Ending homelessness among U.S. Veterans by 2015 is a federal priority. Veterans comprise a disproportionate fraction of the nation's homeless population, with an estimated 1 of every 4 homeless people having served in the military. While the overall number of homeless Veterans is declining, the number of homeless women Veterans is increasing. Women Veterans are four times more likely than non-Veteran women to experience homelessness. Risk factors for women Veterans' homelessness include mental health conditions, substance abuse, and a prior experience of military sexual trauma, with the majority of homeless women Veterans experiencing one or more of these conditions. Serious mental illness is associated with chronic homelessness. Veterans who are homeless on any given night represent only a fraction of a larger at-risk population. In prior research, we found that homeless women Veterans experienced multiple cycles in and out of homelessness over their lifetimes, and many housed women Veterans also had risk factors for homelessness. Previously, we examined how risk factors interplay and accumulate over the life course to result in homelessness. With a grounded understanding of the interconnected roots of homelessness, we hypothesized that it would be possible to identify critical junctures where intervention-and possibly prevention-are possible. Barriers to receipt of social and psychosocial services among homeless and at-risk women Veterans that we previously identified included: lack of information about services, limited access to servies, and lack of coordination across services.
Current VA homelessness screening aims to identify Veterans who are homeless, and those whose homelessness is imminent. However, the elimination of Veteran homelessness requires preventing those at risk from reaching this state. Previously, we developed a follow-up screening instrument to complement VA homelessness screening by identifying women Veterans in primary care and women's health settings who are at-risk for homelessness - the Veterans Homelessness Vulnerability Tool (or V-Tool). The V-Tool is applicable to those who do not screen positive for current or imminent homelessness. Our objective with this RRP was to pilot test the V-Tool at one site, using the QUERI Consolidated Framework for Implementation Research (CFIR) to guide our implementation process. Our specific aims corresponded consecutively to CFIR planning, engaging, executing, and reflecting and evaluating phases.
Per the CFIR, for Aim 1--the Planning stage--we conducted a diagnostic analysis of knowledge, attitudes, and beliefs regarding vulnerability screening for homelessness. This analysis entailed semi-structured interviews with clinicians and clinical staff in women's health clinics as well as homelessness services (e.g., HUD-VASH). During this stage, we also conducted semi-structured interviews with women Veteran VA healthcare users to assess their understanding of the draft V-Tool screening questions. For Aim 2-the Engaging stage-we refined the V-tool screener based on Aim 1 findings, and educated and trained clinicians to use the screener. The Executing stage (Aim 3) entailed implementing the V-tool in one healthcare system and generating preliminary reports. Finally, the Reflecting and Evaluating stage (Aim 4) involved further refinements to the V-tool and additional clinician and patient interviews to obtain feedback on those refinements. The tool was then programmed for use in CPRS. The V-Tool CPRS instrument takes the form of a clinical reminder dialogue.
Interviews with clinicians and patients revealed four important themes for the development and deployment of the V-tool. (1) Regarding the target population, homelessness vulnerability screening should be risk-based screening rather than universally applied to all screening negative for imminent homelessness. This was operationalized by using CPRS-assessable homelessness risk factors as inclusion criteria for screening eligibility. Though reducing sensitivity of the V-Tool screening process, this process significantly increases usability. (2) Regarding screening, the focus should be on the impact of the risk factor on the Veterans' 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. (3) Regarding referrals, clinicians and clinical staff overwhelmingly expressed the need for services to be in place prior to the initiation of screening. Women Veterans described prior VA experiences when all needed services were not in place. (4) Regarding the clinical settings for screening, mental health and social work staff thought that screening could be expanded to include these 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. It was critical to obtain multiple perspectives on the V-Tool content and process because each group of stakeholders had somewhat differing perspectives on and priorities for addressing homelessness risk.
Although services for homeless Veterans are growing in response to recent federal efforts, numerous barriers to care remain, particularly for women. A major barrier is limited awareness among both clinicians and vulnerable Veterans of factors that increase women Veterans' vulnerability for homelessness, and knowledge of services to alter these risks. The V-Tool screening and referral process is designed to close this gap. This project incorporated stakeholder perspectives into this process and is informing multi-site deployment of the V-Tool. It is also informing the design of an evaluation of the outcomes of the V-Tool screening and referral process. The ultimate goal of the V-Tool is to increase the identification and referral of at-risk Veterans into VA mental health, social service, and other treatment and preventive services, and to thereby contribute to primary homelessness prevention efforts.
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