• Despite health insurance often being used as a surrogate measure for having access to and receiving care, prior researchers have found that the previous negative health care experiences homeless persons have had can influence their health-seeking behavior and receipt of future care. In this paper, the researchers examine homeless veterans’ past experiences and attitudes about care, motivating interests in wanting health care, reasons for not having a source for regular care, and if they reported needing care and not getting it in the previous six month.
• Using a prospective, community-based randomized controlled trial of homeless veterans eligible for but not receiving primary, the researchers found that some of the main reasons homeless veterans delayed seeking primary care were because of lack of trust of health care providers, stigma associated with being homeless, the health care process, and health care not being affordable.
• Among homeless veterans reporting a need for care, 66.2% reported seeking and receiving care at either an emergency department or an urgent care setting. Additionally, substance abuse was a significant reasons for some homeless veterans not seeking care.
• The findings in this study identify how homelessness and poverty serve as a barrier to health equity and access, and underscore the role of social determinants in defining health equity and health disparities. Furthermore, homelessness is a potential marker for underlying attitudes, preconceptions, and misconceptions drawn from negative past experiences.
“We describe data from a multi-center community- based survey of homeless veterans who were not accessing available primary care to identify reasons for not getting this care as well as for not seeking health care when it was needed. Overall, 185 homeless veterans were interviewed: The average age was 48.7 years (SD 10.8), 94.6% were male, 43.2% were from a minority population. The majority identified a recent need for care and interest in having a primary care provider. Reasons for delaying care fell into three domains: 1) trust; 2) stigma; and 3) care processes. Identifying a place for care (OR 3.3; 95% CI: 1.4-7.7), having a medical condition (OR 5.5; 95% CI 1.9-15.4) and having depression (OR 3.4; 95% CI: 1.4-8.7) were associated with receiving care while not being involved in care decisions was associated with no care (OR 0.7; 95% CI 0.5-0.9). Our findings support the importance of considering health access within an expanded framework that includes perceived stigma, inflexible care systems and trust issues.”
People working with homeless veterans and nonveterans need to be aware of unmet need for health care that would benefit from going to a primary care provider for care as well as any perceived barriers that person may have in accessing care in non-acute settings. The VA has established a network of clinics specifically dedicated to providing wrap-around point-of-contact continuity care to homeless Veterans (Homeless PACTs) and those doing outreach should try to connect Veterans to this program. All clinicians need to recognize a health care event as an opportune time to address underlying causes of homelessness and work with their homeless patients to develop pathways out of homelessness that include access to timely, relationship-driven care. Being aware of potential negative perceptions in establishing that relationship is important. Health care administrators should remain aware that not all homeless patients know how to navigate the health system or necessarily what to expect from that care, and they need to explore ways they can make accessing care and the care being provided amenable to the needs of homeless persons. Since homeless persons might not always have health insurance, health providers and administrators should offer assistance with paying for health care, and clearly explain the billing process.
The VA has made ending homelessness among veterans a top priority. The VA needs to continue to connect homeless and at-risk veterans with health care services and supports and expand programming that has shown to be effective in engaging them in needed care and services.
For Future Research
Despite the significant implications of this study, including implementing population-tailored approaches to the organization and delivery of health care services to homeless veterans, this study has several limitations. The findings may not be generalizable to all homeless veterans in the United States since the study was based in the northeast. Additionally, almost 95% of the sample were men,
with the average age being 48.7. Given the increase in women veterans, future studies on primary care and homeless veterans should oversample homeless women veterans to have a more representative sample of women. Another limitation is that the findings presented are from survey data. As a result of the survey data, responses could have been influenced by social desirability bias or do not correlate with actual behavior. To reduce social desirability bias, future researchers should consider utilizing other methods of collecting data, such as mixed-methods.