While working as a primary care doctor at a Department of Veterans Affairs hospital in Rhode Island a decade ago, Thomas O’Toole realized that large numbers of homeless veterans and those at risk of winding up on the streets were not receiving the medical care or the housing assistance, food and social services they desperately needed.
O’Toole responded by establishing a clinic that integrated medical care and support services for veterans—an initiative that has since expanded into a national program now available at 62 VA medical facilities. O’Toole followed this successful pioneering effort by creating a second national project now operating at those 62 medical facilities that identifies and helps homeless veterans who repeatedly need acute medical services.
“Tom’s leadership, innovation and creativity—his willingness to think outside of the box—have been a huge factor in ensuring we can reach a tough, sick population and do right by them,” said Lisa Pape, executive director of the Veterans Health Administration Homeless Program.
The two initiatives started by O’Toole are critical elements of achieving the Obama administration’s goal of preventing and ending veteran homelessness.
O’Toole, now the director of the VA’s National Center on Homelessness Among Veterans, initially piloted his Veterans Patient Aligned Care Team program in 2006 in Rhode Island, and began expanding it nationwide in 2011. The program provides comprehensive medical, mental health, case management and social services in one setting for the highest-risk, highest-need homeless veterans who are unable or unwilling to get the care they need through traditional channels.
The VA said that about 18,000 veterans are enrolled in this national program at any given time, and about 25,000 participate on a yearly basis. Based on an analysis of data over one year, the VA said there was a net reduction of 3,222 emergency room visits and 872 hospitalizations for the participants, leading to an estimated savings of $14.1 million per quarter in health expenditures.
“It became pretty clear what we were doing as a medical unit wasn’t necessarily on par with what we could be doing and should be doing with an extremely vulnerable population group,” O’Toole said of the incorporation of social services with health care. “Our whole focus is, how do we engage veterans in a care system by making it more responsive to their needs?”
Vincent Kane, associate director of the VA Medical Center in Lebanon, Pennsylvania, said, “The marriage of medicine with social work case management was a game-changer.”
In 2014, O’Toole initiated the Hot Spotter project, his second major initiative. This project works through the 62 established aligned care programs and identifies and assists the roughly 10 percent of homeless veterans who use 65 to 70 percent of the VA’s acute health services.
During the past year, more than 6,500 veterans were helped through comprehensive care plans developed to address the root causes of their recurring health and social problems. The plans involved expediting housing placement; facilitating access to clinical services for substance abuse treatment, mental health care or chronic disease management; and educating the veterans on how to get care without going to an emergency room when their situation is not urgent.
“Homeless veterans who frequently go to the emergency room are called super-utilizers” and rack up extraordinarily high hospital bills, said Dr. Madhulika Agarwal, VA deputy undersecretary for health and policy services. She added that the Hot Spotter project has provided a means of intervention to keep homeless veterans out of the hospital and provide them with a better quality of life.
O’Toole’s work at the VA has been “innovative, compassionate and inspiring,” Agarwal said.
“He is someone who thinks about nothing other than how to do the most public good for those who have been given the least,” she said.
Dr. Rajiv Jain, a retired VA assistant deputy undersecretary, said O’Toole has had “a significant and substantial effect on veteran health care.’’
“It takes a very special person to look after this most challenged patient group,” said Jain. These are not your regular patients. They are not always compliant and they are not able to communicate well.” He added that O’Toole “cares deeply about these patients and that is visible in his work.”
O’Toole now is working on medical transitional care for homeless veterans who are too sick to sleep in a shelter but not sick enough to be in a nursing home.
“This is another great innovation that Tom came up with, to figure out how we can meet the needs of this in-between population,” said the VA’s Pape.
These homeless veterans have served the nation,” O’Toole said. “It is our moral obligation to provide care and service, to really be our brother’s keeper.”
“To see so many vets succeed and advance in their lives, to be a part of something as profound as seeing somebody’s life come back, is incredibly satisfying on a very personal level.”