Quality of Depression Care for Veterans Affairs Primary Care Patients with Experiences of Homelessness.

Jones AL, Chu K, Rose DE, Gelberg L, Kertesz SG, Gordon AJ, Wells KB, Leung L. Quality of Depression Care for Veterans Affairs Primary Care Patients with Experiences of Homelessness. Journal of general internal medicine. 2023 Aug 1; 38(11):2436-2444.

Related HSR&D Project(s)

• CDA 19-233 – Quality of Mental Health Services for Homeless Veterans in Primary Care Settings
• CDA 19-108 – Improving Depression Management in Primary Care

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Abstract:

BACKGROUND: Persons who experience homelessness (PEH) have high rates of depression and incur challenges accessing high-quality health care. Some Veterans Affairs (VA) facilities offer homeless-tailored primary care clinics, although such tailoring is not required, within or outside VA. Whether services tailoring enhances care for depression is unstudied. OBJECTIVE: To determine whether PEH in homeless-tailored primary care settings receive higher quality of depression care, compared to PEH in usual VA primary care. DESIGN: Retrospective cohort study of depression treatment among a regional cohort of VA primary care patients (2016-2019). PARTICIPANTS: PEH diagnosed or treated for a depressive disorder. MAIN MEASURES: The quality measures were timely follow-up care (3 + completed visits with a primary care or mental health specialist provider, or 3 + psychotherapy sessions) within 84 days of a positive PHQ-2 screen result, timely follow-up care within 180 days, and minimally appropriate treatment (4 + mental health visits, 3 + psychotherapy visits, 60 + days antidepressant) within 365 days. We applied multivariable mixed-effect logistic regressions to model differences in care quality for PEH in homeless-tailored versus usual primary care settings. KEY RESULTS: Thirteen percent of PEH with depressive disorders received homeless-tailored primary care (n = 374), compared to usual VA primary care (n = 2469). Tailored clinics served more PEH who were Black, who were non-married, and who had low income, serious mental illness, and substance use disorders. Among all PEH, 48% received timely follow-up care within 84 days of depression screening, 67% within 180 days, and 83% received minimally appropriate treatment. Quality metric attainment was higher for PEH in homeless-tailored clinics, compared to PEH in usual VA primary care: follow-up within 84 days (63% versus 46%; adjusted odds ratio [AOR] = 1.61, p = .001), follow-up within 180 days (78% versus 66%; AOR = 1.51, p = .003), and minimally appropriate treatment (89% versus 82%; AOR = 1.58, p = .004). CONCLUSIONS: Homeless-tailored primary care approaches may improve depression care for PEH.