Each week the monthly spotlight features a topic-related HSR&D study.

Spotlight on Homelessness

Identifying and Measuring Risk for Homelessness among Veterans

January 2020

Introduction

In January 2019, the U.S. Department of Housing and Urban Development’s (HUD) Point-in-Time (PIT) count showed that nationally 37,085 Veterans experienced homelessness. This number represented a 2% decline over the previous year’s count¹. While the number of homeless Veterans remains high, it is half of what the homeless Veteran population was in 2010³. Most are male, while about 9% are female, and nearly half are African American or Hispanic. Homeless Veterans served in conflicts from World War II to the current wars in Afghanistan and Iraq. Nearly half served during the Vietnam era⁴.

VA offers multiple specialized programs to help homeless Veterans including Grant/Per Diem and Compensated Work Therapy programs, as well as Domiciliary, Substance Use, and PTSD Residential Rehabilitation and Treatment. VA has established research centers including the National Center on Homelessness among Veterans and the Northeast Program Evaluation Center (NEPEC). Among important findings are that trauma, childhood problems, and discharge status have correlations to Veteran homelessness, and that Veterans’ housing and mental health improved with free legal services in a VA facility⁵.

HSR&D continues to make research into Veteran homelessness a high priority. Examples of HSR&D research include studies investigating how to screen Veterans to determine if they are at-risk of becoming homeless, how to keep those at-risk Veterans from losing housing, and how best to assist currently homeless Veterans⁶. Following are examples of recent and ongoing research by HSR&D investigators into this important topic.

• Identifying and Measuring Risk for Homelessness among Veterans
• Quality of Care for Hepatitis C in Veterans Who Are Homeless
• Group Motivational Interviewing for Homeless Veterans in VA Services
• Patient-Aligned Care Teams Tailored to the Homeless Can Reduce Acute Care Services and Healthcare Costs

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Identifying and Measuring Risk for Homelessness among Veterans

Impact: This research highlights how screening for housing instability among Veterans accessing outpatient healthcare can link them with responsive interventions.

Veterans are overrepresented within the homeless population and have greater risk of homelessness compared to the general population living in poverty. VA has focused programming and policies on ending chronic Veteran homelessness and preventing new episodes of homelessness among Veterans and has allocated more than $1 billion toward homelessness prevention and rapid rehousing services since 2011 through the Supportive Services for Veteran Families (SSVF) program. To assist in the identification of Veterans in need of these services, the VA National Center on Homelessness Among Veterans developed the Homelessness Screening Clinical Reminder (HSCR), a two-question universal screener that assesses housing instability and risk among Veterans who present for outpatient care. During 2013-2014, almost 5.8 million Veterans responded to the HSCR. Among those, 0.8% reported current homelessness and 1.0% reported imminent risk.

This study had three main objectives:

1) Validate the HSCR and assess prevalence and risk for homelessness among Veteran users of VA healthcare services.

2) Assess the effectiveness of the HSCR in linking Veterans who screen positive for homelessness or risk with services.

3) Evaluate the psychometric properties and efficacy of the Homelessness Risk Assessment (HRA), a more extensive instrument used by SSVF providers in Philadelphia, to quantify risk of homelessness among Veterans.

Findings:

• The HSCR is effective at differentiating between homelessness and risk of homelessness and is successful at linking Veterans with services in the majority of cases.
• Clinicians who administer the HSCR describe its utility for addressing an important social determinant of health.
• Veterans report that the questions in the HSCR are consistent with their understanding of the notion of “home.”
• There is a need to change the screening process in the following ways:
  • Target screening to particularly high-risk subpopulations (e.g., Veterans initiating treatment for opioid use disorder)
  • Identify appropriate staff to conduct screening and ensure staff conduct screening consistently
  • Create workflows to address Veterans’ access to resources following a positive screen.

Principal Investigator: Ann Elizabeth Montgomery, PhD, is an investigator with the VA National Center on Homelessness Among Veterans (NCHAV) and the Birmingham VA Medical Center, Birmingham, AL.

Publications (for complete listing, see abstract online (link):

Chhabra M, Sorrentino AE, Cusack M, Dichter ME, Montgomery AE, True G. Screening for Housing Instability: Providers' Reflections on Addressing a Social Determinant of Health. Journal of general internal medicine. 2019 Jul 1; 34(7):1213-1219.

Cusack M, Montgomery AE, Hunt-Johnson N, Dichter M, True G. Making Connections: Understanding How Screening, Triage, and Referral Processes Can Promote Veteran Housing Stability. Social work in public health. 2019 Jun 16; 34(6):483-491.

Byrne T, Montgomery AE, Fargo JD. Predictive modeling of housing instability and homelessness in the Veterans Health Administration. Health services research. 2019 Feb 1; 54(1):75-85.

Fargo JD, Montgomery AE, Byrne T, Brignone E, Cusack M, Gundlapalli AV. Needles in a Haystack: Screening and Healthcare System Evidence for Homelessness. Studies in health technology and informatics. 2017 Jan 1; 235:574-578.

Byrne T, Fargo JD, Montgomery AE, Roberts CB, Culhane DP, Kane V. Screening for Homelessness in the Veterans Health Administration: Monitoring Housing Stability through Repeat Screening. Public health reports (Washington, D.C. : 1974). 2015 Nov 1; 130(6):684-92.

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Quality of Care for Hepatitis C in Veterans Who Are Homeless

Impact: This study created a novel categorization of Veteran homelessness which provides opportunities to target specific populations of homeless Veterans and to tailor interventions for each group’s context and needs. The research also highlights innovative practices in VA hepatitis C clinics to improve outreach to, and treatment of, Veterans experiencing homelessness. These practices are likely transferable to the treatment of other chronic health conditions in hard to reach Veteran populations.   

Hepatitis C virus (HCV) is a major health burden for the US population, and one that, traditionally, has been difficult to treat among homeless persons. Studies among Veterans indicate that HCV may be 4 times more prevalent among homeless compared to housed Veterans, which may in part be due to risk factors such as injection drug use and associated needle sharing. Treatment of HCV has changed dramatically over the past five years due to the introduction of direct-acting antivirals (DAAs), new medications which cure most cases of HCV in 3 months or less. These treatments may create opportunities to cure hard to reach Veterans.

This study used a retrospective cohort analysis of Veterans in VHA care in FY2009-2016 (n=730,424) and site visits to 6 HCV clinics for qualitative data collection.  It will lead to the development of interventions to improve access to health services and quality of care for Veterans experiencing homelessness. Specific aims were to:

• Describe how homeless Hepatitis C virus positive Veterans are distributed among VA medical centers.
• Evaluate quality of care for homeless and non-homeless Veterans as measured by progress along the HCV Care Continuum and the relationship of quality to patient, facility, and housing characteristics.
• Develop interventions to improve HCV care for homeless Veterans.

Findings:

• HCV prevalence was highest among formerly homeless Veterans, nearly 17%. Prevalence was approximately 12% among currently homeless, and 8% among Veterans at risk of homelessness.
• Housed Veterans had 9% probability of initiating treatment, compared to 6-7% among those at risk for homelessness, currently homeless, and formerly homeless Veterans.
• Innovative practices to reach HCV-positive Veterans experiencing homelessness included:
• Portable HCV clinics that could be set up in locations frequented by homeless Veterans
• Group education and treatment sessions
• Adoption of ‘open access’ or drop-in HCV care clinic structures
• Integration of a homelessness social worker into the HCV care team
• Co-location of HCV services or providers with substance use, housing, mental health, and/or primary care providers.
• Mailing of HCV medications, including mailing to nonprofit organizations for Veterans who lacked their own address.

Principal Investigator: D. Keith McInnes, ScD, MSc, is an Investigator with the Center for Healthcare Organization & Implementation Research (CHOIR) at the Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA.

Publications:

Byrne, T., Troszak, L., Midboe, A. M., Fincke, B. G., Shwartz, M., Gifford, A. L., & McInnes, D. K. (2019). A Novel Measure to Assess Variation in Hepatitis C Prevalence Among Homeless and Unstably Housed Veterans, 2011-2016. Public Health Reports, 134(2), 126-131.

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Group Motivational Interviewing for Homeless Veterans in VA Services

Impact: This research highlights an opportunity to deliver an evidence-based treatment to a large number of homeless Veterans with substance use disorder who would not otherwise receive intervention. Introducing motivational interviewing to a group setting can be done with minimal financial investment, little interruption to existing services, or reorganization of VA housing staff.

The task of identifying resource-efficient wraparound treatment services for patients with substance use disorder (SUD) is a matter of urgency as more than 60% of homeless Veterans admitted to VA-supported housing have SUDs. Homeless Veterans with SUDs are vulnerable to treatment dropout, rendering them susceptible to substance use relapse. Conversely, their continuation in outpatient care during their participation in VA housing leads to improved clinical outcomes. According to systematic reviews, individual motivational interviewing (MI) reduces the incidence of SUD, but is labor intensive. Starting in 2012, VA moved toward a 'Housing First' paradigm where larger numbers of homeless Veterans continue to use substances while living in VA housing. Providing MI to these patients may be important for initiating and maintaining their recovery. In particular, delivery of MI in a group format (GMI) may help to alleviate treatment barriers. In a prior controlled trial, GMI resulted in significantly higher outpatient treatment engagement and lower substance use compared to treatment-as-usual among Veterans with both SUD and other co-occurring psychiatric disorders (i.e., PTSD).

This study sought to compare the relative efficacy of GMI to an intervention designed to enhance social and instrumental skills among homeless Veterans called Life Skills for Housing Maintenance (LSHM). Specific factors measured were treatment engagement, substance use, and number of separate inpatient admissions by the 6-month follow up.

Findings:

• GMI was statistically superior to LSHM for enhancing SUD treatment and mental health session attendance as well as community 12-step program attendance.
• Participants in both GMI and LSHM reduced alcohol consumption and hazardous binge drinking days with no differences between groups.
• Participants in GMI and LSHM reduced illicit drug use consumption from baseline, although significant differences favored GMI at 3 months and favored LSHM at 6 months.

Principal Investigator: Elizabeth J. Santa Ana, PhD, is the Associate Director of the Charleston Health Equity and Rural Outreach Innovation Center (HEROIC) at the Ralph H. Johnson VA Medical Center, Charleston, SC.

Publications:

Jaconis M, Santa Ana EJ, Killeen TK, Badour CL, Back SE. Concurrent treatment of PTSD and alcohol use disorder via telehealth in a female Iraq veteran. The American journal on addictions. 2017 Mar 1; 26(2):112-114.

Santa Ana EJ, LaRowe SD, Armeson K, Lamb KE, Hartwell K. Impact of group motivational interviewing on enhancing treatment engagement for homeless Veterans with nicotine dependence and other substance use disorders: A pilot investigation. The American journal on addictions. 2016 Oct 1; 25(7):533-41.

Shorey RC, Martino S, Lamb KE, LaRowe SD, Santa Ana EJ. Change talk and relatedness in group motivational interviewing: a pilot study. Journal of substance abuse treatment. 2015 Apr 1; 51:75-81.

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Patient-Aligned Care Teams Tailored to the Homeless Can Reduce Acute Care Services and Healthcare Costs

Impact: This research highlights opportunities to be proactive in considering how high-need/high-cost vulnerable populations, such as homeless persons, can be cared for in a cost-effective manner. 

Healthcare for socially disadvantaged, high-risk, or high-need patients, such as homeless persons, is often defined by high rates of acute care service use and poor clinical outcomes. This multicenter trial compared healthcare service use and cost outcomes among homeless Veterans enrolled in a traditional (not tailored to a homeless population) PACT (n=83) with outcomes among Veterans enrolled in a homeless population–tailored H-PACT (n=183). [VA’s Patient-aligned Care Team (PACT).] Veterans in this study included those who were living outdoors, and those staying in an emergency shelter or transitional housing. Investigators examined health services use, cost, and patient satisfaction.

Findings:

• 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%).

The Homeless PACT program is now operational in 54 VA medical centers (VAMCs), Community-Based Outpatient Clinics (CBOC), and Community Resource and Referral Centers (CRRC) across the country. In Fiscal Year 2019, more than 17,600 homeless and at-risk Veterans were enrolled in the 80 H-PACT teams across the country, and approximately 22,000 are served annually.

Principal Investigator: Tom O’Toole, MD is Director of the National Homeless Patient Aligned Care Team (PACT) Initiative, and Associate Chief of Staff for Education at the Providence VA Medical Center

Publications:

O’Toole T, Johnson E, Borgia M, et al. Population-tailored Care for Homeless Veterans and Acute Care Use, Cost, and Satisfaction: A Prospective Quasi-experimental Trial. Preventing Chronic Disease. February 15, 2018;15:E23.

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