Comparison of Patient Experience Between Primary Care Settings Tailored for Homeless Clientele and Mainstream Care Settings.

Kertesz SG, deRussy AJ, Kim YI, Hoge AE, Austin EL, Gordon AJ, Gelberg L, Gabrielian SE, Riggs KR, Blosnich JR, Montgomery AE, Holmes SK, Varley AL, Pollio DE, Gundlapalli AV, Jones AL. Comparison of Patient Experience Between Primary Care Settings Tailored for Homeless Clientele and Mainstream Care Settings. Medical care. 2021 Jun 1; 59(6):495-503.

Related HSR&D Project(s)

• CDA 15-074 – Improving Housing Outcomes for Homeless Veterans
• CDA 14-408 – Health Outcomes and Healthcare Use Among Transgender Veterans
• IIR 15-095 – Primary Care Quality and Homeless Service Tailoring

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Abstract:

BACKGROUND: More than 1 million Americans receive primary care from federal homeless health care programs yearly. Vulnerabilities that can make care challenging include pain, addiction, psychological distress, and a lack of shelter. Research on the effectiveness of tailoring services for this population is limited. OBJECTIVE: The aim was to examine whether homeless-tailored primary care programs offer a superior patient experience compared with nontailored ("mainstream") programs overall, and for highly vulnerable patients. RESEARCH DESIGN: National patient survey comparing 26 US Department of Veterans Affairs (VA) Medical Centers'' homeless-tailored primary care ("H-PACT"s) to mainstream primary care ("mainstream PACT"s) at the same locations. PARTICIPANTS: A total of 5766 homeless-experienced veterans. MEASURES: Primary care experience on 4 scales: Patient-Clinician Relationship, Cooperation, Accessibility/Coordination, and Homeless-Specific Needs. Mean scores (range: 1-4) were calculated and dichotomized as unfavorable versus not. We counted key vulnerabilities (chronic pain, unsheltered homelessness, severe psychological distress, and history of overdose, 0-4), and categorized homeless-experienced veterans as having fewer ( = 1) and more ( = 2) vulnerabilities. RESULTS: H-PACTs outscored mainstream PACTs on all scales (all P < 0.001). Unfavorable care experiences were more common in mainstream PACTs compared with H-PACTs, with adjusted risk differences of 11.9% (95% CI = 6.3-17.4), 12.6% (6.2-19.1), 11.7% (6.0-17.3), and 12.6% (6.2-19.1) for Relationship, Cooperation, Access/Coordination, and Homeless-Specific Needs, respectively. For the Relationship and Cooperation scales, H-PACTs were associated with a greater reduction in unfavorable experience for patients with = 2 vulnerabilities versus = 1 (interaction P < 0.0001). CONCLUSIONS: Organizations that offer primary care for persons experiencing homelessness can improve the primary care experience by tailoring the design and delivery of services.