Comparing homeless persons' care experiences in tailored versus nontailored primary care programs

Abstract

Objectives: We compared homeless patients' experiences of care in health care organizations that differed in their degree of primary care design service tailoring.

Methods: We surveyed homeless-experienced patients (either recently or currently homeless) at 3 Veterans Affairs (VA) mainstream primary care settings in Pennsylvania and Alabama, a homeless-tailored VA clinic in California, and a highly tailored non-VA Health Care for the Homeless Program in Massachusetts (January 2011-March 2012). We developed a survey, the "Primary Care Quality-Homeless Survey," to reflect the concerns and aspirations of homeless patients.

Results: Mean scores at the tailored non-VA site were superior to those from the 3 mainstream VA sites (P < .001). Adjusting for patient characteristics, these differences remained significant for subscales assessing the patient-clinician relationship (P < .001) and perceptions of cooperation among providers (P = .004). There were 1.5- to 3-fold increased odds of an unfavorable experience in the domains of the patient-clinician relationship, cooperation, and access or coordination for the mainstream VA sites compared with the tailored non-VA site; the tailored VA site attained intermediate results.

Conclusions: Tailored primary care service design was associated with a superior service experience for patients who experienced homelessness.

FIGURE 1—

Unfavorable experiences in primary care, among persons receiving primary care in 5 different primary care programs, January 2011–March 2012. Note. VA = US Department of Veterans Affairs. Unfavorable experience was defined based on the number of “frankly unfavorable” responses falling into the highest tertile observed for that particular scale (i.e., agree or strongly agree with a negatively worded item, or disagree or strongly disagree with a positively worded item). The highest tertile for unfavorable responses was found to be 2 or more frankly unfavorable responses for the relationship, cooperation and access/coordination scales, and 1 or more frankly unfavorable responses for the homeless-specific needs scale. Tailored non-VA refers to a 26-year old Health Care for the Homeless Program. Mainstream VA sites are non-tailored primary care sites in Pennsylvania (A), and Alabama (B and C). Tailored VA is a VA homeless-tailored primary care program (California). *P < .05; **P < .01.