Yale and the West Haven VA's "H-PACT"

David Rosenthal, MD, was working as a medical resident in Boston, Mass. when he received two job offers from Yale. Rosenthal was given a choice: he could accept a position in health information technologies or he could lead the new medical clinic for people experiencing homelessness at the West Haven facility of Connecticut’s Veterans Affairs.

Rosenthal’s exposure to patients experiencing homelessness was limited, but that didn’t stop him from learning more. He told Chris Ruser, MD, chief of primary care at VA Connecticut, “I have no idea how to care for people experiencing homelessness—I’m a little scared by it to be perfectly honest.” To decide between his two job options, Rosenthal reached out to Jim O’Connell, MD, president of Boston Healthcare for the Homeless Program.

After shadowing O’Connell and treating patients all over the city, “I kind of fell in love with the work,” says Rosenthal. “What better mission is there?” He selected the VA position.

Since arriving at the West Haven VA in 2012, Rosenthal, assistant professor of medicine and medical director of VA Connecticut’s Homeless Patient Aligned Care Team (H-PACT), and his team have made their H-PACT the top performing program out of 65 in the country.

The H-PACT system began in 2006 in Providence, Rhode Island with Thomas O’Toole, MD. O’Toole noticed how homeless veterans crowded the emergency room at Providence’s VA hospital, presenting with conditions that could have been preempted with primary care.

To address this problem, O’Toole set up a walk-in clinic specifically for veterans experiencing homelessness. Down the hall from the emergency room, the clinic catered to the specific health issues that accompany homeless life. From there, the idea for VA-funded H-PACTs materialized.

In O’Toole’s initial experiment, “he showed that if you provide a fixed site, open access model, a different model of care for people experiencing homelessness, you will reduce hospitalization and ER utilization,” says Rosenthal. “But I think the most important insight was that it improved people’s quality of care.”

West Haven’s H-PACT is made up of four permanent staff members. It is just one facet of a larger program that assists veterans with mental health and socioeconomic issues: the Errera Community Care Center. “We’re the top performing H-PACT in the country in terms of all our metrics: case management, substance abuse, [and engaging high utilizing patients],” says Rosenthal. “I think the reason is because we’re located in the Errera Center.”

The Errera Center greets veterans with an open lobby suffused with sunlight, decorated with military paraphernalia, and artwork made by the center’s veterans. On either side of the lobby, veterans can find offices to help them combat or cope with mental illness, substance use disorders, homelessness and/or aging. If they need medical care, veterans experiencing homelessness can visit the walk-in clinic on weekday mornings. There, they will find showers, laundry facilities, and soon, a kitchen, as well as the H-PACT team.

According to Chaya-Sarah Naiditch, nurse care manager, their H-PACT’s co-location with social and psychological services has been key to the clinic’s success. When patients visit H-PACT for their primary care needs, they can take the elevator upstairs to find housing assistance or other services at the same time. For veterans who may not have a permanent address where they can receive mailed appointment reminders or who lack reliable transportation, this setup may be key to ensuring they receive necessary care. Without this system, “there’s a lot more barriers to get them to come back,” says Naiditch.

H-PACT’s accessibility, the confidence patients derive from seeing the same staff each visit, and the hard work invested by staff allow veterans invest in the team and the process. Since H-PACT first came to West Haven, “medical providers have done an amazing job of connecting with veterans and building relationships that makes them feel safe and respected no matter what their circumstances. That makes them want to come back,” says Naiditch.

For the H-PACT team, these relationships set apart caring for veterans experiencing homelessness from more customary care. Comparing H-PACT versus traditional primary care, Rosalia Casorla, H-PACT’s licensed practical nurse, says, “there’s more to it. It’s more effort being able to give more of yourself to patients. [With H-PACT] you see that you’re making a difference in someone’s life. That’s what’s gratifying.”