摘要：Objectives. We compared homeless patients’ experiences of care in health care organizations that differed in their degree of primary care design service tailoring. Methods. We surveyed homeless-experienced patients (either recently or currently homeless) at 3 Veterans Affairs (VA) mainstream primary care settings in Pennsylvania and Alabama, a homeless-tailored VA clinic in California, and a highly tailored non-VA Health Care for the Homeless Program in Massachusetts (January 2011-March 2012). We developed a survey, the “Primary Care Quality-Homeless Survey," to reflect the concerns and aspirations of homeless patients. Results. Mean scores at the tailored non-VA site were superior to those from the 3 mainstream VA sites ( P < .001). Adjusting for patient characteristics, these differences remained significant for subscales assessing the patient–clinician relationship ( P < .001) and perceptions of cooperation among providers ( P = .004). There were 1.5- to 3-fold increased odds of an unfavorable experience in the domains of the patient–clinician relationship, cooperation, and access or coordination for the mainstream VA sites compared with the tailored non-VA site; the tailored VA site attained intermediate results. Conclusions. Tailored primary care service design was associated with a superior service experience for patients who experienced homelessness. In the United States, homelessness affects more than 1.5 million persons per year and more than 630 000 individuals nightly. 1,2 A lack of stable domiciles makes medical care much more challenging, and is associated with increased prevalence of medical and psychiatric conditions 3 and mortality. 4 Accompanying these challenges is a pattern of excess hospital and emergency department utilization, 5 lack of a usual source of care, 6 uninsured status, 7 and inadequate access to care when needed. 8 Health care programs to remediate homeless persons’ challenges in accessing health care began in 1985, when the Robert Wood Johnson Foundation and the Pew Memorial Trust initiated funding for specialized Health Care for the Homeless Programs. In 1987, this funding was assumed by the federal government. 9 Since that time, experts have advocated tailoring service design and delivery to assure that high quality care is provided to homeless patients. 10–12 However, it is helpful to view tailored service design on a continuum because modifications are diverse and may include a combination of elements, such as outreach workers to develop relationships outside of traditional settings, primary care services in shelters or on the streets, team-based care, co-location of homeless-dedicated primary and mental health providers, special education for providers, capacity to assist with sustenance needs such as food or hygiene items, and a robust consumer role in organizational governance. 12–14 Some modified programs have reported improved appointment attendance, 15 reductions in hospital admissions, and improvements in disease outcomes. 16 However, such modifications are not required of publicly funded homeless primary care providers, and they are not the norm. For example, among 208 federally funded Health Care for the Homeless Programs in 2010, only 15 had designated outreach providers (National Health Care for the Homeless Council, analysis of health resources and services administration uniform data set, unpublished data, 2012). One policy analysis reported that primary care for the homeless remains inadequate, even when insurance is available. 17 The Patient Protection and Affordable Care Act (PPACA), coupled with efforts to encourage the Patient-Centered Medical Home model in public and private settings 18 lends impetus to efforts to assure that vulnerable populations obtain care that is truly patient-centered. 7,19,20 To date, there has been no evaluation of whether efforts to tailor service delivery for homeless clients yield a superior patient experience. Homeless patients’ experiences in primary care are important for several reasons. Patient ratings of their care correlate with whether care relationships are sustained, 21 recommendations are adhered to, 22 and in some reports, whether behavioral conditions improve. 23,24 Also, as emphasized by developers of other primary care rating tools, 25,26 patients are the optimum reporters of whether primary care delivery fulfills the desired attributes described by the Institute of Medicine and others, 27,28 including accessibility, comprehensiveness, continuity, ease of communication, and sensitivity to context. 29 Our study compares patients' assessments of their own care across 5 primary care settings that varied in the degree of homeless-tailored service design, from none (i.e., “mainstream primary care”) to intensive tailoring. Given the lack of a population-specific survey, we developed a new patient-reported instrument specifically for homeless persons. We hypothesized that ratings would be superior for care obtained in settings that tailored services for homeless clientele. Because homeless patients have reported significant negative experiences in care, 30,31 our secondary hypothesis was that unfavorable experiences would be more common in mainstream primary care compared with tailored settings.
