Gabrielian Sonya, Chen Jennifer C, Minhaj Beena P, Manchanda Rishi, Altman Lisa, Koosis Ella, Gelberg Lillian
1 VA Greater Los Angeles, Los Angeles, CA, USA.
2 UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
J Prim Care Community Health. 2017 Oct;8(4):338-344. doi: 10.1177/2150131917699751. Epub 2017 Apr 1.
Homeless adults have low primary care engagement and high emergency department (ED) utilization. Homeless-tailored, patient-centered medical homes (PCMH) decrease this population's acute care use. We studied the feasibility (focused on patient recruitment) and acceptability (conceptualized as clinicians' attitudes/beliefs) of a pilot initiative to colocate a homeless-tailored PCMH with an ED. After ED triage, low-acuity patients appropriate for outpatient care were screened for homelessness; homeless patients chose between a colocated PCMH or ED visit.
To study feasibility, we captured (from May to September 2012) the number of patients screened for homelessness, positive screens, unique patients seen, and primary care visits. We focused on acceptability to ED clinicians (physicians, nurses, social workers); we sent a 32-item survey to ED clinicians (n = 57) who worked during clinic hours. Questions derived from an instrument measuring clinician attitudes toward homeless persons; acceptability of homelessness screening and the clinic itself were also explored.
Over the 5 months of interest, 281 patients were screened; 172 (61.2%) screened positive for homelessness; 112 (65.1%) of these positive screens were seen over 215 visits. Acceptability data were obtained from 56% (n = 32) of surveyed clinicians. Attitudes toward homeless patients were similar to prior studies of primary care physicians. Most (54.6%) clinicians agreed with the homelessness screening procedures. Nearly all (90.3%) clinicians supported expansion of the homeless-tailored clinic; a minority (42.0%) agreed that ED colocation worked well.
Our data suggest the feasibility of recruiting patients to a homeless-tailored primary care clinic colocated with the ED; however, the clinic's acceptability was mixed. Future quality improvement work should focus on tailoring the clinic to increase its acceptability among ED clinicians, while assessing its impact on health, housing, and costs.
无家可归的成年人初级保健参与度低，急诊科（ED）利用率高。针对无家可归者的以患者为中心的医疗之家（PCMH）可减少该人群的急性护理使用。我们研究了一项试点计划的可行性（重点是患者招募）和可接受性（概念化为临床医生的态度/信念），该计划将针对无家可归者的PCMH与急诊科设在同一地点。在急诊科进行分诊后，对适合门诊治疗的低急症患者进行无家可归情况筛查；无家可归的患者可在同一地点的PCMH或前往急诊科就诊之间做出选择。
为研究可行性，我们记录了（2012年5月至9月）接受无家可归情况筛查的患者数量、筛查呈阳性的患者、就诊的独特患者以及初级保健就诊情况。我们关注急诊科临床医生（医生、护士、社会工作者）的可接受性；我们向在门诊时间工作的急诊科临床医生（n = 57）发送了一份包含32个项目的调查问卷。问题源自一份测量临床医生对无家可归者态度的工具；还探讨了无家可归情况筛查及诊所本身的可接受性。
在感兴趣的5个月期间，共筛查了281名患者；172名（61.2%）筛查无家可归呈阳性；其中112名（65.1%）呈阳性的患者进行了215次就诊。从56%（n = 32）的受访临床医生处获得了可接受性数据。对无家可归患者的态度与先前对初级保健医生的研究相似。大多数（54.6%）临床医生同意无家可归情况筛查程序。几乎所有（90.3%）临床医生支持扩大针对无家可归者的诊所；少数（42.0%）临床医生认为急诊科设在同一地点效果良好。
我们的数据表明，将与急诊科设在同一地点的针对无家可归者的初级保健诊所招募患者是可行的；然而，该诊所的可接受性喜忧参半。未来的质量改进工作应侧重于调整诊所，以提高其在急诊科临床医生中的可接受性，同时评估其对健康、住房和成本的影响。
