Center of Excellence – Project CTRS

Care Treatment and Rehabilitation Service (CTRS)

^{Evaluating the impacts of a novel program for Veterans experiencing unsheltered homelessness during the coronavirus disease 2019 (COVID-19) pandemic.}

^{Veterans experiencing homelessness (VEHs) are disproportionately vulnerable to disease epidemics, including the coronavirus disease 2019 (COVID-19) pandemic. To mitigate risk for COVID-19 among VEHs, the VA Greater Los Angeles created the Care, Treatment and Rehabilitation Service (CTRS), an outdoor, low-barrier to entry transitional housing option on the West Los Angeles VA Medical Center campus. The CTRS, at its inception, offered a protected outdoor environment (“safe camping”) where Veterans can live, access hygiene resources, and receive three meals/day.}

^{Though the CTRS was developed in response to the COVID-19 pandemic, it also addresses the longstanding needs of a highly vulnerable group of Veterans whose preferences and goals may not align with traditional transitional housing and other shelter resources for VEHs.}

^{This user-informed quality improvement project identifies program enhancements (e.g., provider trainings, Veteran resources, or clinical processes) that can improve appropriate VA service use and care experiences among VEHs who engage in the CTRS. The COE can develop, test, and evaluate these enhancements using a rapid cycle improvement approach.}

PIs: Lisa Altman, MD, Sonya Gabrielian, MD, MPH

Download

Care Treatment and Rehabilitation Service (CTRS): a novel service for homeless Veterans on the West Los Angeles VA campus that evolved from a sanctioned encampment to a tiny home community with on-site supportive services, 

CTRS Demographics

Average Age: 54 years (Range: 24-80)

Gender: 94% Male and 6% Female

Race/Ethnicity

• 52% White
• 41% Black/African American
• 14% Hispanic/Latino

Average length of Stay: 70 days

Service Connection: 25/105 are 100% service connected, i.e., receive $4200 a month from VA

Veterans at CTRS are highly vulnerable

• Per chart review:
• 92% had a mental health diagnosis within the past 5 years
• 65% had a diagnosis of serious mental illness (schizophrenia spectrum or other psychotic disorder or bipolar disorder) in the past 5 years
• In 2019 (year before their stay at CTRS), Veterans at CTRS had high rates of acute care use
  • 62% had 4 or more emergency department visits
  • 51% had 1 or more inpatient stays on a medical/surgical or psychiatric unit

While living at CTRS, Veterans (n=317) had low rates of engagement in traditional VA care

• 45% of 474 total primary care visits were missed
• 67% of 502 total mental health/substance use disorder visits were missed

Summary of CTRS Quality Improvement Efforts of the UCLA/VA Center of Excellence (COE) on Veteran Resilience and Recovery

Weekly Vaccine Clinics started January 2022:

• 46 COVID Vaccines administered on-site 75% of Veterans at CTRS have received 1+ COVID vaccine
• 5 Influenza Vaccines administered
• 6 Hepatitis A/B Vaccines administered (since 2/23/22)
• 8 TDAP Vaccines administered (since 3/9/22)

Narcan Prescriptions

• MDs & NPs initiated Narcan prescriptions on-site
• Veteran Narcan training/ demonstration was conducted on 3/9/22, with now 20 out of 105 Veterans having prescriptions for Narcan (represents a tripling in prescriptions since February 2022)

Hepatitis C treatment at CTRS

• Many Veterans at CTRS had active Hepatitis C but could not make it to liver ultrasound / laboratory / liver clinic appointments to initiate care, despite living on campus
• Chart Review on 2/2022 showed that 11 Veterans at CTRS had active Hepatitis C
  • 1 Veteran cured, 6 actively on treatment, 2 about to start treatment, 1 awaiting labs

Highlights

Weekly Huddle with CTRS Staff

In late October 2021, our team instituted a weekly huddle between medical providers, mental health providers, on-site Social Workers and Veteran peer support specialists, allowing us to triage patients needing medical care and establish a team approach to providing care on-site (“encampment medicine team”).

Consultations with USC Street Medicine

UCLA/VA COE funding has enabled routine consultations at CTRS with the USC Street Medicine team.

• February 2022 visit focused on Veteran and Staff Safety,
• March 2022 visit focused on Safety through Harm Reduction
• April 2022 visit focused on determining acuity of Veterans at CTRS and meeting their service needs
• The first meeting of Veteran Community Advisory board, suggested by the USC Street Medicine team and facilitated by Veteran peer advocates and a COE investigator, was on April 7^th, 2022

Encampment Medicine Team

• Doctors and Nurse Practitioners at CTRS started weekly primary care medical huddles in March 2022 to triage patients on site more effectively and make sure we were reaching the highest risk patients with our primary care services
• The huddle aimed to connect Veterans to additional VA services, including the Homeless Patient Aligned Care Teams (HPACT), mental health care, and the Mental Health Intensive Care Management (MHICM, for Veterans with serious mental illness).
• The HPACT Registered Nurse care manager was engaged to work with Veterans who are unassigned to primary care referred, aiming to get them scheduled with the HPACT
• We refer Veterans to Substance Use Disorder (SUD) clinic and providing care on-site for SUD.

Our encampment medicine team prioritizes Veterans who have high Care Assessment Need (CAN) scores, which suggest high risk for hospitalization/mortality, and those with no future appointments to make sure we are seeing Veterans who are at high risk of admission to the hospital or lost to follow up.