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IIR 13-334 – HSR&D Study

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IIR 13-334
Identifying and Measuring Risk for Homelessness among Veterans
Ann Elizabeth Montgomery PhD MSW MPA
Birmingham VA Medical Center, Birmingham, AL
Birmingham, AL
Funding Period: July 2015 - June 2019

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.

(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.

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.

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.

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.


Journal Articles

  1. Cusack M, Montgomery AE, Hunt-Johnson N, Dichter M, True G. Making Connections: Understanding How Screening, Triage, and Referral Processes Can Promote Veteran Housing Stability. Social work in public health. 2019 Jun 16; 1-9.
  2. Chhabra M, Sorrentino AE, Cusack M, Dichter ME, Montgomery AE, True G. Screening for Housing Instability: Providers' Reflections on Addressing a Social Determinant of Health. Journal of general internal medicine. 2019 Jul 1; 34(7):1213-1219.
  3. Cusack M, Montgomery AE, Sorrentino AE, Dichter ME, Chhabra M, True G. Journey to home: Development of a conceptual model to describe Veterans' experiences with resolving homelessness and housing instability. Housing Studies. 2019 Apr 15; doi:10.1080/02673037.2019.1598551.
  4. Yu B, Montgomery AE, True G, Cusack M, Sorrentino A, Chhabra M, Dichter ME. The intersection of interpersonal violence and housing instability: Perspectives from women veterans. The American Journal of Orthopsychiatry. 2018 Dec 31.
  5. Byrne T, Montgomery AE, Fargo JD. Predictive modeling of housing instability and homelessness in the Veterans Health Administration. Health services research. 2019 Feb 1; 54(1):75-85.
  6. Montgomery AE, Sorrentino AE, Cusack MC, Bellamy SL, Medvedeva E, Roberts CB, Dichter ME. Recent Intimate Partner Violence and Housing Instability Among Women Veterans. American journal of preventive medicine. 2018 Apr 1; 54(4):584-590.
  7. Dichter ME, Wagner C, Borrero S, Broyles L, Montgomery AE. Intimate partner violence, unhealthy alcohol use, and housing instability among women veterans in the Veterans Health Administration. Psychological Services. 2017 May 1; 14(2):246-249.
  8. Byrne T, Nelson RE, Montgomery AE, Brignone E, Gundlapalli AV, Fargo JD. Comparing the Utilization and Cost of Health Services between Veterans Experiencing Brief and Ongoing Episodes of Housing Instability. Journal of urban health : bulletin of the New York Academy of Medicine. 2017 Feb 1; 94(1):54-63.
  9. Fargo JD, Montgomery AE, Byrne T, Brignone E, Cusack M, Gundlapalli AV. Needles in a Haystack: Screening and Healthcare System Evidence for Homelessness. Studies in health technology and informatics. 2017 Jan 1; 235:574-578.
  10. Montgomery AE, Dichter ME, Thomasson AM, Roberts CB. Services Receipt Following Veteran Outpatients' Positive Screen for Homelessness. American journal of preventive medicine. 2016 Mar 1; 50(3):336-43.
  11. Byrne T, Montgomery AE, Fargo JD. Unsheltered Homelessness Among Veterans: Correlates and Profiles. Community mental health journal. 2016 Feb 1; 52(2):148-57.
  12. Montgomery AE, Byrne TH, Treglia D, Culhane DP. Characteristics and Likelihood of Ongoing Homelessness Among Unsheltered Veterans. Journal of health care for the poor and underserved. 2016 Jan 1; 27(2):911-22.
  13. Byrne T, Fargo JD, Montgomery AE, Roberts CB, Culhane DP, Kane V. Screening for Homelessness in the Veterans Health Administration: Monitoring Housing Stability through Repeat Screening. Public health reports (Washington, D.C. : 1974). 2015 Nov 1; 130(6):684-92.
Conference Presentations

  1. Montgomery AE, Byrne TH, Fargo JD, Treglia D, Culhane DP. Novel Research Identifying Increased Risk Factors for Homelessness in US Veterans: Unsheltered homelessness Among Veterans Accessing Outpatient Care at the VHA. Paper presented at: American Psychological Association Annual Convention; 2016 Aug 4; Denver, CO.
  2. Montgomery AE. Screening for Homelessness. Paper presented at: National Coalition for Homeless Veterans Annual Conference; 2016 Jun 1; Washington, DC.
  3. Montgomery AE. Subpopulation Deeper Dive: Female Veterans. Paper presented at: National Coalition for Homeless Veterans Annual Conference; 2016 Jun 1; Washington, DC.
  4. O T, Hutchinson N, Manning TE, Montgomery AE. Using "Big Data" to Improve Population Health: The VA Homeless Program "Hotspotter" Initiative. Presented at: Society of General Internal Medicine Annual Meeting; 2016 May 13; Hollywood, FL.
  5. Byrne TH. Identifying and measuring risk for homelessness among veterans: Evidence from the U.S. Department of Veterans Affairs. Presented at: Boston University School of Social Work Research Seminar Series; 2015 Sep 1; Boston, MA.
  6. Byrne TH, Montgomery AE. Characteristics and likelihood of ongoing homelessness among unsheltered veterans. Paper presented at: National Alliance to End Homelessness National Conference on Ending Homelessness; 2015 Jul 1; Washington, DC.

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