In this Issue: Working to End Homelessness among Veterans
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Between 2009 and 2015, homelessness among Veterans declined by 35% (or 25,642 Veterans).1 Much of this reduction is due to significant work on the part of community, regional and national stakeholders in improving access to care and resources for Veterans currently experiencing or at risk for homelessness, including the collaboration with the Department of Housing and Urban Development (HUD) on the HUD-VA Supportive Housing (HUD-VASH) subsidy program. The HUD-VASH Program is a joint effort between HUD and VA to move Veterans out of homelessness and into permanent housing by combining housing vouchers with case management services.
However, providing healthcare for the homeless Veteran population presents challenges to traditional models of medical care. For example, an estimated 80% of homeless Veterans face some type of mental health and/or substance abuse disorder, which can endanger housing stability and exacerbate treatment dropout and relapse.2 Homeless Veterans also suffer significantly higher mortality rates,3 are hospitalized at higher rates and, on average, cost three times as much to care for than their housed counterparts.4 Reduction in Veteran homelessness also has been helped by the development of Homeless Patient-Aligned Care Teams (H-PACT), which target the specific and wide-ranging needs of the homeless Veteran population by co-locating care providers.
The VA Homelessness Health Services Research Initiative, supported by HSR&D, in partnership with the National Center on Homelessness among Veterans, funded four studies aimed at implementing health services best practices and improving outcomes for Veterans facing or at risk of homelessness:
- Homeless Solutions in a VA Environment (H-SOLVE; PI: Stefan G. Kertesz, MD, Birmingham VA): The H-SOLVE project was designed to assess VA's transition to the Housing First approach. Investigators followed implementation of Housing First at eight VA facilities with an aim toward identifying barriers and facilitators to effective implementation of this policy at both the healthcare system and policy levels, and informing VA policy on future Housing First implementation. [The Housing First approach is an evidence-based supportive housing model that emphasizes permanent supportive housing - and provides housing without prerequisite abstinence, psychiatric stability, or treatment program completion.]
- Population-based Outreach Services to Reduce Homelessness among Veterans with SMI (Re-Engage; PI: Amy M. Kilbourne, PhD, QUERI Director):The Re-Engage projectoversaw implementation of a care management-based system that aimed to re-engage Veterans with serious mental illness and/or a history of homelessness who had been lost to VA healthcare services. By the end of December 2014, the program had identified 5,233 Veterans who had been lost to care at 158 VA facilities. Program coordinators were successful in contacting 25% of eligible Veterans and re-engaging 24% of those Veterans with care.
- Aligning Resources to Care for Homeless Veterans (ARCH; PI: Thomas O'Toole, MD, Providence VA): The ARCH study examined the effectiveness of four different approaches to delivering comprehensive primary care for homeless Veterans, including a version of the Patient Aligned Care Team (PACT) model for primary care tailored to homeless Veterans (H-PACT). In determining optimal approaches for delivering primary care, investigators aimed to improve chronic disease management and reduce emergency department visits and hospitalizations.
- Addiction Housing Case Management for Homeless Veterans Enrolled in Addiction Treatment (ACHM; PI: Andrew J. Saxon, MD, Seattle VA):ACHM randomized 181 homeless Veterans to either addiction treatment with an addiction/housing case manager (experimental group) or addiction treatment with a weekly housing group (control group), in order to evaluate whether addiction/housing case management resulted in earlier transition and/or more stable housing patterns among Veterans entering addiction treatment.
The H-SOLVE, ARCH, and ACHM studies were all motivated by the need to develop and provide better integrated approaches to care, combining primary care with mental health, social and/or substance abuse services. Implementing effective integrated care presents a number of challenges for traditional healthcare settings, as it requires organizations to coordinate and communicate across multiple teams of providers. Integrated care for homeless Veterans also involves housing placement and retention, which require VA providers to build networks with local housing agencies, landlords, and other parties 'outside the walls' of the VA.
In evaluating whether joint addiction/housing case management is more effective at improving outcomes than traditional addiction support groups, the AHCM study has the potential to inform the best integration of substance use specialists in homeless Veteran care. Similarly, the H-SOLVE study is investigating how best to integrate housing solutions into more traditional VA medical care. Finally, the ARCH study's evaluation of H-PACT's integrated care system aims to redesign care to better address barriers to care for homeless Veterans and their multiple needs at any particular "treatable moment." Over a 12-month study period, H-PACT-enrolled Veterans have shown significantly more primary care and social work visits than Veterans enrolled in non-tailored PACT, as well as fewer emergency department visits and hospitalizations. H-PACT Veterans also had lower total cost and mental health cost than PACT Veterans.
Ensuring continuity ofcare also is of special concern as, in addition to facilitating homeless Veteran care, continuous care may diminish the risk of Veterans with mental health or substance abuse challenges becoming homeless. Building on strong evidence from the Office of the Medical Inspector that initial implementation of the Re-Engage program resulted in 72% of contacted Veterans returning to care and a six-fold reduction in mortality compared to those not returning to care,5 the nationwide implementation of Re-Engage signaled continuity of care as a strong VA organizational priority.
In studying and guiding implementation at multiple VA medical centers, both the H-SOLVE and Re-Engage projects were able to identify important organizational barriers and facilitators to improving care for homeless Veterans. The H-SOLVE project found significant variation in implementation fidelity of the Housing First initiative across eight VAMCs. Frontline providers responsible for finding and obtaining housing for Veterans at need faced significant logistical problems, including tight rental markets and availability of resources necessary to secure housing and facilitate Veteran transfers.6,7 Further, both the H-SOLVE and Re-Engage studies documented challenges with respect to frontline providers grappling with new organizational priorities. H-SOLVE, for example, found that providers newly tasked with arranging housing as a first priority felt they needed to trade-off with their case management duties, which in some instances led to turnover and burnout, 6 while the coordinators implementing Re-Engage at times struggled to find available appointments for Veterans wishing to be re-engaged with care.8
These studies also have identified key facilitators of successful program implementation. H-SOLVE found that site leadership played a key role in implementing Housing First. Although national VA leadership expressed strong support for the initiative, effective medical center leaders showed commitment by joining frontline providers in public shows of support and promoting mid-level managers who could further champion the needs of homeless Veterans. Site leaders also played a key role in aligning local organizational goals with the Housing First mission; for example, by including discussion of Veteran homelessness in institutional messaging and town meetings.7
Both studies also found that frontline providers played a key role in successfully implementing the new initiatives. In implementing Re-Engage, local providers faced barriers to re-engaging Veterans with care due to limited control over the appointment schedule and limited appointment availability. However, providers were also able to identify strategies for overcoming these barriers, including developing new networks with care providers, emphasizing incentives of timely appointments, and directly coordinating referrals with integrated care teams. 8 In H-SOLVE, successful frontline providers also were required to forge new relationships in securing housing for homeless Veterans, often with parties outside VA, including community housing and rental agencies.
These studies also shed light on the potential of adapting initiatives to local needs. The ARCH study has implemented and evaluated several models of H-PACT, adapting model provision based on site-specific need, capacity, geography and focus. The Re-Engage study incorporated facilitation, or semi-structured weekly phone calls focused on coordinator coaching, for some sites that had difficulty with implementing the initiative. Their evaluation found that facilitation helped local providers to better identify and address barriers and significantly improved the short-term uptake of the program.9
In a report on H-SOLVE, Kertesz et al. notes, "Hospitals traditionally focused on medical care do not typically lead efforts to solve large social problems".7 The VA has made significant inroads to eradicating Veteran homelessness. With new decisions and priorities for VA leadership on the horizon, the four projects funded by the HSR&D Homelessness Health Services Research Initiative have shed light on the best ways to organize care for Veterans facing or at risk of homelessness, as well as the potential challenges and strategies for success in implementing new models of care provision for homeless Veterans nationwide.
1. Part 1: Point-in-Time Estimates of Homelessness. The 2015 Annual Homeless Assessment Report (AHAR) to Congress. The U.S. Department of Housing and Urban Development, Office of Community Planning and Development.
2. Data Report. National Survey of Homeless Veterans in 100,000 Homes Campaign Communities. November 2011.
3. Birgenheir D, Lai Z, Kilbourne A. Datapoints: Trends in mortality among homeless VA patients with severe mental illness. Psychiatric Services. 2013;64(7):608.
4. O'Toole T, Buckel L, Bourgault C, et al. Applying the chronic care model to homeless Veterans: Effect of a population approach to primary care utilization and clinical outcomes. American Journal of Public Health. December 2010;100(12):2493-2499.
5. David C, Kilbourne A, Pierce J, et al. Reduced mortality among Department of Veterans Affairs patients with schizophrenia or bipolar disorder lost to follow-up and engaged in active outreach to return to care. American Journal of Public Health. 2012;102:S74-S79.
6. Austin E, Pollio D, Holmes S, et al. VA's expansion of supportive housing: Successes and challenges on the path toward Housing First. Psychiatric Services. May 1, 2014;65(5):641-647.
7. Kertesz S, Austin E, Holmes S, et al. Making Housing First happen: Organizational leadership in VA's expansion of permanent supportive housing. Journal of General Internal Medicine. December 2014;29(4):835-844.
8. Goodrich D, Bowersox N, Abraham K. Leading from the middle: Replication of a re-engagement program for Veterans with mental disorders lost to follow-up care. Depression Research and Treatment. September 25, 2012; Epub.
9. Kilbourne A, Goodrich D, Lai Z, et al. Re-engaging Veterans with serious mental illness into care: Preliminary results from a national randomized trial. Psychiatric Services. January 1, 2015;66(1)90-93.