# Primary Care Continuity and Utilization Patterns for Veterans With Homeless Experience

## TL;DR

Veterans who have experienced homelessness had better primary care continuity when treated in clinics specifically tailored for them, compared to general clinics.

## Contribution

This study demonstrates that homeless-tailored clinics improve primary care continuity without increasing reliance on emergency or specialty care.

## Key findings

- VHEs in H-PACTs had higher primary care continuity compared to mainstream PACTs.
- H-PACTs were associated with fewer specialty visits and lower emergency department use.
- Tailored clinics did not substitute specialty or emergency care for primary care.

## Abstract

This cohort study examines whether veterans with homeless experience receiving care in homeless patient aligned care teams vs mainstream patient aligned care teams have different levels of primary care continuity.

How do continuity and patterns of care differ between primary care clinics tailored for veterans with homeless experience (VHEs) compared with nontailored clinics?

This cohort study involving 2271 VHEs found that VHEs in tailored clinics had significantly higher continuity than VHEs in nontailored clinics, with no indication of substitution of specialty or emergency visits for primary care.

These findings suggest that tailored primary care clinics may result in higher continuity and overall less intensive health care delivery for this vulnerable population.

Continuity of care is a key aspect of high-quality primary care. Vulnerable populations often experience fragmented care. Some US Department of Veterans Affairs (VA) clinics offer primary care in patient aligned care teams (PACTS) tailored for veterans with homeless experience (VHE), termed H-PACTs.

To test the hypothesis that primary care continuity would be higher for VHEs in H-PACTs than for VHEs in mainstream VA PACTs and to compare other service utilization patterns by primary care clinic type.

Retrospective observational cohort study including national survey data combined with VA electronic health records data from primary care clinics at 26 VA medical centers. Participants were VHEs who completed the national survey and had 2 or more primary care visits in the 12 months before the survey. The survey was completed between April and October 2018 and data were analyzed from April 2020 to November 2025.

Enrollment in H-PACTs or mainstream PACTs.

Continuity was calculated using the usual provider of care (UPC) measure, which is the proportion of primary care visits with the most frequently seen clinician. High continuity was defined as a UPC of 0.75 or higher. Multivariable regression models examined the association of H-PACT enrollment with high continuity, and other utilization measures included mental health, specialty visits, emergency department (ED) visits, and hospitalizations.

A total of 2271 VHEs in H-PACTs (2140 [94.2%] male; 932 [41.0%] Black, 1050 [46.2%] White, and 263 [11.6%] other; mean [SD] age, 58.1 [9.3]) and 1627 VHE in mainstream PACTs (1393 [85.6%] male; 674 [41.4%] Black, 740 [45.5%] White, and 192 [11.8%] other; mean [SD] age, 60.7 [12.1]) were included. Compared with those in mainstream PACTs, VHEs in H-PACTs had a higher mean (SD) UPC (0.81 [0.23] vs 0.77 [0.25]; χ21 = 21.6; P < .001) and were more likely to achieve high continuity (1483 patients [65.3%] vs 938 [57.7%]; χ22 = 25.0; P < .001). After multivariable adjustment, care in H-PACTs remained associated with high continuity (odds ratio [OR], 1.48; 95% CI, 1.33-1.66). In adjusted analyses, compared with those in mainstream PACTs, VHEs in H-PACTs had significantly more primary care visits (4.6 vs 4.0; z score = 5.28; P < .001), fewer specialty visits (6.2 vs 7.9 visits; z score = −4.66; P < .001), and were less likely to have an ED visit (OR, 0.83; 95% CI, 0.75-0.92).

In this study, VHEs in H-PACT clinics had higher primary care continuity with no indication of substitution of specialty or emergency visits for primary care. The H-PACT model is associated with less intensive health care delivery.