2023 HSR&D/QUERI National Conference

1187 — Migration to Health Care among Unstably Housed Veterans Living in Rural Areas

Lead/Presenter: Ann Elizabeth Montgomery,  Birmingham VA Health Care System
All Authors: Montgomery AE (Birmingham VA Health Care System, University of Alabama at Birmingham School of Public Health), DeRussy A (Birmingham VA Health Care System) Byrne TH (Center for Healthcare Organization & Implementation Research, Boston University School of Social Work) Nelson RE (IDEAS Center, VA Salt Lake City Health Care System, University of Utah School of Medicine)

Housing instability is associated with adverse health outcomes and is a barrier to health care access. This may be especially true among Veterans experiencing housing instability in rural areas, given that they are less likely to access Veterans Health Administration (VHA) health care and services to address other needs, such as housing, are scarce. The objective of this study is to explore whether Veterans experiencing housing instability in rural areas are more likely than their urban counterparts to migrate and the association with their use of health care services.

The study sample comprised Veterans with an incident indicator of housing instability (n = 559,513), about 23% of whom either live or access services in a rural area. We conducted a discrete-time survival analysis with person-quarter as the unit of analysis to predict migration (i.e., a single geographic relocation of [a] more than 40 miles or [b] less than 40 miles and a change in urban/rural status), controlling for sociodemographics, geographic location, and services use (i.e., outpatient and inpatient medical, mental health, and substance use services as well as emergency department care).

Compared with Veterans identified as unstably housed in urban areas, those in rural areas had greater hazards of migration (hazards ratio 1.35, 95% confidence interval 1.33 – 1.37) and do so, on average, one quarter sooner than urban counterparts after being identified as unstably housed (i.e., the median time to migration is 4 vs 5 quarters, p < .001). Controlling for urban/rural location, a number of other characteristics were associated with increased hazards of migration: race other than Black/African American; younger age; receipt of compensation related to a service-connected disability; VHA services use including inpatient substance use care, inpatient and outpatient mental health care, and emergency department use; and use of VHA Homeless Programs.

This study provides evidence that unstably housed Veterans either living in or accessing care in rural areas have an increased risk of migrating over a 5-year period. This is particularly the case among those who have accessed VHA Homeless Programs and care related to behavioral health needs.

Results of this study are important to ensure that Veterans experiencing housing instability in rural areas—a particularly understudied and vulnerable population—receive assistance to address their housing and health care needs.