摘要：Objectives. We compared a population-tailored approach to primary care for homeless veterans with a usual care approach. Methods. We conducted a retrospective prolective cohort study of homeless veterans enrolled in a population-tailored primary care clinic matched to a historical sample in general internal medicine clinics. Overall, 177 patients were enrolled: 79 in the Homeless-Oriented Primary Care Clinic and 98 in general internal medicine primary care. Results. Homeless-oriented primary care–enrolled patients had greater improvements in hypertension, diabetes, and lipid control, and primary care use was higher during the first 6 months (5.96 visits per person vs 1.63 for general internal medicine) but stabilized to comparable rates during the second 6 months (2.01 vs 1.31, respectively). Emergency department (ED) use was also higher (2.59 vs 1.89 visits), although with 40% lower odds for nonacute ED visits than for the general internal medicine group (95% confidence interval = 0.2, 0.8). Excluding substance abuse and mental health admissions, hospitalizations were reduced among the homeless veterans between the 2 periods (28.6% vs 10.8%; P < .01) compared with the general internal medicine group (48.2% vs 44.4%; P = .6; difference of differences, P < .01). Conclusions. Tailoring primary care to homeless veterans can decrease unnecessary ED use and medical admissions and improve chronic disease management. Homeless persons get sick more often, utilize acute medical services at substantially higher rates, and experience 1.5 to 3.5 times higher rates of mortality than do their age-matched nonhomeless counterparts. 1 – 6 Homeless persons also underutilize primary care services, often seek care in EDs, 2 , 7 and commonly require acute care hospitalization. 3 These utilization patterns are even more pronounced among homeless veterans. In a national sample of homeless persons, Kushel et al. found that although 62.8% of participants had 1 or more ambulatory visits and 26.8% were enrolled in the Veterans Affairs (VA) system, only 5.6% of care occurred in VA-based clinics. 1 Almost one quarter of the sample did not receive care when needed, and veterans were more than twice as likely to be hospitalized as were nonveteran homeless persons. 1 Studies to date have typically focused on the emergency department (ED) or hospital as the site for intervention. Redelmeier et al., in a randomized controlled trial, showed a reduction in ED use when care was coupled with a social work intervention. 8 Okin et al. achieved similar results applying case management to high-frequency ED users. 9 O'Toole et al. showed a reduction in ED use for homeless persons with substance use disorders who enrolled in a day hospital program after an acute medical hospitalization. 10 Sadowski et al. demonstrated a reduction in ED use and in subsequent hospitalizations when case management and housing support followed an acute care hospital admission. 11 Much attention has also been placed on improving access to primary and preventive health services, with federally funded Health Care for the Homeless clinics serving as the model. 12 – 15 However, few controlled studies have evaluated whether this population-based approach to care optimizes outcomes for homeless persons. The Homeless-Oriented Primary Care Clinic at the Providence VA Medical Center adapted the integrated care approach of the Health Care for the Homeless program to an urban hospital-based setting in the VA health system. The current retrospective cohort study compares health services utilization and chronic disease outcomes among Homeless-Oriented Primary Care patients with those of a matched sample of homeless veterans seen in a typical VA general internal medicine clinic. Our intent was to determine whether a population-tailored approach to how primary care is organized and delivered to homeless veterans is associated with better health care and utilization outcomes.
