摘要：Objectives. We compared service use among homeless and nonhomeless veterans newly enrolled in a medical home model and identified patterns of use among homeless veterans associated with reductions in emergency department (ED) use. Methods. We used case–control matching with a nested cohort analysis to measure 6-month health services use, new diagnoses, and care use patterns in veterans at the Providence, Rhode Island, Veterans Affairs Medical Center from 2008 to 2011. Results. We followed 127 homeless and 106 nonhomeless veterans. Both groups had similar rates of chronic medical and mental health diagnoses; 25.4% of the homeless and 18.1% of the nonhomeless group reported active substance abuse. Homeless veterans used significantly more primary, mental health, substance abuse, and ED care during the first 6 months. Homeless veterans who accessed primary care at higher rates (relative risk ratio [RRR] = 1.46; 95% confidence interval [CI] = 1.11, 1.92) or who used specialty and primary care (RRR = 10.95; 95% CI = 1.58, 75.78) had reduced ED usage. Homeless veterans in transitional housing or doubled-up at baseline (RRR = 3.41; 95% CI = 1.24, 9.42) had similar reductions in ED usage. Conclusions. Homeless adults had substantial health needs when presenting for care. High-intensity primary care and access to specialty care services could reduce ED use. Homelessness is associated with premature morbidity and mortality at much higher rates compared with those who are housed. 1,2 Exposure to the environment, trauma, challenges managing chronic diseases, mental illnesses, and addictions, as well as deferred and delayed medical needs, often define the health needs of this population. 3–5 Unfortunately, the care homeless persons receive is often based in emergency departments (EDs), and these patients do not receive chronic care management or preventative services in this setting. 6 Passage of the Affordable Care Act by the US Congress and the potential for near-universal health care coverage with state implementation may result in improved access for many traditionally underserved and high-risk or high-need populations, including the homeless. Furthermore, implementation of Accountable Care Organizations will place greater importance on better management of these populations. In many ways, the vertically and horizontally integrated structure of the Veterans Health Administration (VA), their programmatic focus on high-risk, high-need population veteran groups, and the emphasis placed on data-driven care, can serve as a prototype for Accountable Care Organizations. An example of this is the development of the Patient Aligned Care Team (PACT) within the VA that serves as the medical home model for that care system. We presented data from a case–control study of homeless and nonhomeless veterans newly assigned to a primary care medical home (general population or homeless-specific PACT) with a nested cohort analysis of homeless veterans accessing care within the homeless PACT care. The goal was to identify the demand for care and the use of health services among newly enrolled homeless veterans and factors associated with redirecting that use to ambulatory settings.
