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2023 HSR&D/QUERI National Conference Abstract

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4083 — Improving Encampment Medicine Services in a VA-Sanctioned Tiny Home Community for Homeless-Experienced Veterans

Lead/Presenter: Matthew McCoy,  COIN - Los Angeles
All Authors: McCoy M (Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles), Cannedy, S (Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles) Sherrell, TC (Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles) Lynch, K (Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles) Altman, L (Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles) Hamilton, AB (Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles) Gelberg, KL (Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles) Santini, C (Community Engagement and Rehabilitation Services, VA Greater Los Angeles Healthcare System, Los Angeles) Gabrielian, S (Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles)

Objectives:
During the coronavirus 2019 (COVID-19) pandemic, VA Greater Los Angeles’ leadership sanctioned a novel tent encampment (Care, Treatment and Rehabilitation Service (CTRS)) for Veterans experiencing homelessness (VEH). CTRS evolved from tents to tiny homes, enabling VEHs to live in pallet shelters (private sleeping cabins with lights, heaters, and air conditioning) with on-site hygiene facilities and three meals a day on medical center grounds. This innovation addressed the longstanding needs of a subset of VEHs whose housing preferences do not align with traditional transitional housing settings. As many VEHs in CTRS struggle to access healthcare in brick-and-mortar settings, an “encampment medicine team” was developed to provide integrated primary and mental health care on-site. To enable improvements in services, we characterized Veteran and staff perceptions of the encampment medicine team and identified best practices used outside VA to provide healthcare to homeless encampments.

Methods:
Between September 2020 and September 2021, we conducted ethnographic site visits (>100 hours) and semi-structured qualitative interviews with VEHs enrolled in CTRS (n = 21) and CTRS staff (preventive medicine physician, peer specialists, social workers; n = 11). Between January 2022 and June 2022, we interviewed encampment medicine team clinicians (primary care, nursing, mental health; n = 8). We conducted site visits (>20 hours) with non-VA national street medicine experts and conducted semi-structured interviews (n = 9) with them regarding best practices for delivering care to unsheltered adults. We used rapid qualitative analyses to synthesize data relevant to improving the encampment medicine team.

Results:
VEHs desired social service providers and healthcare clinicians display an empathic and integrated approach to addressing their military and trauma histories. CTRS staff emphasized the need for Veterans to develop housing plans that were aligned with and informed by their healthcare needs and overall functioning. The encampment medicine team and non-VA experts described the value of building rapport with VEHs before offering health care or housing, i.e., treating Veterans on their own timelines. Non-VA street medicine teams emphasized the values of harm reduction, cultivating communicative pathways between interdisciplinary staff (e.g., medical and processing huddles), and building partnerships with homeless consumers who function as “community leaders.”

Implications:
To create a field-based, integrated primary care-mental health encampment medicine team, that employs a low-barrier, harm reduction approach to homeless services, there is a need for: greater clinician-social service provider teamwork with strong communication systems; slow, empathic approaches to building trusting relationships; balancing VEHs’ current medical and housing needs; and engaging VEHs with informal peer leadership roles as persons with lived expertise.

Impacts:
Qualitative methods were used to improve care processes for an encampment medicine team. These findings resulted in viable improvements to services, including: stronger partnerships among clinicians, social workers, and peer support specialists, with the unified goal of building trusting relationships with VEHs; enhanced communication processes, including “team triage” and huddles regarding VEHs’ primary care and mental health needs, and a user-friendly panel management and tracking system for VEHs’ needs and care coordination. Additional improvements included the creation of a weekly Veteran Engagement Committee meeting for VEHs to offer feedback to staff and clinicians about their care.