An evening primary care clinic for homeless veterans: A social determinants approach to intensive care management for complex, vulnerable, high-utilizer patients

In the US Department of Veterans Affairs (VA), a patient-centered medical home model known as the Patient Aligned Care Team (PACT) and related population-oriented primary care approaches have been advocated to improve healthcare coordination, particularly for vulnerable, homeless Veterans. Meanwhile, recent expansion of a VA Housing-First model shows promise in housing homeless Veterans. In practice, integration of these healthcare and housing models is poorly understood. In a VA-funded demonstration project in Los Angeles, we adapted Social Determinants of Health, Community Oriented Primary Care (COPC) and Ambulatory Intensive Caring Unit (AICU) approaches to establish a clinic for homeless Veterans with complex social and medical needs and high utilization of emergency and inpatient services. Preliminary results show 7 month reductions in emergency department utilization (36%) and hospitalizations (33%). We also observed improvements in 'vertical' and 'horizontal' integration among health, housing and social service sectors. This approach represents a model for coordinated, intersectoral action to improve health and social determinants for high-utilizer homeless adults and other complex, vulnerable patients. To our knowledge, this is the first approach to describe the application of the World Health Organization's Conceptual Framework for Social Determinants of Health Interventions in the design of homeless healthcare delivery and one of the first applications of the AICU model to care for high-risk homeless adults.