This quality improvement (QI) dissertation is a case study of the homeless-oriented Patient Centered Medical Home demonstration program, referred to as the Homeless Patient Aligned Care Team (HPACT) at West Los Angeles VA Medical Center (WLA). The WLA HPACT program was implemented to address the complex needs of the homeless and at-risk for homelessness population using the Patient Centered Medical Home model (PCMH) - a multi-disciplinary, team-based approach to primary care. Unlike traditional PCMH models, the WLA HPACT demonstration program employed a series of complex care management interventions to tailor care for homeless Veteran patients. The primary goal of the WLA HPACT demonstration program was to decrease the number of emergency department (ED) visits among patients assigned to the WLA HPACT team by identifying tools and processes to perform complex care management for the WLA HPACT panel of patients. This dissertation identifies barriers and best practices to address needs of WLA HPACT patients to support the demonstration program's goal of decreasing their ED utilization.

Tis problem-solving QI dissertation was carried out in three phases - literature review, diagnosis, and implementation. In the first phase, we conducted a literature review of the factors contributing to homeless Veteran ED utilization patterns. In the diagnosis phase, we undertook a local needs assessment (conducted by informal stakeholder focus groups) to determine the organizational context for the WLA HPACT program and how to best evaluate HPACT's objective to reduce ED utilization rates for HPACT patients. The implementation phase of this QI dissertation employed a mixed-method progress-focused formative evaluation to examine patient characteristics, intervention processes, ED utilization patterns, staff perceptions on perceived barriers and interventions to address gaps in care to decrease ED visits for current HPACT patients. The evaluation used qualitative key informant interviews and quantitative descriptive data analysis.

The findings of this early implementation QI project inform clinical and organization processes for the WLA HPACT demonstration program that should be considered for on-going implementation. Recommendations for future implementation include complex care management interventions for patients with pain needs, substance abuse conditions, as well as modifications to organizational features of the program such as hours of operations, and team composition.