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BACKGROUND/RATIONALE:
While the VA has in many areas surpassed mainstream health systems in improving quality or reducing disparities, multiple reports suggest that it has not met with similar success in assuring primary care to homeless veterans. Several studies, most from organizations outside the VA, suggest that efforts to tailor the primary care delivery system for homeless patients ("customization") can enhance primary care access or outcomes. The VA has the potential to adopt such an approach if data show convincingly that it enhances the quality of primary care. However, the appropriate method for measuring the quality of primary care for homeless patients remains elusive, in part because standard single-disease performance measures fail to account for complex medical and social issues affecting their care. We therefore seek to develop a patient-reported measure of primary care quality appropriate to the homeless patient (Primary Care Quality-Homeless, PCQ-H), and to compare quality across 3 VHA Medical Centers and 1 non-VHA program representing an established, mature example of customized homeless primary care services.
OBJECTIVE(S):
Objective 1: Using the Institute of Medicine (IOM)'s constructs for quality primary care, to operationalize high-quality primary care for the homeless using the perspectives of homeless persons, clinicians, and administrators of programs for the homeless;
Objective 2: Based on Aim 1, to develop a patient-reported instrument (PCQ-H) and establish its validity and reliability;
Objective 3. To compare the quality of primary care among homeless adults who obtain VA primary care services to the quality of care for homeless adults who obtain primary care services in a highly-customized program.
METHODS:
The study will enlist homeless patients, providers and organizational leaders in identifying relevant themes of primary care quality, using constructs available from IoM reports on primary care and quality of care. We will operationalize those themes in a patient-reported survey. Through administration of that survey to 450 homeless patients across 4 settings, we will compare primary care quality between less customized (i.e. mainstream) and more customized service delivery programs. The findings will assist the VA in determining how best to arrange primary care services for homeless veterans. The PCQ-H instrument itself will serve as a tool for future studies seeking to relate patient-reported quality to other quality indicators, and to organizational characteristics.
FINDINGS/RESULTS:
None at this time
IMPACT:
With as many as 400,000 veterans experiencing homelessness each year, the primary care of this population represents a high priority to the VHA, and a VHA-recognized "challenge." Primary care can play a central role in improving health. However, multiple studies suggest that while the VA has in many areas surpassed mainstream health systems in improving quality or reducing disparities, it has not met with similar success in assuring primary care to homeless veterans, and it may even lag behind the mainstream in regard to primary care access. While the VA most typically relies on referring homeless veterans to mainstream clinics for their primary care, data suggest that service delivery systems customized to the homeless confer benefits in outcomes and utilization. The VA has identified co-location of mental health and primary care, one of many possible elements of customization, as a priority in its Mental Health Strategic Plan for 2005, but so far made only modest efforts to advance this priority. The optimum quality measures for guiding the VHA's efforts on behalf of this VA-declared priority population, unique in its complexity, are lacking.
Starting with constructs for quality and primary care laid out by the Institute of Medicine, we seek to devise a relevant, "person-based" instrument for primary care quality for homeless patients (PCQ-H), and to compare quality across 4 environments spanning from a mainstream, noncustomized VA program to a mature and well-developed example of primary care customization. These data will provide the VHA with information to guide its ongoing effort to reconfigure homeless services, and position us to assist the VHA in implementation and in measuring the impact of future changes to service delivery in a declared priority area.
PUBLICATIONS:
None at this time.
DRA:
Health Services and Systems, Special (Underserved, High Risk) Populations
DRE:
Quality of Care, Treatment
Keywords:
Homeless, Organizational issues, Primary care
MeSH Terms:
none
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