Novel VA Program Provides Critical Resources to Homeless Veterans

By Stephanie Jordan
CANP Correspondent

Gov. Gavin Newsom first announced a homelessness task force during his State of the State address in February, calling homelessness in California an escalating human crisis. This month, he is quoted as saying, “The State of California has never had a homeless plan. The State of California has been nowhere to be found on the issue of homelessness. I know what the problem is. None of us need a report telling us what the problem is.” The task force is instead expected to meet across the state and provide Newsom with at least one annual report highlighting successful homelessness prevention strategies. The report will serve as a guide in the creation of regional plans to combat homelessness.

One such program that should be included in the Governor’s report is the Veterans Affairs Center of Excellence Interprofessional Academic-Homeless Patient Aligned Care Team (IA-HPACT), co-founded by Kristin Kopelson, a certified Family and Acute Care Nurse Practitioner and Associate Director of the program at the Veterans Affairs (VA) Greater Los Angeles Primary and Ambulatory Care Clinics.

Kopelson notes that it was during her undergrad years that her eyes were first opened to how great a place the VA is to practice. Although she ultimately went to work for UCLA for eight years, an invitation in 2004 to interview at the VA was too good to pass up.

“This is a mission-driven organization with the goal of helping vets to get to their best possible health for the long-term,” explains Kopelson. “It is a very collaborative environment with an integrated approach.”

In a November announcement, U.S. Housing and Urban Development (HUD) Secretary Ben Carson reported that veteran homelessness in the U.S. “continues to decline.” HUD’s Annual Homeless Assessment Report found the total number of reported veterans experiencing homelessness in 2018 decreased 5.4 percent since the previous year, falling to nearly half the number of homeless veterans reported in 2010. Although the new national estimate is very encouraging overall, 29 percent of the nation’s homeless vets can be found in California.

“The homeless are often looked at as an underserved population,” says Kopelson. “Here at the VA, they are not underserved, but they are a very vulnerable population. We have vast resources available to homeless vets: housing, social work, health care, case managers, etc. But first we have to get them connected to those services. This is often a challenge. Many, 80 percent or more, need mental health care services. This in itself can be a super hurdle.”

Kopelson goes on to explain that trying to get something like diabetes under control can be hampered by a patient’s paranoia. Outreach workers do their best to make inroads and earn trust in what the VA can do, if given the chance. Once a patient takes that first step towards services, Kopelson and colleagues can begin to get to work.

As the first Primary Ambulatory Care Lead Nurse Practitioner and Site Manager, Kopelson oversaw outpatient clinical care of 22,000 veterans, in addition to practicing as a primary care provider. As a member of the VA Greater Los Angeles primary care nursing leadership, Kopelson was an implementation team member of the Patient Centered Medical Home model at the VA in 2011, now better known as the Patient Align Care Team (PACT).

“It was clearly the right move for veterans,” recalls Kopelson. “Their care and satisfaction improved immensely. As a primary care provider and nurse practitioner, my team was one of two in Greater Los Angeles to receive VA Central Office recognition for Sustained Gold High Performing Team status in the first year of measurement.”

Kopelson underscores that working with the homeless vets requires a collaborative approach. “You can’t do it alone,” she states. “You need a team.”

And a well trained team to be sure. When the opportunity arose in 2015 to start a residency for NPs in homeless primary care as part of an inter-professional training team, Kopelson jumped at the chance. Kopelson co-founded the IA-HPACT, designed to educate and train the next generation of health care professionals. NP residents and students, along with other trainees from internal medicine, pharmacy, psychiatry, psychology, and social work, learn and practice as a team to effect change for this special population. It is the first academic NP residency with a homeless veteran focus, and the first NP residency in the Los Angeles area. 

“I felt poised to support the patient-centered VA health care vision and mission of PACT for the VA homeless. These patients would benefit from the teamwork and systems redesign that PACT affords,” said Kopelson. “Also, while many NPs and other health care professionals are drawn to care for vulnerable populations, it is a daunting undertaking at the start of a career. Our inter-professional and NP residency goals were to develop the trainees’ clinical and professional skills necessary to achieve competence in caring for homeless veterans. This included developing team-based care competencies. Early on, the residency leadership discovered we had a common belief that humanism would be at the core of care. Thriving in this environment would depend on the development of specific humanism traits and skills. This has guided our daily activities.”

Humanistic Care

One of the first steps with a new patient is to try to determine what circumstances led to the homelessness and to build a rapport. This can be difficult to do with homeless veterans.

“How can clinicians stay humanistic – respectful, empathic, and compassionate – with patients with complex behavioral, social, or physical issues?” asks Kopelson. “To help, in our interprofessional patient-centered medical home for homeless veterans, we designed a compact set of techniques, summarized on a pocket card, and termed it The Humanism Pocket Tool (HPT). It comprises heuristics for interacting both with patients and team members, because staying compassionate requires a culture of humanism within the clinic.”

Kopelson goes on to say that the HPT has seven techniques that can help clinicians and trainees overcome impulsive reactions to homeless veterans that are often angry, threatening, malodorous, and poorly adherent to treatment. These traits, in addition to vexing combinations of physical disorders, mental disorders, and poverty, can make treating homeless veterans challenging.

“It is easy to burn out, to de-personalize patients. It is an automatic response to react to someone that is smelly or angry. We naturally do not run toward it,” admits Kopelson. “It is not enough to want to be involved with homeless vets. We have to be prepared to prevent burnout, and we don’t always have success. We have found you must be in the right frame of mind, a humanistic frame of mind. So we use these techniques, as a team to try to get to know this special population of patients as people.”

For instance, The Humanism Pocket Tool recommends that the team know what the homeless person aspires to. Where does he or she see him or herself, and then refer to that – “Mr. X, who aspires to go to art school, is hindered by lack of money and substance use. We are working toward getting him back on his feet.” The team has learned that patients not only feel more cared for, but also can focus on the aspirations (to see a daughter, to get a job) as a higher purpose for improving their health and circumstance.

Residency is Unique

Kopelson fostered an academic partnership with UCLA, and the NP residency is now training its third annual cohort. The NP resident clinical experience includes managing the primary care of homeless veterans in a supportive team, as well as a rotation in street medicine and other electives to augment advanced clinical knowledge. In addition to NP residents, the program also precepts UCLA NP students and had its first California State University, Long Beach post-master’s mental health NP trainee this cohort.

“All trainees are mentored by interprofessional faculty to achieve professional competencies in homeless care, primary care-mental health integration, humanism, leadership, and teamwork,” concludes Kopelson. “I am so pleased to see the growth and development of our trainees in managing complex patients with a depth of knowledge beyond their years. They demonstrate confidence in community and will go forth in service with the tools to positively change outcomes.”