Discussion
high-functioning
In this community-partnered randomized clinical trial of an A-ICU intervention for medically and socially complex patients experiencing homelessness, we found no differences in hospitalizations at 6 months between those receiving A-ICU care and those receiving EUC. However, the intervention increased outpatient visits and improved patient-reported social functioning and self-rated health. These findings suggest that A-ICU and other intensive primary care interventions may have positive effects on the care of high-need, high-cost patients but may not achieve the goal of reduced acute care utilization, at least in the short term.To our knowledge, this is the first randomized clinical trial to assess the effect of an A-ICU model for patients at a FQHC with high rates of poverty and acute care utilization. Our intervention and population were similar to those in the Veterans Affairs (VA) Homeless Patient Aligned Care Team program. Data from that program showed reduced costsSeveral factors may explain why 6-month hospitalization rates did not improve. First, our EUC comparator was a high-functioning patient-centered medical home with high levels of patient access, staff members with experience in culturally appropriate care, and links to CHWsOur results and those of other studies suggest that 6 months may be too short a period to see changes in hospitalization rates. For our population of patients living in high poverty and experiencing high stigmatization with years of negative interactions with the health care system, effective use of primary and acute care services may require years and involve building rapport with clinicians, trust in health care institutions, and skills in navigating complex health care systems. In qualitative interviews, SUMMIT team members noted that our current health care system is not designed to meet the needs of this patient population.The SUMMIT intervention led to more outpatient primary care and behavioral health visits, higher social functioning, and better self-reported health. These findings are consistent with those of prior studies of intensive primary care in the VA, which showed similar increases in outpatient visits and patient satisfaction.Our results must also be interpreted in the context of the social and health-related challenges faced by SUMMIT patients. Although SUMMIT was designed to address social determinants underlying the poor health of its patients, A-ICU interventions like SUMMIT are effectively bandages for deep wounds caused by the social deprivation faced by the patients they serve. The effectiveness of intensive primary care interventions may be limited without larger policy and community-level systems changes necessary to address the living and working conditions that lead to poverty, poor health outcomes, and health inequity.