Food insecurity among homeless Veterans approaches 50% (O’Toole 2017). Several activities addressing this need have been initiated, including clinical screening in the VA Homeless Patient Aligned Care Team (HPACT), based in building 402, food distribution on campus to general VA population (Thursday 12-1:30pm), food distribution in HPACT, internship for UCLA undergraduates to assist in clinic, Healthy Teaching Kitchen, and potentially the Veterans Garden. Westside Food Bank is an active community partner.
Currently in a late pilot stage, the HTK is an implementation of a VA national program, and operates weekly Thursday 11am-1pm. Preventive Medicine Resident Kay Hooshmand (PM2) is developing a curriculum (for patients, and health professionals in the future) and evaluation plan. There is potential to collaborate with many partners, develop additional days, and additional sites, determine operational best practices, best patient populations, and collaborate with UCLA and national groups.
The recently completed VA Master Plan for the West Los Angeles medical center campus outlines an extensive land-use and development intervention to assist in alleviating Veteran homelessness. There is limited mention of the Veterans Garden which in the past has been a small functioning farm of approximately 10 acres. There are many stakeholders interested in revitalizing this space, including UCLA and community partners, but at this time there is no formalized oversight of the area.
Through the VA HUD-VASH program there are approximately 4,500 Veterans living in the community with rent subsidies and case management coordinated by the VA. There are approximately 3,500 patients empanelled HPACT in the West Los Angeles system, overlapping with with the HUD-VASH population. Social needs among these population are significant, and addressing social determinants of health is a priority of HPACT (O’Toole 201x). Community groups and other community assets could be coordinated at the population or community level using existing community partners (Healthy African American Families - HAAF) and other community groups. One example cited in a recent IOM report discussed community partnerships to reduce outlets selling alcohol. Community based approaches require targeting based on where Veterans live using tools like Geographic Information Systems (GIS) in which the VA has robust tools.
The VA employees several homeless outreach workers who canvass Los Angeles in search of homeless Veterans. HPACT providers and trainees have worked with outreach workers in the past to encourage Veterans to seek medical and mental health care. Current outreach workers have limited training, and often do not used motivational interviewing approaches, or do not see themselves as community health workers as defined by other organizations, but have the potential to contribute in those ways.
Homeless and formerly homeless Veterans have higher prevalence of hepatitis C than other groups. An ongoing project has initiated treatment in HPACT. Ongoing efforts require patient identification and coordination in which there is a robust system in place. This represents a mature population management intervention program that can be instructive to participate in.
Possibly the single leading cause of medical care spending in the VA system, there is little oversight of the identification and treatment of patients (it is a collateral duty of a single provider at each medical center and clinic). While annual screening of tobacco use is conducted with high fidelity, the resulting referral and treatment pattern is not well measured. Not effort is made to prioritize treatment by disease state or demographics. Access to care is not a limiting factor, likely because clinical interventions include telephone, group, and video conferencing technologies in place of one-on-one, face-to-face, encounters.
Group visits are an example of a clinical care model that focuses on patient experiences and knowledge, combined with multiple clinical perspectives, often addressing chronic medical conditions or other problems based which in part require behavior change. Clinically superior for many conditions, it is also an efficient method to deliver services. As health systems focus more on disease prevention and wellness, group visits could be a model that assists in transitioning from disease care to health care.
To further the mission of the UCLA Preventive Medicine Residency requires telling the story of the projects we complete, the people we serve and the residents/fellows and community partners who complete the projects. This can be done through both traditional methods (publications, conference presentations) and new methods (web, social media).