Spotlight: Research to Support Ending Veteran Homelessness
In 2009, President Obama committed to ending homelessness among Veterans. At that time, Veterans comprised one of every four homeless persons—approximately 12 percent of all homeless adults in the country. However, great strides have been made in reducing Veteran homelessness since initiating that priority goal: According to the most recent survey by the Department of Housing and Urban Development, Veteran homelessness has fallen overall by 33 percent.1 Between 2013 and 2014 alone, homelessness among Veterans declined by 10 percent—the largest decrease since Veteran homelessness fell by 12 percent from 2010 to 2011.2
This considerable reduction in the number of homeless Veterans is attributable to wide-reaching national, regional, and community-based contributors, of which VA's Health Services Research and Development Service (HSR&D) has been part. Studies funded by HSR&D have provided both data and practical impact on a wide range of issues aimed at reducing homelessness among Veterans, including: identifying risk factors for homelessness; understanding how to better engage Veterans in primary care; and assessing screening tools to identify women Veterans at risk for homelessness. The following are just a few of the ongoing investigations addressing some of those issues.
Investigators in this study have been assessing VA's transition to the "Housing First" approach of placing Veterans in permanent, supportive housing through the use of rental vouchers. This study examined the experiences of eight VA facilities undertaking this endeavor in 2012.
A multidisciplinary team interviewed facility leadership, mid-level managers, and frontline staff at the participating facilities, which represented four U.S. regions, and explored how individuals throughout the organization experienced and responded to the challenges of transitioning to a Housing First approach.
Investigators reported that those VA medical centers effective in advancing Housing First differentiated themselves in the degree to which leadership was able to engage and organize change. Further, investigators assert that the ingredients for effective community leadership focused on ending homelessness are not unique to VA, and should inform the work of local leaders (mayors, community councils, etc.) and non-profit philanthropic agencies.
This study resulted in the following publication(s):
Austin EL, Pollio DE, Holmes S, Schumacher J, White B, Lukas CV, Kertesz S. VA's expansion of supportive housing: successes and challenges on the path toward Housing First. Psychiatric Services. 2014 May 1; 65(5):641-7.
Kertesz SG, Austin E, Holmes S, Pollio DE, White B, Schumacher JE, VanDeusen Lukas CK. Making Housing First Happen: Organizational leadership in VA's expansion of permanent supportive housing. Journal of General Internal Medicine. 2014 Dec;29 Suppl 4:835-44.
Austin E, Kertesz S, Tsemberis S. Timing and Momentum in VA's Path Toward Housing First: In Reply. Psychiatric Services 2014; 65: 836-837.
Poor health is closely associated with homelessness, as serious illness, chronic disease, or disability frequently incur financial challenges. For those already facing economic stress, healthcare costs may spur a downward spiral into homelessness.3 Once without stable housing, individuals with chronic disease may not have sufficient resources to effectively manage their condition. Given that one-quarter of homeless adults are Veterans, and that homeless persons experience higher mortality rates and shorter life expectancy associated with preventable and manageable chronic illnesses, engaging homeless Veterans in primary care is a critical priority for VA.
In this study, investigators sought to determine whether a personalized health assessment/brief intervention (PHA/BI) linked to community outreach would be more likely to both engage homeless Veterans in primary care-based, chronic disease management and to sustain that care, as well as sustain the associated behavior changes necessary to exit homelessness.
Investigators conducted a multi-site, prospective, randomized controlled trial, enrolling 185 homeless Veterans from the Providence, RI and New Bedford, MA areas. Veterans enrolled were not currently engaged in primary care. Study participants received either a PHA/BI-based intervention, clinical orientation intervention (alone or in combination), or usual care (social work/housing focused) outreach.
The study resulted in several key findings and impacts, including:
- Identifying key reasons why homeless Veterans in need of, and with access to, care, were not receiving it. Reasons for delaying care fell into three domains: trust, stigma, and care processes.
- Tailoring outreach to homeless Veterans can increase their access and use of primary care and other health services within VA.
- Engagement in healthcare is associated with expedited housing stabilization and improved outcomes.
- Development of performance report monitors that link health service use and clinical engagement with housing outcomes for H-PACT teams.
- Development of a "risk profile" indicator that can be used to pre-emptively identify recently housed Veterans at risk for a return to homelessness.
This study has resulted in the following publications:
- O'Toole TP, Pirraglia PA, Dosa D, Bourgault C, Redihan S, O'Toole MB, Blumen J, Primary Care-Special Populations Treatment Team. Building care systems to improve access for high-risk and vulnerable veteran populations. Journal of General Internal Medicine. 2011 Nov 1; 26 Suppl 2:683-8.
- O'Toole TP, Buckel L, Bourgault C, Blumen J, Redihan SG, Jiang L, Friedmann P. Applying the chronic care model to homeless veterans: effect of a population approach to primary care on utilization and clinical outcomes. American Journal of Public Health. 2010 Dec 1; 100(12):2493-9.
Estimates of Veterans experiencing homelessness are based on the number of Veterans currently being directed to specific VA homeless services and on those who have previously received such services. However, a major focus of VA's homelessness prevention efforts are directed toward Veterans considered "at-risk" for homelessness, especially for the first time. In this study, investigators are leveraging VA's integrated electronic health record, which incorporates recorded clinical notes in addition to administrative data. By applying natural language processing (NLP) technology to these clinical notes, investigators plan to develop electronic algorithms for identifying Veterans who are currently homeless or who are at risk for becoming homeless. By applying these algorithms, investigators then plan to review the extent to which Veterans are receiving appropriate services.
While complete study results are expected in 2016, early findings using NLP indicate that homeless Veterans were much higher utilizers of VA resources and produce approximately 12 times as many documents as non-homeless Veterans. In addition, investigators have shown that NLP detected mentions of either direct or indirect evidence of homelessness in a significant portion of Veterans earlier than indicated by structured data.
Investigators expect that when completed, this research will have a positive impact on managing and preventing homelessness among Veterans who seek care within the VA healthcare system. Further, when implemented, the electronic algorithms developed and validated in the study should have direct impact on planning and allocation of resources to prevent and end homelessness among Veterans seen in VA healthcare settings.
This study has resulted in the following publications:
- Gundlapalli AV, Redd A, Carter ME, Palmer M, Peterson R, Samore MH. Exploring patterns in resource utilization prior to the formal identification of homelessness in recently returned veterans. Studies in health technology and informatics. 2014 Jan 1; 202:265-8.
- Redd A, Carter M, Divita G, Shen S, Palmer M, Samore M, Gundlapalli AV. Detecting earlier indicators of homelessness in the free text of medical records. Studies in health technology and informatics. 2014 Jan 1; 202:153-6.
- Divita G, Shen S, Carter ME, Redd A, Forbush T, Palmer M, et al. Recognizing Questions and Answers in EMR Templates Using Natural Language Processing. Studies in health technology and informatics. 2014;202:149-52.
- Gundlapalli AV, Redd A, Carter M, Divita G, Shen S, Palmer M, et al. Validating a strategy for psychosocial phenotyping using a large corpus of clinical text. Journal of the American Medical Informatics Association. 2013 Dec;20(e2):e355-64.
Although services for homeless Veterans are growing in response to recent federal efforts, numerous barriers to care remain, particularly for women Veterans. A major barrier is limited awareness (among both clinicians and vulnerable Veterans) of factors that increase women Veterans' risk for homelessness, and knowledge of services to alter those risks. Completed in 2013, this study sought to close that knowledge gap by pilot-testing a previously developed screening mechanism, the V-Tool.
The V-Tool is a secondary screening instrument that complements VA's existing homelessness screening by identifying—and linking to services—women Veterans who are predisposed to, or at chronic risk for homelessness. Investigators pilot-tested the V-tool at one healthcare system, and conducted interviews with clinicians and Veterans in order to assess both provider and patient usability.
Study findings from clinician and patient interviews revealed four important themes for the development and deployment of the V-tool:
- Target population. Homelessness vulnerability screening should be risk-based, rather than universally applied to all those screening negative for imminent homelessness.
- Screening focus. Interviews indicated that screening should focus on the impact of the risk factor on the Veteran's housing stability, rather than on the presence of the risk factor itself. This links the follow-up actions for a positive V-Tool screen more closely to homelessness services, and reduces overlap with other VA initiatives.
- Referrals. Clinicians and clinical staff overwhelmingly expressed the need for referral services to be in place prior to the initiation of screening.
- Clinical settings. Mental health and social work staff thought that screening could be expanded to include those settings because of the overlap in content of the V-Tool with information that is already collected as part of initial mental health and social work intakes.
The ultimate goal of the V-Tool is to contribute to primary homelessness prevention efforts through increased identification of, and referral for at-risk Veterans into VA mental health, social service, and other treatment and preventive services. Findings from this study are informing multi-site deployment of the V-Tool, as well as expansion of the current imminent homelessness screener to incorporate screening for homelessness vulnerability and referral of at-risk Veterans as part of VA's comprehensive homelessness prevention process.
This study has resulted in the following publication:
Hamilton AB, Washington DL, Zuchowski J. Gendered social roots of homelessness among women Veterans. Annals of Anthropological Practice. 2014 Sep 2; 37(2):92-107.
- The 2014 Annual Homeless Assessment Report to Congress. Office of Community Planning and Development, United States Department of Housing and Urban Development.
- National Coalition for the Homeless. Fact Sheet: Health Care and Homelessness.