The H-PACT model has three main objectives: to engage homeless veterans in care, to address unmet health needs, and to facilitate the delivery of services that will help patients find permanent housing. The model, O’Toole said, “takes the best of PACT and builds on it … the idea is to really engage these high-risk veterans into care, stabilize them both socially and clinically, and then be able to transition them into a PACT team as they become more medically and socially stabilized.”
The H-PACT model has proliferated swiftly: There are 60 active sites throughout the United States, and O’Toole and colleagues are launching new studies and tracking results as more are established. “We’re literally building the plane as we’re learning to fly it,” he said.
Individuals who took part in the 2013 count of Portland, Oregon area homeless gather outside of the Portland VAMC’s Community Resource & Referral Center, which serves homeless veterans, or those at risk of becoming homeless, with access to care and benefits. During the last week of January, the VA, the U.S. Department of Housing and Urban Development, and local agencies across the country conduct Point-in-Time (PIT) counts to get a statistically reliable, unduplicated count of sheltered and unsheltered homeless veterans, individuals, and families in the United States. While much progress has been made to eradicate veteran homelessness, the 2015 PIT count of 47,700 veterans homeless on a given night means there is still work to be done.
VA photo by Kelli D. Foesch
O’Toole’s study, Aligning Resources to Care for Homeless Veterans (ARCH), is actually a series of studies funded through the VA Homelessness Health Services Research Initiative. ARCH studies have compared outcomes of the H-PACT and traditional PACT models, along with comparisons of four different variations of the H-PACT model. So far, these studies have demonstrated that H-PACT patients, overall, had fewer emergency room visits and hospitalizations and were more engaged in ambulatory care services. In addition, compared to traditional PACT care for veterans, H-PACT care costs about $10,000 less per homeless veteran per year.
The H-PACT, O’Toole said, “has been a pretty good program. And it’s been nice to have the funding available to design this research and create the evidence base as we’re pushing a new model of care through the VA.”
Addiction Housing Case Management (AHCM): The leader of this study, Andrew Saxon, MD, is a psychiatrist in the VA Puget Sound Health Care System and director of the VA Center of Excellence in Substance Abuse Treatment and Education (CESATE). The AHCM study, Saxon said, grew out of an earlier investigation of more than 700 veterans who were entering addiction treatment. A secondary analysis of their health records revealed that among this group, veterans who were homeless had worse substance abuse outcomes. “They also utilized more in-patient and emergency services,” Saxon said, “and were generally a sicker population.”
Saxon then launched the AHCM study, aimed at improving outcomes for homeless veterans entering addiction treatment: Among 181 homeless veterans in Seattle, Washington, Saxon’s team randomly assigned some who were being treated for addiction – the experimental group – to an addiction/housing case manager who would simultaneously address the issues of homelessness and substance abuse. The experimental intervention was based on an evidence-based model known as assertive community treatment (ACT), designed to overcome the chaotic circumstances that often prevent patients with chronic mental illness from receiving services. In ACT, a caseworker is expeditionary when necessary. Rather than wait for clients to arrive, he or she ventures out into the community to find clients and connect them with services – with a psychiatrist or social worker or physician, for example. Saxon’s control group, also veterans receiving addiction treatment, attended a weekly drop-in housing group led by two accomplished social workers.
The AHCM was designed to evaluate whether AHCM resulted in earlier transition into housing and/or more stable housing among veterans entering addiction treatment, and Saxon’s team learned that it didn’t appreciably improve housing outcomes. “What we found,” he said, “was that about two-thirds of the participants, regardless of experimental condition, ended up housed at the end of a year. But one-third didn’t end up housed.”
The AHCM study is a good illustration of how difficult it can be to isolate variables in such a perplexing social context. The study doesn’t prove that AHCM doesn’t work; it simply showed that it didn’t work given the complexities of this group. Further explorations of the differences between participants who did and didn’t end up in housing at the end of the year may reveal more about the complex relationship between homelessness and addiction.
Saxon’s team had early difficulties finding a sizeable population; the study was designed for an era when substance abuse treatment might have been a requirement for housing. When the VA adopted Housing First as its approach, it de-linked housing and addiction treatment, and many potential participants had no incentive to join the AHCM study. Another unexpected discovery was that the adapted AHCM approach applied resources that many potential participants viewed as simply too overwhelming, given their already difficult lives.
The AHCM study is a good illustration of how difficult it can be to isolate variables in such a perplexing social context. The study doesn’t prove that AHCM doesn’t work; it simply showed that it didn’t work given the complexities of this group. Further explorations of the differences between participants who did and didn’t end up in housing at the end of the year may reveal more about the complex relationship between homelessness and addiction.