Primary Care Continuity and Utilization Patterns for Veterans With Homeless Experience

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.