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Homeless Veterans largely satisfied with community health care options

April 16, 2021

By Tristan Horrom
VA Research Communications

Veterans who have experienced homelessness value the option to receive health care in the community, found a study by VA researchers. The majority of Veterans surveyed had positive views of community care they received. However, coordination challenges exist when Veterans receive health care both in the community and from VA.

“Nights without shelter, current homelessness, and chronic homelessness did not appear to limit Veterans’ access to community care,” conclude the researchers. “The findings imply that the VHA’s evolution from a direct provider to a payer of health services has not impeded healthcare access for highly vulnerable Veterans.”

The results appeared in the April 6, 2021, issue of the journal Medical Care.

In 2014, the Veterans Choice Program made it possible for eligible Veterans to receive health care from private health care organizations in the community. The program uses a network of providers to expand care for VA patients who lived far away from VA facilities or faced long wait times for appointments. The program was expanded by the MISSION Act in 2018.

While helping Veterans receive care outside VA increases their access to health care services, it could also lead to coordination problems. Some concern exists that Veterans receiving care from more than one source could result in fragmented care and poor clinical outcomes.

This may be especially true in vulnerable populations such as homeless Veterans. Homeless Veterans often have complex health care needs, with high rates of chronic medical, mental health, and substance use conditions. They also often have difficulty accessing services. Because VA focuses on care coordination to manage the often-complex medical needs of homeless Veterans, there is some worry that moving care outside of the centralized VA system could cause problems.

To explore how the Veterans Choice Program affected this population, researchers surveyed nearly 5,000 Veterans in a 2018 mail survey. The survey was conducted before the MISSION Act was implemented in 2019. The survey recruited Veterans with recent experiences of homelessness from 26 VA medical centers. Fourteen percent of those surveyed were currently homeless, 15% had lacked shelter in the past six months, and 19% experienced chronic homelessness.

About 27% of those surveyed used community care. Of those, 83% said they were satisfied with the community care they received. In addition, 75% were satisfied with how quickly they were able to receive community care.

Older Veterans, female Veterans, and those managed in a homeless patient-aligned care team (H-PACT) were more likely to be satisfied with community care. Results also showed that Veterans with psychological distress and financial hardship were more likely to use community care, a finding unique to this study.

While most Veterans surveyed were satisfied with their care, care coordination did suffer somewhat, as the researchers expected. Veterans who used both VA health care and community care reported poorer care coordination than those who only used VA. Satisfaction with community care was also lower for Veterans with fewer personal resources (i.e., travel difficulties, financial hardship, and limited social support).

According to study first author Dr. Audrey L. Jones of the VA Salt Lake City Health Care System, one place to look for lessons to improve care coordination for homeless Veterans is in the H-PACT system. H-PACT is a coordination effort that is geared specifically to the needs of Veterans experiencing homelessness. “We found homeless-experienced Veterans managed in H-PACT, compared to other PACTs, were more satisfied with their time to receive community care,” explains Jones. “They also had more favorable perceptions of VA care coordination. Taking a closer look at what works in H-PACT might help the VA improve care coordination for vulnerable Veterans managed in traditional VA primary care environments.”


Although more work is needed to improve care coordination, the results show that a community care option can be valuable for homeless Veterans, according to the researchers. “Initiatives to improve the coordination of health care across VA and community care settings will continue to be important as more Veterans choose community care option,” says Jones.

The findings are part of a larger VA Health Service Research and Development (HSR&D) study to determine which factors of H-PACT matter most. The researchers, led by Dr. Stefan Kertesz of the Birmingham VA Medical Center and the University of Alabama, Birmingham, hope to identify specific components of H-PACT—such as on-site services, staffing, and team culture—that promote positive care experiences for homeless Veterans.

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