Substance use disorders (SUDs) are significant modifiable risk factors for homelessness. Homeless Veterans entering SUD treatment have worse treatment outcomes and incur more costs than their housed counterparts. Many homeless Veterans never obtain housing after treatment entry, and a substantial proportion of those who do subsequently return to homelessness. Assertive community treatment/intensive case management shows promise in improving housing status in this population. This study compares intensive addiction/housing case management (AHCM) for homeless Veterans newly entering VA SUD treatment to a housing support group (HSG).
The primary study aims were to determine whether AHCM, relative to HSG, resulted in 1) increased number of days housed and greater likelihood of entry into long-term housing; 2) lower health care utilization and cost and greater cost-effectiveness; and 3) greater improvement in functional status, SUD, and psychiatric outcomes between baseline and 12 months.
This parallel-design, randomized clinical trial occurred at VA Puget Sound between September 2011 and November 2015. Eligible participants (400 expected) were currently homeless and initiated a new episode of VA SUD care in the past 30 days. Following baseline assessment, Veterans were randomized - stratified by gender and primary SUD - to AHCM and HSG conditions and followed for 12 to 24 months. All Veterans received SUD treatment as usual. The AHCM condition involved case management visits, weekly through month 6 and monthly between months 6-12, focused on identifying and obtaining housing, support and coordination of SUD, psychiatric and medical care, community outreach, and life skills training. The control condition was a weekly drop-in housing support group. Assessments occurred every 3 months for 1 year and every 6 months for up to 2 years post-randomization and assessed housing status (housing history, timeline follow-back interview), functional status, SUD and psychiatric outcomes (SF-36V, Addiction Severity Index [ASI]) and non-VA service utilization. Qualitative interviews assessing barriers and facilitators to obtaining housing occurred at 12 months. VA health care and housing-related service utilization for the 1 year before and 2 years after study enrollment was obtained from VA Corporate Data Warehouse (CDW) and Housing Registry (HOMES). Longitudinal analyses compared differences in change over time between baseline and month 12 in percent days housed, functional status, SUD, and psychiatric outcomes. Logistic regression models assessed the likelihood of long-term housing entry and alcohol/drug abstinence. Negative binomial regression models were used to compare number of outpatient visits and inpatient days. Analyses were adjusted for age, primary SUD, lifetime psychiatric hospitalizations, ASI alcohol composite score, and days homeless in the prior 90 days at baseline.
In total 181 Veterans enrolled in the study (45% of expected, AHCM: n=91, HSG: n=90). Twelve-month study completion rates did not differ by treatment (AHCM: n=62, 68%, HSG: 53, 59%). At baseline, AHCM participants reported more lifetime psychiatric hospitalizations (p=0.009), and HSG participants exhibited more severe ASI alcohol composite scores (p=0.005). The groups were balanced on other baseline characteristics and demographics. Housing status varied at baseline, with 41% (n=74) homeless for 1 year and/or for 4 episodes, 34% (n=61) homeless for 6 to 12 months and/or for 2 to 3 episodes, and 25% (n=45) homeless for the first time and for <6 months. AHCM participants received more study interventions, attending a mean 21.4 (SD=14.4) case management visits, compared to a mean 2.0 (3.9) group visits among HSG participants.
Both groups significantly increased percent days in their own home (estimated increase 39.4%, 95% CI: 29.6-49.2), percent days in transitional housing (estimated increase 19.8%, 95% CI: 12.3-27.4) and percent days housed (estimated increase of 59.0%, 95% CI: 50.4-67.7) between baseline and month 12 per self-report. No differences were detected between the HSG and AHCM conditions. Per self-report, 66 (79.5%) and 55 (80.9%) participants in the AHCM and HSG conditions, respectively, entered long-term housing at any time between baseline and month 12; this excluded 30 participants (8 AHCM, 22 HSG) without follow-up data. Using VA HOMES data to supplement self-report data (participants with fully missing data presumed unhoused), 74 (81.3%) and 64 (71.1%) participants in the AHCM and HSG conditions, respectively, entered long-term housing (OR=1.9, 95% CI: 0.9-4.0, p=0.088). Among participants who entered long-term housing (n=138), no differences were detected between the HSG and AHCM conditions in days to housing entry (M=108.0, SD=86.6) or likelihood of losing housing (43, 31.2%) as determined by self-report supplemented by HOMES data.
Participants randomized to AHCM remained in VA SUD treatment an estimated 52.7 days (95% CI: 16.0-89.3; p=0.005) longer than HSG participants. Differences were not detected in the incidence of VA primary care, specialty medical/surgical, mental health, homeless service or rehabilitation visits between baseline and month 12. The AHCM condition had a higher rate of VA acute care service use, including emergency department visits (IRR=1.76, 95% CI: 1.21-2.55, p=0.003), inpatient medical days (IRR=6.48, 95% CI: 2.87-14.62, p<0.001) and inpatient psychiatric days (IRR=2.65, 95% CI: 1.13-6.22, p=0.025). Differences were not detected in non-VA acute service use, per self-report. Given the lack of differences in outcomes and higher use of acute services by AHCM participants, cost-effectiveness analyses were not conducted.
Both groups showed significant improvement over time on the ASI family (p=0.005), employment (p=0.035), alcohol (p<0.001), drug (p<0.001), and psychiatric (p<0.001) composite scores and SF-36 Mental Component Summary (p=0.004), and were more likely to be abstinent from alcohol and drugs in the past 30 days (p<0.001). The HSG condition showed greater improvement in alcohol composite scores compared to AHCM (estimated difference at month12=0.13, 95% CI: 0.04-0.23, p=0.006).
Both conditions improved significantly with respect to housing status and SUD- and psychiatric-related outcomes, suggesting that for the majority of Veterans standard SUD and housing care services at VA may address their needs. Such findings may be due in part to the increased funding and staffing of VA housing programs that occurred during the study's lifetime. However, for the approximately 24% of participants not entering long-term housing, as well as those who lost housing, different approaches to outreach and ongoing intervention will be required.
- Cox KB, Malte CA, Saxon AJ. Characteristics and service utilization of homeless veterans entering VA substance use treatment. Psychological Services. 2017 May 1; 14(2):208-213.
- Malte CA, Cox K, Saxon AJ. Providing intensive addiction/housing case management to homeless veterans enrolled in addictions treatment: A randomized controlled trial. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors. 2017 May 1; 31(3):231-241.