BACKGROUND/RATIONALE:
Veterans are overrepresented within the homeless population and have greater risk of homelessness compared to the general population living in poverty. The U.S. Department of Veterans Affairs (VA) has focused programming and policies on ending chronic homelessness and preventing new episodes of homelessness and has allocated more than $1 billion toward homelessness prevention and rapid rehousing services since Federal Fiscal Year (FFY) 2011 through the Supportive Services for Veteran Families (SSVF) program. To assist in the identification of veterans in need of these services, the VA National Center on Homelessness Among Veterans developed the Homelessness Screening Clinical Reminder (HSCR), a two-question universal screener that assesses housing instability and risk among veterans who present for outpatient care. During FFY 2013-2014, almost 5.8 million veterans responded to the HSCR; among those, 0.8% reported current homelessness and 1.0% reported imminent risk.

OBJECTIVE(S):
(1) To validate the HSCR and assess prevalence and risk factors for homelessness and risk among veteran users of Veterans Health Administration (VHA) healthcare services; (2) to assess the effectiveness of the HSCR at linking veterans who screen positive for homelessness or risk with subsequent services; and (3) to evaluate the psychometric properties and efficacy of the Homelessness Risk Assessment (HRA), a more extensive instrument used by SSVF providers in Philadelphia, PA to quantify risk of homelessness among veterans.

METHODS:
This study is employing a mixed methods approach, using a combination of data from existing VA data sources and primary data collection. The evaluation and validation of two instruments-the HSCR and the HRA-will use secondary data collected during regular operations at VHA and Philadelphia SSVF providers. To assess the effectiveness of the HSCR at linking veterans to needed services, the study team is using a mixed methods explanatory sequential design in which initial analysis of VA administrative data is followed by analysis of primary qualitative data collected during interviews with veterans, social workers, and clinicians.

FINDINGS/RESULTS:
Results from this study indicate that the HSCR is effective at differentiating between homelessness and risk of homelessness and is successful at linking Veterans with services in the majority of cases. Clinicians who administer the HSCR describe its utility for addressing an important social determinant of health and Veterans report that their understanding of the questions that comprise the HSCR are consistent with both physical (affordable, permanent, structurally and functionally adequate) and psychological (safe and comfortable) notions of "home." While the HRA may effectively predict imminent risk of homelessness, the results from this study do not provide sufficient evidence to amending the HSCR items, including adding questions from the HRA. Rather, results point to the need to change the screening process, including (1) who administers the HSCR (physicians generally reported that they are not the appropriate providers to do so and linkage with post-screening services is higher among Veterans screened by other providers), (2) how the questions are asked (providers indicate that they do not ask the questions as written but Veterans report a nuanced understanding of the questions), and (3) the post-screening process for linking Veterans with appropriate services, particularly those who may not be eligible for acute services due to literal or chronic homelessness, which demonstrates an inherent mismatch among Veterans' needs, policies around eligibility for services, and availability of resources.

IMPACT:
The existing body of research related to homelessness prevention is limited in terms of its practical application to policies and programs; the results of this study are poised to inform the current processes for responding to Veterans who report current housing instability. It will have an immediate impact on the system of care by informing and guiding more efficient and effective use of homelessness prevention resources.

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External Links for this Project

NIH Reporter

Grant Number: I01HX001467-01A2
Link: https://reporter.nih.gov/project-details/8867462

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PUBLICATIONS:

None at this time.

DRA: Other Conditions
DRE: Diagnosis
Keywords: Clinical Diagnosis and Screening, Homeless, Risk Factors
MeSH Terms: none