One in three homeless men and nearly one quarter of all homeless adults are veterans, which translates to almost 200,000 veterans homeless on any given night. Although the Department of Veteran Affairs (VA) has developed several innovative programs to address this need, veterans in many communities are not accessing them. In a community-based survey of homeless adults in Pittsburgh and Philadelphia, only 41% of the veterans were accessing the VA system for health care. These results are devastating as homeless persons have an age-adjusted mortality over 3 times higher than the general population and life expectancy almost 30 years less, often from preventable and manageable chronic illnesses. There is also an urgent need to address this issue given the expected increase in homelessness projected among at-risk OEF/OIF/OND returning Veterans.
This study aimed to test the hypothesis that a personalized health assessment/brief intervention (PHA/BI) with or without a clinic orientation that was linked to community outreach is more likely to both engage the homeless veteran in primary care based chronic disease management and to sustain that care and associated behavior changes necessary to exit homelessness. Key questions addressed include: (1) Will the outreach intervention increase health seeking behavior?; (2) Can initial engagement be sustained in a continuity care model?; (3) Will this intervention facilitate changes/improvements in health seeking behavior that include participation in substance abuse treatment care, compliance with mental health care, and enrollment in VA-based homeless programs?; (4) Can this intervention impact compliance with prescribed treatments?; and (5) do any observed changes correlate with serial behavioral measures and qualitative assessments?
We conducted a multi-site prospective randomized controlled trial in which 221 homeless veterans from the Providence and New Bedford areas not currently engaged in primary care were identified and enrolled and 185 were ultimately determined to be eligible to receive either a PHA/BI-based intervention, clinical orientation intervention (alone or in combination) versus usual care (social work/housing focused) outreach. Baseline assessments included demographics, medical, mental health and substance use co-morbidities, health seeking behavior, readiness for behavior change, and motivation for health care. Serial assessments at months 1 and 6 assessed evolving readiness and motivation as well as changes in homeless status (sheltering, employment/income, etc.). Actual utilization of services was assessed using the CPRS electronic medical records.
This research has resulted in several key findings that have advanced the field of homeless research. Three papers reporting on these findings are currently under review at high impact peer reviewed journals . The findings include:
(1) Reasons why homeless Veterans who are needing care and have access to it are not receiving it:
The majority of homeless in our community sample of out-of-treatment Veterans identified a recent need for care and interest in having a primary care provider. Reasons for delaying care fell into 3 domains: 1) trust; 2) stigma; and 3) care processes. Identifying a place for care (OR 3.3; 95% CI: 1.4-7.7), having a medical condition (OR 5.5; 95% CI 1.9-15.4) and having depression (OR 3.4; 95% CI: 1.4-8.7) were associated with receiving care while not being involved in care decisions was associated with no care (OR 0.7; 95% CI 0.5-0.9). Our findings support the importance of considering health access within an expanded framework that includes perceived stigma, inflexible care systems and trust issues.
(2) Tailoring outreach to homeless veterans can increase their access and use of primary care and other health services within VA: The primary aim of this study was to conduct a randomized controlled trial of different interventions (personal health assessment/brief intervention, clinic orientation alone and in combination) aimed at increasing rates of treatment engagement among a community sample of treatment-naive homeless veterans.
Our findings suggest that treatment-resistant/avoidant homeless Veterans can be effectively engaged in primary care through a tailored outreach process. Further, this engagement in primary care was both sustained and resulted in care being provided across the continuum of needs facing this population. This is significant because it represents a minimally intrusive intervention that was effective in bringing homeless Veterans into the care system and addressing unmet, deferred and delayed care that are often critical to the process of exiting homelessness. The combination of the personal health assessment coupled with the clinic orientation was the most effective. This was followed by the clinic orientation alone, which had comparable results at one month but had a substantially higher proportion accessing care by six months than the personal health assessment/brief intervention-alone group. Both interventions alone and in combination were more effective than usual care. This suggests that previously identified barriers to care related to both not having a perceived need for care and not knowing where to go or how to access care are not "fixed" but rather are amenable to change through targeted outreach.
(3) Engagement in health care is associated with expedited housing stabilization and improved outcomes.
In a post-hoc analysis of the randomized controlled trial that was aimed at increasing homeless Veterans use of primary care, our findings suggest that those veterans who did access care were more likely to move into stable housing arrangements and to move in faster. Receipt of care occurred on average prior to their actual move to more permanent and stable housing further suggesting that this association was precipitated by the process of treatment engagement rather than by receipt of housing. This is significant because it represents research that for the first time demonstrates the role of clinical care and treatment engagement in helping secure stable and permanent housing.
In addition, data from this study has been pooled with previously collected data from other studies our team has conducted, resulting in manuscripts (published and in press) on the following related topics:
(1) how the recent economic downturn impacted Veteran homelessness and health seeking behavior (Journal of Health Care to Poor and Underserved)
(2) health care needs and utilization associated with homeless persons newly accessing care (American Journal of Public Health)
(3) clinical factors associated with chronic and recurrent versus one-time homelessness among veterans (Journal of Community Psychiatry - in press)
The findings from this study have already had a direct and tangible impact within VA and the field of homeless care. Because the PI for this project (O'Toole) is also the national director of the Homeless PACT program and part of the core faculty at the National Center on Homelessness Among Veterans, we have had a direct conduit to the field for rapid dissemination and implementation. For example:
(1) Findings from the tailored outreach RCT have been incorporated into the community outreach modules at each of the H-PACT teams (N=54) and are being implementing across the country
(2) Findings from the "New to Care" article published in AJPH have been presented at the H-PACT cyberseminar series and incorporated into the national Quality Improvement Initiative to Reduce Emergency Department Use among Homeless Veterans project sponsored by the national H-PACT program office.
(3) We are currently working with the Office of Data and Analytics to develop performance report monitors that link health service use/clinical engagement with housing outcomes for H-PACT teams..
(4) We are currently working with the National Center to develop a "risk profile' indicator that can be used to pre-emptively identify recently housed Veterans at risk for recidivism back to homelessness.
Because of the novel and clinically relevant nature of the findings being generated from this study we further expect the impact to be seen beyond VA and have already had several inquiries from HHS Health Care for the Homeless groups as well as from international researchers.
- Johnson EE, Borgia M, Rose J, O'Toole TP. No wrong door: Can clinical care facilitate veteran engagement in housing services? Psychological Services. 2017 May 1; 14(2):167-173.
- O'Toole TP, Pape L. Innovative Efforts to Address Homelessness Among Veterans. North Carolina Medical Journal. 2015 Nov 1; 76(5):311-4.
- O'Toole TP, Johnson EE, Borgia ML, Rose J. Tailoring Outreach Efforts to Increase Primary Care Use Among Homeless Veterans: Results of a Randomized Controlled Trial. Journal of general internal medicine. 2015 Jul 1; 30(7):886-98.
- 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.