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VA's Comprehensive Approach to Ending Homelessness Brought Larger Gains than in the General Population
This analysis compared Veteran homelessness to homelessness in the general population during a 16-year study period. Findings showed that over the 13-year active period of Ending Veteran Homelessness initiative, there was a 55% decrease in homelessness among Veterans compared with a 9% decrease among the general population. Interviews with policy leaders suggest that adopting a “Housing First” policy and community partnerships played a significant role in VA outcomes. For example, one policy leader noted: Housing First served as an important counter to the “treatment first” model… which was a long-term obstacle to permanent housing for many Veterans. The decline in Veteran homelessness was coupled with substantial growth in housing vouchers, grants to community partner agencies, and growth in VA clinical and social programming to provide homeless-tailored wrap-around services and supports once Veterans were housed.
Date: January 29, 2024
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Significant Increase in Telehealth for Primary Care among Homeless Veterans Following the Pandemic
This study sought to examine the extent to which homeless-experienced Veterans used telehealth services in primary care – and to characterize users before and after the onset of the pandemic. Findings showed that despite decreased access to health information technology and low pre-pandemic telehealth use, Veterans experiencing homelessness sustained a high use of telehealth in primary care post-pandemic: 1 in 5 Veterans experiencing homelessness participated in video visits, and the majority contacted their primary care teams by phone. High telehealth use was also maintained beyond the first year of COVID-19. For example, compared to pre-pandemic, telehealth use increased substantially two years post-pandemic (video: 1% versus 21%; phone: 61% versus 77%). Women and racial-ethnic minorities had higher video uptake proportionately, suggesting that telehealth may address access disparities among these homeless-experienced patient groups.
Date: January 22, 2024
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Homelessness Associated with Increased Rates of All-Cause Mortality among Veterans with Lung and Colorectal Cancer
This study sought to characterize the diagnosis, treatment, surgical outcomes, and mortality of unhoused compared to housed patients who received care in VA for lung, colorectal cancer (CRC), and breast cancer. Findings showed that homelessness was associated with increased rates of mortality for lung and colorectal cancer, as well as later stage at diagnosis for colorectal cancer. Veterans experiencing homelessness had longer postoperative lengths of stay for all cancer types, but no differences in other treatment or surgical outcomes were observed. For all three cancers, unhoused Veterans were more commonly Black compared to housed Veterans (35% vs 16% in lung cancer, 41% vs 20% in CRC, and 45% vs 30% in breast cancer) and younger, with the average age at diagnosis 64 years (vs 69) for lung cancer, 61 years (vs 68) for CRC, and 54 years (vs 58) for breast cancer. Differences in oncologic outcomes in breast, CRC, and lung cancer between housed and unhoused patients in VA were present but smaller than observed in other settings. Thus, there may be important systems in VA that could inform policy to improve outcomes for unhoused patients.
Date: December 21, 2023
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Veterans Do Not Always Receive Appropriate Continuation of OUD Medications During Surgical Hospitalizations
This study sought to describe practice patterns of perioperative buprenorphine use within VA – and patient outcomes up to 12 months following surgery. Findings showed that the majority of VA surgical patients in this study who received buprenorphine for opioid use disorder experienced a dose hold at some point during the perioperative period despite a trend in clinical guidelines recommending buprenorphine continuation: 40% of Veterans were instructed to hold buprenorphine prior to surgery, more than 60% did not receive buprenorphine on the day of surgery, and 55% did not receive a buprenorphine dose on the day following surgery. Homelessness/housing insecurity and rural residence were the only two predictors explored in this study that were associated with decreased likelihood of a perioperative buprenorphine dose hold. Discontinuation of buprenorphine following surgery also was relatively common. One month following surgery,13% of Veterans had no active buprenorphine prescription, increasing to 25% and 33% at 6- and 12-months post-surgery, respectively. As holding buprenorphine perioperatively does not align with emerging clinical recommendations – and carries significant risks – educational campaigns or other provider-targeted interventions may be needed to ensure patients with OUD receive recommended care before and after surgery.
Date: September 20, 2021
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Personal and Community Risk Factors Associated with Unsheltered Homelessness among Veterans
This study sought to answer the question, “Among Veterans who have experienced homelessness, what distinguishes those who were recently unsheltered from those who were not?” Findings showed that among Veterans experiencing homelessness, being unsheltered correlated with individual (e.g., poverty) and community risk factors (e.g., poor access to shelter). Veterans who reported being unsheltered were more likely to report a criminal justice history, poor social support, medical and drug problems, and financial hardship, and they were more likely to be unmarried. Unsheltered Veterans more often came from communities with warmer weather and higher rent burden, and from communities with lower shelter bed availability. Having a greater number of personal and community risk factors was associated with a greater likelihood of having been unsheltered.
Date: July 15, 2021
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VA Workgroup Consensus Statement on Suicide among Homeless Veterans and What We Still Need to Learn
This article serves as a consensus statement by the recently formed VA Suicide Prevention among Veterans Experiencing Homelessness Workgroup – and provides a brief overview of current initiatives to prevent suicide among homeless Veterans. This consensus statement also discusses methods of conducting research within this complex subset of the Veteran population, as well as future research endeavors necessary to inform gaps in knowledge. While VA has implemented several initiatives to prevent suicide among homeless Veterans, there is a continued need to understand how best to tailor these initiatives. Further, because homeless Veterans often access various community services (e.g., homeless shelters, community emergency departments), an effective collaboration between VA and the community is needed.
Date: April 1, 2021
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Temporary Financial Assistance Improves Homeless Veterans’ Odds of Becoming Stably Housed
Temporary financial assistance (TFA) provides funds for rent, utility payments, security deposits, and other housing-related expenses for Veterans who have lost – or are at risk of losing – stable housing. This study sought to determine whether TFA improves housing outcomes for Veterans with housing instability. Findings showed that compared to Veterans not receiving temporary financial assistance, those receiving TFA were substantially more likely to have stable housing outcomes. Investigators also found a positive association between the amount of TFA received and stable housing. More than 90% of Veterans with TFA amounts of at least $2,000 exited the Supportive Services for Veteran Families program to stable housing. Results offer support for a continued and perhaps expanded policy shift toward offering TFA to more homeless Veterans.
Date: February 10, 2021
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Use of VHA Homeless Programs Decreases Suicide
This study assessed whether participation in VHA Homeless Programs is associated with reduced risk of all-cause and suicide mortality among Veterans with housing instability. Findings showed that the use of VHA Homeless Programs among Veterans reporting housing instability was significantly associated with reduced hazards of all-cause and suicide mortality. More than one-half of Veterans reporting unstable housing on the Homelessness Screening Clinical Reminder accessed homeless services during the observation period, and the use of any homeless service was associated with a 6% reduction in risk for all-cause mortality. The risk of both all-cause and suicide mortality was reduced significantly with each additional service used. With each additional VHA Homeless Program accessed, the risk of dying by suicide was lowered by 19%. Veterans who accessed 4 or more VHA Homeless Programs had 78% reduced hazards of suicide death compared with those who did not access any VHA Homeless Programs. Veterans’ receipt of interventions to address housing instability may be particularly important for reducing suicide risk, perhaps by addressing unmet basic human needs such as housing.
Date: November 18, 2020
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Methods of Suicide Differ Between Stably and Unstably Housed Veterans
This study examined whether Veterans’ methods of suicide varied by housing status. Findings showed that across the study period, 3% of Veterans in the study population were unstably housed. Among the 7,005 Veterans who died by suicide, 4% were unstably housed. After accounting for demographic and health factors, unstably housed Veterans had an 86% increased hazard of suicide from self-poisoning from exposure to drugs and other biological substances, compared to stably housed Veterans. Unstably housed Veterans also were more than 3 times more likely to die by suicide from jumping from a height and more than 2.5 times more likely to die by suicide from unspecified means than stably housed Veterans. Among stably housed Veterans, nearly 3 of 4 suicides involved firearms; in contrast, for unstably housed Veterans, less than half of suicides involved firearms. Understanding methods of suicide can inform prevention and intervention efforts, allowing VA to tailor suicide prevention programs for unstably housed Veterans. In particular, lethal means safety efforts (i.e., counseling and public health approaches) to suicide prevention should consider unstably housed Veterans at greater risk for using different means of suicide.
Date: April 12, 2020
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Among Veterans Who Experience Homelessness, Non-fatal Overdose is a Relatively Common Problem
Overdose is one of the most common causes of death for younger homeless individuals, but the prevalence of non-fatal overdose among the homeless is unknown. Investigators in this study administered a survey to Veterans who had experienced homelessness (current or past) and received primary care at one of 26 VA medical centers across the nation asking if they had experienced an overdose within the past three years that required an ED visit or immediate medical care (and the substances involved in the overdose) – and/or if they had witnessed someone else experience an overdose during the same time period. Findings showed that 7% reported an overdose in the previous three years. Those who reported an overdose were nearly three times as likely to have witnessed an overdose. Compared to Veterans without overdose, those reporting an overdose were younger, more likely to be white, more likely to be homeless at the time of the survey, more likely to be taking medication for mental health issues, had greater psychological distress, and were more likely to report an alcohol or drug problem. Alcohol was the most common substance reported with overdose, nearly as common as all drugs combined and more than twice as common as opioids. Improving access to addiction treatment for homeless and recently-housed Veterans, especially for those who have experienced or witnessed overdose, could protect this population. Also, given the prevalence of high emotional distress in persons who experienced overdose, enhanced mental health services could mitigate some risk for individuals residing on the streets, in shelters, or newly in housing.
Date: March 17, 2020
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VA Opioid Treatment Outcomes Vary Significantly among Homeless and Unstably Housed Veterans
To better address the opioid epidemic in Veterans who are unstably housed or homeless, it is necessary to determine where gaps in opioid-related care exist. This study examined a national sample of 59,954 Veterans who accessed VA homeless programs and represented a range of homeless experiences; 6% of this cohort (3,624 Veterans) entered a homeless program with a history of opioid use disorder (OUD). Findings showed that among the subgroup of homeless Veterans with an OUD history, opioid dose prescribing practices and rates of medication for addiction treatment (MAT) and naloxone receipt varied significantly. Less than one-quarter (23%) of Veterans received a prescription for naloxone, with homeless program-level rates of receipt ranging from 19% to 32%. Thirty-eight percent of Veterans received MAT in the year following entry into a VA homeless program, with program-specific rates ranging from 31% to 50%. Rates of high-dose opioid prescribing and concomitant opioid-benzodiazepine prescribing were highest, and rates of MAT and naloxone prescribing were lowest, among those ages 55+. Current treatment gaps indicate the need for universal policy goals to address OUD among Veterans at risk of being homeless – or who are currently or formerly homeless. Implementation strategies are needed to tailor opioid treatment access and dissemination to homeless and similar vulnerable Veteran groups.
Date: August 1, 2019
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Benefits of Medical Home Model Tailored for Homeless Veterans Versus Standard Primary Care
This study examined whether a homeless-tailored medical home model (H-PACT) offers a better patient experience than standard VA primary care. Findings showed that Veterans empaneled in H-PACT were more likely than those receiving standard primary care in the same facilities to report positive experiences with access, communication, office staff, provider ratings, and comprehensiveness. Veterans receiving standard care in facilities with H-PACT among their services were more likely than Veterans from facilities without H-PACT to report positive experiences with communication and self-management support. Patient-centered medical homes that are designed to address the social determinants of health offer a better care experience for homeless Veterans than standard primary care approaches.
Date: April 1, 2019
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Cardiovascular Care and Research for Women Veterans
This review presents important information on five areas of cardiovascular disease (CVD) care for women Veterans: 1) rapidly changing demographics; 2) prevalence of traditional risk factors; 3) prevalence of less traditional risk factors (i.e., homelessness, military sexual trauma, and mental health disorders); 4) treatment and outcomes of CVD; and 5) the current state and future directions of women’s health research. The rapidly growing population of women Veterans represents a specific at-risk population with characteristics that set them apart from their male counterparts as well as civilian women regarding CVD risk factors and CVD recognition, diagnosis, treatment, and possibly outcomes. Significant advancements have been made over the past decade in better characterizing CVD in women Veterans, but there remains a large gender gap and paucity of prospective, randomized, interventional clinical trials.
Date: February 19, 2019
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Unique Link between Homelessness and Suicide
Evidence suggests suicide rates are much higher among those who are homeless or have been homeless. This study sought to replicate these previous findings with a larger, national population cohort. After controlling for common risk factors, results suggest a unique link between homelessness and suicide. Veterans with a history of homelessness were 8.8 times more likely to have attempted suicide than Veterans with no history of homelessness (25% vs. 3%). In the total study cohort (Veterans and non-Veterans), lifetime homelessness was significantly and independently associated with lifetime suicide attempts. The association between homelessness and suicide was stronger among Veterans than non-Veterans.
Date: January 2, 2019
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Homeless Veterans Report More Positive Experiences in Facilities with Homeless-Tailored Primary Care Teams
In 2012, VA implemented homeless-tailored primary care teams (HPACTs) that could improve the primary care experience for homeless patients. This study compared the primary care experiences of homeless and non-homeless Veterans from 25 VA facilities that had HPACTs available in 2012 and 485 facilities lacking HPACTs. Findings showed that in facilities lacking HPACT programs, homeless Veterans reported more negative experiences with communication and fewer positive experiences with comprehensiveness, compared to non-homeless Veterans in the same facilities. In facilities with HPACTs, homeless Veterans reported more positive and/or fewer negative experiences with office staff, provider ratings, comprehensiveness, and self-management support, compared to non-homeless Veterans in the same facilities. Many of the domains in which homeless Veterans reported more positive experiences than non-homeless Veterans are key targets of the HPACT program. Facilities with HPACT programs offer a better primary care experience for homeless Veterans, reversing the pattern of relatively poor primary care experiences that is often associated with homelessness.
Date: July 1, 2018
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While the Numbers of Homeless Veterans Continue to Decrease, their Needs Remain Unchanged
For more than two decades, VA’s Project Community Homelessness Assessment, Local Education and Networking Groups (CHALENG) has conducted an annual national survey to assess the needs of homeless Veterans. This study compiled five years of CHALENG survey data (available since the 2011 report) and examined changes in the characteristics of geographically diverse homeless Veteran respondents and their ratings on unmet needs. Findings showed that while the sociodemographic characteristics of homeless Veterans have changed over time (i.e., increasing number of aging, female, and white Veterans), their needs have largely remained unchanged. Across years 2012-2016, there were slight increases in unmet needs related to case management, food, emergency shelter, and medical services, but the highest-rated unmet needs that affected the most homeless Veterans were related to credit, utilities, furniture, dental care, and disability income. The need for legal assistance regarding evictions and foreclosures also was reported as one of the top unmet needs for all five years. Over four of the five years, legal assistance for child support – and in three of the five years, child care also were reported as common unmet needs. Homeless Veterans have begun to identify other needs beyond obtaining housing that pertain to sustaining housing and improving social functioning. Findings highlight numerous areas that may need further attention and intervention as VA continues to prioritize ending homelessness among Veterans.
Date: May 3, 2018
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Women Veterans Who Experienced Past-Year Intimate Partner Violence Significantly More Susceptible to Housing Instability
This study used VA clinical screening data to assess the relationship between recent experience of intimate partner violence (IPV) and housing instability among women Veterans. Findings showed that female Veteran patients who screened positive for past-year IPV had up to four times the odds of experiencing housing instability. Women Veterans who screened positive for past-year IPV were significantly more likely to have an indicator of housing instability if they identified as Black or African American, previously screened positive for military sexual trauma, had a mental health diagnosis, or a substance use disorder. Women Veterans receiving compensation for a disability incurred during military service – and those who were married – were significantly less likely to have an indicator of housing instability. IPV interventions should assess for both physical and psychological housing needs, and housing interventions should coordinate with IPV programs to address common barriers to resources.
Date: April 1, 2018
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Homeless Population-tailored Patient-Aligned Care Team Can Reduce Acute Care Services and Healthcare Costs
This trial compared healthcare service use and cost outcomes among homeless Veterans enrolled in a traditional (not tailored to a homeless population) PACT with outcomes among Veterans enrolled in a homeless population–tailored H-PACT. Findings showed that annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036), and most cost savings came from fewer VA and non-VA hospitalizations. A significantly greater percentage of Veterans in the PACT arm compared to H-PACT were hospitalized for any cause (35% vs 23%), had a mental health–related ED visit (48% vs 34%), or attended group therapy (54% vs 40%). In addition, there were significant differences in primary care provider–specific visits (H-PACT 5 vs PACT 4 visits), mental healthcare visits (H-PACT 9 vs PACT 13 visits), 30-day prescription drug fills (H-PACT 41 vs PACT 59 fills), and use of group therapy (H-PACT 40% vs PACT 54%). Results indicate that a population-tailored medical home approach for socially disadvantaged populations can both reduce reliance on acute care service use and generate significant cost savings.
Date: February 15, 2018
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Special Journal Issue Features Articles by HSR&D Researchers on Homelessness among Veterans
For more than two decades, VA has dedicated substantial resources to addressing homelessness among Veterans. Moreover, in the past five years VA has spent billions of dollars on a federal initiative to prevent and end homelessness among Veterans. This special issue of Psychological Services focuses on homelessness and includes several articles by HSR&D researchers.
Date: May 1, 2017
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Engagement in Hepatitis C Virus Care among Homeless and non-Homeless VA Patients
This study sought to describe engagement in hepatitis C virus (HCV) care among homeless and non-homeless Veterans in the new era of HCV treatment, which includes direct-acting agents (DAAs) with shorter treatment durations, fewer side effects, and higher sustained virologic response (SVR) rates than the older treatment regimens. Findings showed that VA providers do a better job of testing for and diagnosing chronic HCV infection among homeless Veterans than they do among non-homeless Veterans: 90% of homeless Veterans who were estimated to have chronic HCV were diagnosed by laboratory testing compared with 77% of non-homeless Veterans. The percentage of the total homeless population with chronic HCV infection who had ever received HCV antiviral therapy (23%) was lower than the percentage of the total non-homeless population who had ever received HCV antiviral therapy (31%). However, the cumulative SVR rates achieved among homeless Veterans who had ever received HCV antiviral therapy (68%) and non-homeless Veterans who had ever received HCV antiviral therapy (74%) were comparable. Efforts are needed to identify appropriate interventions to ensure that more homeless Veterans are candidates for HCV antiviral therapy. Homelessness should not necessarily preclude receipt of HCV antiviral therapy as the direction of future HCV care and treatment eligibility criteria with all-oral DAA regimens is considered.
Date: March 1, 2017
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Effects of Homeless Veterans’ Use of Peer Mentors
This trial tested the use of peer mentors among homeless Veterans at VA primary care clinics. Findings showed that while significant impacts of peer mentors on healthcare patterns or costs were not detected, some patients engaged in frequent contact with peer mentors. Most (87%) of the peer mentor group had at least one peer contact – and spent the most time discussing housing and health issues. Patients also spent time discussing basic needs (i.e., food and clothing), VA benefits, work experience, and social issues. Peer mentor patients had more outpatient encounters, although differences were not significant. There were no other differences in utilization or costs between groups. Costs of the peer mentor intervention were estimated to be $737 per patient. Peer mentors may serve a key role in building trust between patients and providers to foster engagement with the healthcare system.
Date: February 1, 2017
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Military Sexual Trauma is Independent Risk Factor for Homelessness among Veterans, Particularly Male Veterans
This study examined the relationship between military sexual trauma (MST) and post-deployment homelessness among a large cohort of OEF/OIF Veterans, including whether the relationship varied by sex, and whether MST was a predictor of homelessness independent of other risk factors (i.e., mental health and/or substance use disorders). Findings showed that a positive MST screen was independently related to post-deployment homelessness. In unadjusted models, Veterans with a positive screen had odds for homelessness that were approximately double those who screened negative. Moreover, findings in the 30-day and 1-year follow-up cohorts suggested a greater risk for homelessness among men with a history of MST than among women. After adjusting for mental health and substance use diagnoses, MST screening status remained a significant predictor of homelessness, with Veterans who had a positive MST screen having approximately 1.5 times greater odds for homelessness than those who screened negative. Findings of greater risk among men also remained. Among Veterans with a positive MST screen, the incidence of homelessness was 2% within 30 days, 4% within one year, and 10% within five years. The stronger risk conferred by MST for homelessness among men suggests that men with a positive MST screen are a particularly vulnerable group.
Date: June 1, 2016
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Association between Separation from Military due to Misconduct and Homelessness
This study analyzed the association between misconduct-related separations and homelessness among recently returned active-duty military service members. Findings showed that the incidence of homelessness at their first encounter with VA healthcare was significantly greater for Veterans who experienced separation due to misconduct compared to Veterans with a normal separation, as well as within one year and at five years. Although only 6% of the Veterans in this study separated for misconduct, they represented 26% of homeless Veterans at their first VA healthcare encounter, 28% within 1 year of separation, and 21% within 5 years. The overall incidence of homeless among Veterans was 0.3% at the time of their first VA healthcare encounter, 1% within one year, and 2% within 5 years. These findings support reports of recently returned Veterans with records of misconduct having difficulties re-entering civilian life.
Date: August 25, 2015
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Commentary Challenges Findings in Previous Study on Housing First Approach for Homeless Veterans
Recently, VA adopted an evidence-based approach to housing and recovery known as “Housing First,” which includes: removing traditional pre-conditions to housing (i.e., completing substance abuse treatment), providing extensive support for recovery, and delivering support services according to the Veteran’s choice. However, a 2013 article offered a skeptical view of both Housing First as a recovery approach and HUD-VASH as a program. This Commentary suggests that the study reported in that article was problematic, both in its conceptualization of the matters it sought to address – and in its science. However, despite these limitations, the 2013 study highlights pressing challenges in the adoption of Housing First, including the necessity for strong resource supports for clinical care in combination with leadership actions necessary to foster institutional change.
Date: July 1, 2015
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Substantial Proportion of Homeless and Unstably Housed Veterans with Minor Children has Serious Mental Illness
This study examined the prevalence of homeless and unstably housed Veterans with minor children and compared sociodemographic characteristics, as well as medical and mental health conditions of homeless and unstably housed Veterans with and without children. Findings showed that unstably housed Veterans were more likely to have children than homeless Veterans, and women more likely than men. Among both homeless and unstably housed male Veterans with minor children, only about one-third to one-half had custody of their minor children, whereas among women, nearly all had custody of their minor children. Both homeless male and female Veterans with children were younger and less likely to have chronic medical conditions and psychiatric disorders than their homeless counterparts. However, 72% of male and 67% of female Veterans with children had a psychiatric diagnosis, and 11% of both men and women were diagnosed with a psychotic disorder. Men also were more likely to have PTSD and other anxiety disorders compared to male Veterans without children. Veterans with minor children were more likely to be referred and admitted to VA’s permanent supported housing program than other Veterans, and women with minor children in their custody were even more likely to be referred and admitted than men. Rates of referrals to mental health services were relatively low (22% and 25% for Veterans with and without children, respectively) given the high prevalence of psychiatric diagnoses in the sample.
Date: May 15, 2015
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No Significant Association between Public Support Income, VA Disability Compensation, and Money Spent on Alcohol and Drugs among Homeless Veterans
This study describes the amount of money homeless Veterans report spending on alcohol and drugs, and examines the association between public support dollars received – and VA disability compensation in particular – and dollars spent on alcohol and drugs. Findings showed that about one-third of homeless Veterans reported spending money on alcohol and about one-fifth reported spending money on drugs in the past month. However, no positive association was found between public support income and money spent on alcohol or drugs, and there was no association found between VA disability compensation and substance use. This suggests that the amount of income homeless Veterans received from disability and other public support sources did not influence their amount of substance use. Employment income was positively associated with days of alcohol use and money spent on alcohol, as well as with money spent on drugs. Other sources of income (e.g., family and friends, panhandling) were also positively associated with alcohol use and money spent on alcohol along with drug use and money spent on drugs. In contrast, public support income was negatively associated with alcohol use and money spent on alcohol.
Date: March 1, 2015
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Pilot Study Implements HIV Rapid-Testing in Homeless Shelters
Investigators in this pilot study developed and implemented an HIV rapid-testing/linkage-to-care initiative between VA and local government in Los Angeles County (LAC) to provide rapid testing in homeless shelters – and to link individuals with HIV to care. The initiative was considered a success, with stakeholders noting that the collaboration had prompted their participation in testing within homeless shelters. For example, stakeholders stated that once VA investigators were able “to solidify and secure those shelters, it was easy for us to come in… all that groundwork was done,” showing that different levels of government (i.e., federal, county, city) can work collaboratively to implement HIV testing. During the 26-month duration of the initiative, counselors made 189 visits and administered 817 tests (4.5% were to Veterans), identifying seven preliminary HIV-positive individuals. Five were confirmed and linked to care, one did not return for results, and the other refused linkage to care. Cost analysis showed that the cost per HIV-positive individual was $5,714, with costs highest during the first six months. The initiation and support provided by VA was a catalyst in allowing other agencies to concentrate resources. Investigators note this model can be adapted as a “plug and play” intervention, for the most part.
Date: January 1, 2015
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JGIM Supplement Highlights VA’s Partnered Research
In this JGIM Supplement, 12 articles describe partnered research at various stages – from conceptualizing partnered research to examples of findings borne from bi-directional collaborations with investigators and leaders from clinical operations. These articles cover a wide range of topics highly relevant to VA policy and practice, including performance measure implementation on provider motivation, opioid management, suicide prevention, homelessness, medical home models, and communication of adverse events.
Date: November 1, 2014
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Affordable Care Act May Impact Continuity of Care for Homeless VA Healthcare Users
This study compared Veterans who are likely eligible for the Medicaid expansion (LEME) and those who are not LEME, stratified by homeless status. Findings showed that among all VA healthcare users under the age of 65, homeless Veterans were two times more likely to be LEME than non-homeless Veterans (64% vs. 30%). Regardless of housing status, Veterans who were LEME were physically healthier than those not LEME. However, Veterans who were LEME were more likely to have substance use disorders and PTSD. Among homeless VA healthcare users, those who were LEME were less than half as likely to be married, to be an OEF/OIF/OND Veteran, and had less than one-third the income of Veterans who were not LEME. Among non-homeless VA healthcare users, those who were LEME were younger and more likely to be OEF/OIF/OND Veterans. Cross-sytem use of VA and Medicaid-funded services may be advantageous for Veterans with extensive medical and psychiatric needs, but also risks fragmented care. Information and education for VA clinicians and patients about possible implications of the Affordable Care Act may be important.
Date: September 1, 2014
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Only Small Percentage of Veterans with Mental Illness Access VA Employment Services
This study sought to assess the reach of Therapeutic and Supported Employment Services (TSES) over one year by examining the percentage of VA healthcare users with psychiatric diagnoses that accessed any TSES services, as well as specific types of services (i.e., supported employment, transitional work, incentive therapy, and vocational assistance). Findings showed that only a small percentage of Veterans with psychiatric diagnoses (4%) accessed even one VA employment service in FY10. Among Veterans who accessed at least one visit for employment services, 35% received transitional work, 30% vocational assistance, 28% supported employment (considered the gold standard, evidence-based practice), and 8% incentive therapy. Veterans with schizophrenia and bipolar disorder were more likely to receive any employment services and to receive supported employment than Veterans with depression, PTSD, or other anxiety disorders. Veterans with depression and PTSD were more likely to receive transitional work and vocational assistance than those with schizophrenia. African Americans, and those with a substance use disorder or an indication of homelessness were more likely to receive employment services, but were less likely to receive supported employment, specifically.
Date: July 1, 2014
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Supportive Housing May Address Homeless Veterans’ Underuse of VA Services
This study examined rates of VA healthcare use (inpatient and outpatient) among four groups of Veterans: 1) formerly homeless Veterans housed through Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH); 2) currently homeless Veterans; 3) housed, low-income Veterans not in HUD-VASH; and 4) housed, not low-income Veterans. Findings showed that currently homeless Veterans underuse healthcare relative to housed Veterans, and HUD-VASH may address utilization differences by providing housing and linkages to needed services. Veterans who participated in HUD-VASH had more inpatient, outpatient, and emergency department visits than currently homeless Veterans. Higher primary care use among HUD-VASH Veterans may explain many of the differences in service use seen between HUD-VASH Veterans and their currently homeless peers.
Date: May 1, 2014
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Characteristics and Outcomes of Homeless Male and Female Veterans
This study examined a recent national sample of homeless Veterans in the Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program to report differences between homeless male and female Veterans on individual characteristics at referral, as well as housing and clinical outcomes over a one-year period after program admission. Findings showed that among Veterans who stayed in the program, there were no gender differences in housing outcomes over time, except females tended to stay more nights in someone else’s place, while males stayed more nights in transitional housing. Homeless female Veterans were younger, more likely to have recently served in the military, had shorter homeless histories, were less likely to have been incarcerated, and were less likely to have alcohol and drug use disorders. Despite being less likely to report combat exposure, female Veterans were more likely to have PTSD than male Veterans. Homeless female Veterans also were much more likely to have dependent children with them, and to plan to live with family members in supported housing. For all Veterans, it took an average of over 40 days to be admitted to HUD-VASH after referral, an average of over 40 days to obtain a voucher after being admitted, and then an average of more than 50 days to sign a lease after obtaining a voucher.
Date: April 14, 2014
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Strong Association between Substance Abuse and Homelessness among Veterans
This study examined the prevalence of alcohol and drug use disorders among homeless Veterans entering the HUD-VASH program, and its association with both housing and clinical outcomes. Findings showed that there was a strong association between substance abuse and homelessness, particularly in Veterans with comorbid alcohol and drug use disorders. The majority (60%) of homeless Veterans admitted to the HUD-VASH program had a substance use disorder (SUD), and the majority (54%) of those had both an alcohol and drug use disorder. In the first 6 months after entering the HUD-VASH program, significant improvements were observed in both housing and clinical outcomes, with no significant differences between Veterans with and without substance use disorders on housing outcomes. However, Veterans with any substance use disorder showed improvement at a slower rate than those with no SUD.
These findings suggest that despite strong associations between SUD and homelessness, the HUD-VASH program is able to successfully house homeless Veterans with SUD, although additional services may be needed to address their substance abuse after they become housed.
Before entering supported housing, homeless Veterans with comborbid alcohol and drug use disorders had more extensive histories of being homeless than Veterans with only alcohol or only drug use disorders, while those with no SUD had the least extensive homeless histories.
Compared to other homeless Veterans, those with both alcohol and drug use disorders were most likely to have comorbid psychotic or mood disorders. Homeless Veterans with both alcohol and drug use disorders or only a drug use disorder were more likely to also have PTSD.
Date: February 1, 2014
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VA’s “Housing First” Approach to Helping Homeless Veterans Presents Several Challenges
Over the past three years VA has shifted toward a Housing First (HF) approach to its HUD-VASH program, pivoting away from the traditional approach (often termed “Treatment First”), which emphasized housing readiness prior to awarding rental vouchers. This study examined the experiences of eight VA facilities that were at varying stages of HF adoption in 2012. Findings showed that front-line staff faced challenges in rapidly housing homeless Veterans due to difficult rental markets, the need to coordinate with local public housing authorities, and a lack of available funds for move-in costs. Finding interim sheltering options for Veterans waiting for housing (i.e., with no expectations of sobriety or treatment participation) also presented a significant challenge to the implementation of HF. Staff struggled to balance the time spent on housing search activities with intensive case management of highly vulnerable Veterans; this tension is acute immediately after the release of vouchers, when facilities are closely monitored on the speed with which the vouchers are used. Facility leadership supported HF implementation through resource allocation, performance monitoring, and reliance on mid-level managers to meet the challenges of implementation. The authors suggest that HF cannot successfully proceed unless VA is able to secure housing in discrete geographies and markets. Moreover, securing housing while simultaneously advancing the recovery agenda for each Veteran remains an ambitious undertaking.
Date: January 15, 2014
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Better Experiences among Homeless Patients with Tailored Primary Care
This study compared assessments of recently or currently homeless patients across five settings that varied in their degree of homeless-tailored service design – from none (i.e., “mainstream primary care”) to intensive tailoring. Four of the five sites were in VA. Findings showed that patients rated their primary care experience more highly when their healthcare was obtained in settings that explicitly tailored services for the homeless population through variations in service design. Survey scores at the tailored non-VA site were higher (reflecting more positive experiences with care) than at the three mainstream VA sites. The tailored VA site generally had scores that were either similar to the three mainstream VA sites or somewhat higher, depending on the subscale of interest. An unfavorable experience was a 1.5 to 2 times more common in domains of patient-clinician relationship, cooperation, and accessibility/coordination for the mainstream VA sites compared to the tailored non-VA site, with the tailored VA site attaining intermediate results.
Date: December 1, 2013
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Homelessness More Prevalent among Female Veterans
This review of the literature sought to assess and summarize the body of knowledge on homelessness among female Veterans, in order to inform policy and highlight important gaps in this literature that could be filled by future research. Findings showed that female Veterans now comprise a larger share of the homeless Veteran population than of the overall Veteran population. Homeless female Veterans are characteristically different from their male counterparts, both with respect to demographic and clinical factors. For example, homeless female Veterans are younger, have higher levels of unemployment, and have lower rates of drug or alcohol dependence or abuse, but they have higher rates of mental health problems than homeless male Veterans. Female Veterans are at an increased risk of homelessness relative to the non-Veteran female population. Studies identified factors that may increase the risk of homelessness among women Veterans, including: unemployment, disability, PTSD, sexual assault or harassment during military service, anxiety disorder, poor health status, and older age.
Date: June 26, 2013
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Veterans Receiving PTSD Disability Benefits May Experience Fewer Symptoms, Less Poverty and Homelessness over Long Term
This study sought to examine long-term outcomes associated with receiving and not receiving VA disability benefits for PTSD. Findings showed that compared to Veterans not receiving VA PTSD disability benefits, Veterans receiving benefits continued to report more severe PTSD symptoms 10 years after applying for benefits, but were more likely to have had a clinically meaningful reduction in PTSD symptoms. Beneficiaries also had reduced odds of poverty and homelessness compared to denied claimants. Employment was low in both groups, and mortality was similar. On average, Veterans who had been awarded PTSD benefits and Veterans who had been denied them both experienced meaningful improvements of similar magnitude in work, role, and social functioning; however, overall functioning remained poor nonetheless. Findings counter common concerns that PTSD disability benefits impede recovery by incentivizing Veterans to remain ill, and suggest that such benefits may be helpful.
Date: October 1, 2011
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Growing VA Research Agenda for Women Veterans
This paper reports on the 2010 VA Women’s Health Services Research Conference, as well as the resulting research agenda for moving forward on behalf of women who have served in the military. Recommendations for the future VA women’s health research agenda, resulting from this conference, included, to name a few: Address gaps in women Veterans’ knowledge and use of VA services (e.g., outreach/education, social marketing, telemedicine); Evaluate and improve quality of transitions from military to VA care; Assess gender differences in the presentation and outcomes of chronic diseases; Determine reproductive health needs of women Veterans; Examine the structure and care models that support patient-aligned care teams; Evaluate variations in mental healthcare needs; Assess and reduce the risk of homelessness among women Veterans; Conduct research on post-deployment reintegration and readjustment among women Veterans; and Develop combat exposure measure(s) that reflect women Veterans’ experiences.
Date: July 6, 2011
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Effect of Housing Vouchers on Homeless Veterans with Mental Illness
This study examined how homeless Veterans with mental illness obtain housing without a voucher, and whether greater employment earnings or better clinical outcomes were associated with such housing success. Findings showed that Veterans who obtained independent housing without a voucher worked more days and had higher employment income than those with a voucher, but they were less satisfied with their housing. Veterans who used vouchers lived in housing with the highest rent, but paid less of their own income toward rent because of their vouchers. They also reported the highest quality of life with respect to their living situation, higher satisfaction with their housing, and higher safety scores. About one-third of Veterans who obtained independent housing without a voucher lived with others, most often with a family member, and reported lower total rent costs, but paid the greatest share of the rent themselves. Approximately 80% of participants were diagnosed with alcohol or drug dependency. There were no differences in psychiatric, substance abuse, or legal outcomes between groups at three months; however, data over all three years shows that Veterans who were not housed had higher psychiatric, substance abuse, and work problems over time than all other groups.
Date: May 1, 2011
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Homelessness Affects Substance Use Treatment Outcomes and Costs among Veterans
This analysis evaluated homelessness among Veterans who had entered VA outpatient substance use disorder treatment, and also explored associations between housing status, treatment outcomes, and use of VA services over one year. Findings suggest that the problem of homelessness among Veterans with substance use disorders remains large, with 65% of 622 Veterans in this study spending at least one night homeless at some point during the study period. Veterans experiencing homelessness during the six months prior to treatment admission had more severe alcohol, medical, employment, legal, and psychiatric problems than Veterans with housing. Abstinence rates did not differ between the homeless and housed groups, and about 65% of participants in each group remained engaged in treatment for 90 days. In addition, results showed that homeless Veterans used more services and had higher total costs than housed Veterans, e.g., homeless Veterans had more inpatient admissions and were more likely to use the emergency room.
Date: July 1, 2010
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Predictors Associated with Homelessness among Women Veterans
Among women Veterans, being unemployed, disabled, or unmarried were the strongest predictors of homelessness. Homeless women Veterans also were significantly more likely than housed women Veterans to have low incomes, to have experienced military sexual assault (53%), to be in fair to poor health, to have diagnosed medical conditions, and to screen positive for anxiety disorder and/or PTSD. Homeless women Veterans were significantly less likely than housed women Veterans to be college graduates or to have health insurance, but were more likely to have used mental health services, VA health care, or been hospitalized in the prior 12 months. Homeless Veterans had an average of four entries into and exits out of homelessness, and the median length of time they spent being homeless (over lifetime) was 2.1 years. Of the homeless women Veterans, 16% had children under the age of 18 living with them in the prior 12 months.
Date: February 1, 2010
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Strong Association between Homelessness and Incarceration among Veterans with Bipolar Disorder
This study assessed the association between homelessness and incarceration in 435 Veterans with bipolar disorder who received inpatient or outpatient care at one large, urban VAMC from 7/04 to 7/06. Findings show that homelessness and incarceration are common among Veterans with bipolar disorder, and share many risk factors. Among Veterans with bipolar disorder, 12% reported having been homeless in the previous four weeks, and 55% reported ever having been homeless or incarcerated. Results also show that lifetime experience of homelessness was associated with 4-fold increased odds of lifetime experience of incarceration. Moreover, recent homelessness was strongly related to recent incarceration. Programs that better coordinate psychiatric and drug treatment with housing programs may reduce the cycle of incarceration, homelessness, and treatment disruption among this vulnerable patient population.
Date: May 1, 2009
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Access to Healthcare among Veterans with Bipolar Disorder
Findings from this study show that despite the fact that all Veterans were currently receiving VA treatment for bipolar disorder, 15%-20% experienced trouble obtaining different aspects of healthcare when needed. Compared with accessing psychiatric care, Veterans with bipolar disorder reported greater difficulty accessing general medical services. Veterans experiencing current bipolar symptoms more frequently avoided psychiatric care due to cost, and perceived greater problems accessing medical specialists. As with mental healthcare services, the dominant influences predicting limitations in obtaining needed general medical care included living alone, an inpatient stay, homelessness, and current bipolar symptoms. The authors suggest that current VA efforts to expand mental healthcare access should be coupled with efforts to ensure adequate access to medical services for Veterans with chronic mental illness.
Date: April 1, 2009
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