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Hawaii, Homelessness & Collaborative Care

Posted By Larry Lantinga, Thursday, March 28, 2013
Military and Veterans

Larry's blog is the fourth
post in a series on
integrated care for
military and veterans.


Hawaii, Homelessness & Collaborative Care! These three concepts can’t possible be included in a blog for CFHA, can they? Well yes, I think they can and here goes.

While vacationing in Hawaii with my lovely wife, children and grandkids I awakened early Sunday morning, brewed a pot of Kona coffee, and grabbed the Honolulu Star Advertiser to begin my Sunday morning ritual. The front page headline in 44 point type read: $77 million Proposed for Homeless! The sub-headline read: Honolulu’s Sidewalk Blight! The story led with findings from a recent survey that Waikiki tourists’ number one complaint was the presence of the homeless near many of the best hotels in town and how these poor travelers are often forced to "….walk out of their way or into the street to avoid getting too close to homeless campers who are blocking sidewalk access and loitering near the convention center.”

Although I wasn’t among those doing the complaining, I didn’t feel very good about being a tourist at that moment. The story went on to report that a local city councilman was proposing $77 million dollars be used to address this problem with the most prominent proposal being the creation of a tent city, well removed from the areas frequented by those poor tourists. I felt like calling the Honolulu paper and telling them "don’t let your politicians waste your money on a tent city, spend it instead on healthcare for your homeless and specifically make that collaborative healthcare!"

Why would I say that? Let me explain.

Homelessness among Veterans is an important issue. Approximately 76,000 Veterans are homeless on any given night in America. And over the course of a year, approximately twice as many will experience some episode of homelessness. Eliminating Veteran homelessness is one of VA’s top priorities and is a challenge that Veterans, their families, and VA have been working to overcome for a number of years. In 2009 the Secretary of the Department of Veterans Affairs, Eric Shinseki announced VA’s goal to end homelessness among Veterans within five years. We are not there yet, but each year the number of homeless Veterans has been decreasing as VA has increased homeless Veterans’ access to permanent supportive housing, supportive employment and benefits, and well designed and coordinated healthcare.

Homelessness is caused by some illnesses, e.g., mental illness, substance abuse, disabling medical conditions. Homelessness causes other illnesses, e.g., exposure, infestation-related disorders, and exposure to infectious diseases such as TB. And last but certainly not least, homelessness exacerbates management of other diseases such as diabetes and hypertension. Homeless individuals are three to six time more likely to become ill than housed individuals. And within the VA, the cost of providing healthcare to homeless Veterans is three times the cost of care for non-homeless Veterans. Thus, the provision of accessible, comprehensive, coordinated and collaborative care is essential to the effective treatment of the homeless.

The research literature pretty strongly suggests that traditional primary care is not a particularly effective health care delivery system for our homeless Veterans. However there is a growing number of studies that show strong support for a model of care in which primary care services are linked with care management, embedded mental health, and housing support. Sounds like collaborative care to me! In a Chicago-based study a program using this approach, a 29% reduction in hospital days and a 24% reduction in emergency department use were achieved.

VA is betting that its new and improved primary care system known as PACT, in combination with dedicated and embedded services for the homeless, will provide a better alternative to address the healthcare needs of its Veterans with multiple medical problems and chronic states of homelessness. PACT is the acronym for Patient Aligned Care Team—VA’s term for patient centered, team based, collaborative primary care. PACT is each Veteran working together with health care professionals to plan for the whole-person care and life-long health and wellness, with a focus on partnerships with Veterans, access to care using diverse methods, coordinated care among team members, and team-based care with Veterans as the center of their PACT.

To make PACT even more relevant to the care of homeless Veterans, VA created a new program known as H-PACT --Homeless-PACT teams. H-PACTs are uniquely formulated to meet the healthcare needs of homeless Veterans. There are several different H-Pact Models being "field tested” in VA at the present time. These models vary depending on geographic location and estimated numbers of homeless Veterans. The most comprehensive H-Pact, suited for larger VAs in urban areas with a large homeless Veterans population, combines a full blown PACT and a comprehensive Homeless Veteran Treatment Team that are co-located and fully integrated and have their own panel of homeless primary care Veterans. And yet another H-PACT model targets those Veterans who are chronically homeless, treatment and service disengaged, or treatment resistant Veterans. This latter model is usually located in the areas frequented by the homeless, often near the non-VA community shelters that are operated in many cities.

H-PACT is a very new program, that was initially started as a small pilot. VA is considering expanding the number of H-PACT teams nationally, if it can find the most effective type of H-PACT from among the several variations that have already started. The Center for Integrated Healthcare will be assisting VA’s Homeless Program Office in conducting some of the initial evaluation work, so stay tuned. Perhaps in a future blog I’ll have more information for you. For now, just remember that collaborative care is at the heart of H-PACT.


Larry Lantinga

Dr. Lantinga is a licensed psychologist who has worked for VA for over 40 years and is currently the Associate Director of the Center for Integrated Healthcare. In this role he is responsible for the day-to-day leadership of the Center, in support of the Executive Director. He also closely collaborates with the researchers and educators in the Center. Dr. Lantinga maintains academic affiliations with faculty positions in the Psychology Department at Syracuse University and in the Departments of Psychiatry and Urology at the State University of New York Upstate Medical University.

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