Housing For Health in the Veterans Affairs Greater Los Angeles Tent Community

THE INNOVATION

In response to the COVID-19 pandemic, the Veterans Administration (VA) Greater Los Angeles Healthcare System initiated an innovative approach to providing integrated primary care services (Supplemental Figure 1). The Care, Treatment and Rehabilitation Services (CTRS), a unique street medicine program, was placed within an encampment that is supported by the West Los Angeles VA health care services and includes onsite provision of 24/7 security, stability of tent sites, 3 meals a day, unlimited water, hygiene stations, face masks, showers, and housing placement services (Supplemental Figure 2).

WHO & WHERE

We are primary care clinicians in a VA interprofessional, academic patient-centered medical home, known as the Homeless Patient Aligned Care Team (HPACT). We implemented a primary care street medicine clinic to treat veterans admitted into the CTRS program.

HOW

The medical team consisted of 5 nurse practitioners, 2 primary care physicians, and 1 preventive medicine physician. During the period of establishment of the primary care program in CTRS, (6/23/2020-8/7/2020), 110 veterans were admitted into the program. Of the 110 veterans, 64 were seen and treated by the medical team. Medical visits were conducted on-site either in front of the veteran’s assigned tent or in a secluded area on the tent site (Supplemental Figure 3). All veterans were tested for COVID-19 within 24 hours of admission and monthly thereafter. Initial medical services focused primarily on the delivery of episodic or urgent care, which did not address the complex medical needs and chronicity of conditions that the veterans were experiencing. The majority were empaneled to a primary care team, but many did not seek routine primary or mental health care. As a result, we changed our approach from solely providing episodic care to building a foundation for delivery of holistic veteran-led primary care.

To conceptualize the delivery of street primary care, we established 5 categories of care (Supplemental Figure 4). This approach aimed to optimize the veteran’s current care team, if they had one, while providing needed care on-site. Many veterans exhibited active substance use disorder, uncontrolled chronic medical and mental health conditions, and social isolation, which necessitated an interprofessional approach of collaboration with psychiatrists and psychologists via iPad video visits.

Adherence to the treatment plan centered on successful engagement of the veteran. As this population is highly vulnerable, disengaged, and distrustful, multiple meaningful interactions were needed to build trust, engagement, and a partnering in care.

Characteristics of the veterans are presented in Supplemental Table 1. Only 2 of the veterans tested positive for COVID-19 and the average Care Assessment Need Score was 90 among the highest medical severity of any veterans.

LEARNING

The innovation of a multilevel approach to primary care provision within a federally run, low-barrier tent encampment is applicable to other programs working with unhoused populations. Structuring care that is veteran-led, using interprofessional collaboration across a wide network of social and health care services provides efficient care that avoids duplication of primary care services. Future implementation will include HOUSED BEDS Plus, a targeted street medicine–oriented assessment (Supplemental Figure 5) and interventions related to substance use disorders, serious mental illness, cognitive impairment, and functional limitations.