if he would come back. Sure enough,
Measuring results based on
health and housing
O'Toole, Kertesz and other experts have
little doubt at this point—though hard
evidence from studies is still being
compiled—that primary care for homeless
veterans works best when it's integrated
with the other homeless services that VA offers—housing, work,
mental health, addiction treatment. "These are crucial pieces for
the homeless, and they are obvious strengths of VA," notes
Kertesz. But how exactly all the pieces should fit together remains
to be determined. The Los Angeles and Providence VA models
seem fairly successful, but researchers are intent on pinpointing the
optimal approach and replicating it across the entire VA system.
Most critical is the housing piece. O'Toole measures outcomes at
his clinic based not only on how many veterans come in for primary
care, and how their health metrics change, but also on how many
eventually end up with housing. "We're trying to connect people to
resources so they're able to go, say, from an emergency shelter into
per diem housing or a domiciliary. Those environments are going to
be more conducive to better chronic disease management."
Another key element, perhaps less tangible, is the attitude with
which care is provided. This may be harder to measure, but it will
likely be captured in the patient survey Kertesz's group is designing.
"We need to convey expectations about high quality and patient
engagement—the same humanity and dignity that would be
afforded any other patients. Patients who are homeless clearly
respond to that," says O'Toole. On a similar note, he echoes
Kertesz's view on the importance of building relationships and
respecting homeless veterans' concerns and needs—even when
they seem to compete with medical goals per se. "Unless we spend
time understanding what the patient's priorities are and meet them
halfway, our agenda will be dead in the water."
As VA's primary care for the homeless evolves, says O'Toole, it
could come to play a key role in the vision—shared by VA
Secretary Eric Shinseki, the National Coalition for Homeless
Veterans, and other advocates—to end homelessness among
O'Toole: "My working philosophy has always been that most
people were not born homeless, and that we should do everything
in our power to make sure they don't die homeless."