Homeless Veterans Research Articles

Drug overdose deaths among homeless veterans in the United States Department of Veterans Affairs healthcare system.

With an epidemic of drug overdoses, contemporary research is needed to examine drug overdose deaths among homeless populations. This study measured rates, types and correlates of drug overdose deaths occurring over a 5-year study period among veterans experiencing homelessness (VEH) and non-homeless veterans (NHV) in the US Department of Veterans Affairs (VA) healthcare system. Retrospective cohort study. USA. A total of 6 128 921 veterans. We followed 399 125 VEH and 5 729 796 NHV between 2017 and 2021 using linked administrative VA and National Death Index data. Multivariable Cox regression models were constructed to estimate hazard ratios (HRs) for homelessness as a predictor of time-to-occurrence of overdose deaths with 95% confidence interval (CIs), sequentially controlling for demographic, medical, substance use and mental health characteristics. Among overdose deaths, 8653 [93.7%, 95% confidence interval (CI) = 93.2-94.2%] were unintentional and 5378 (57.8%, 95% CI = 56.8-58.8%) involved opioids. The overdose-specific mortality rate (per 100 000 person-years) was 227.3 among VEH and 23.2 among NHV (HR = 9.76, 95% CI = 9.36, 10.16), with rates 7-14 times higher among VEH than NHV, depending on the drug involved. In fully adjusted models, homelessness was associated with greater risk of drug overdose death (HR = 3.33, 95% CI = 3.18, 3.49), with the greatest risk involving psychostimulants (HR = 4.19), followed by antiepileptic/sedative/hypnotic drugs (HR = 3.69), synthetic opioids (HR = 3.50) and natural and semi-synthetic opioids (HR = 2.79). US veterans experiencing homelessness appear to have three times the risk for drug overdose deaths than non-homeless veterans. There may be specific risks associated with psychostimulant, antiepileptic, sedative and hypnotic drugs in this population that deserve greater attention.

Role of homelessness and psychiatric disorders in suicide deaths among veterans: A four-way decomposition analysis

Homelessness and suicide are top priorities in the U.S. Department of Veterans Affairs (VA). This study examined the various pathways involving homelessness, substance use, and mental health disorders in relation to suicide deaths among veterans in the VA healthcare system. A retrospective cohort study was conducted among 6,128,921 veterans—399,125 homeless and 5,729,796 non-homeless—followed-up between 2017 and 2021 using VA/Department of Defense linked databases. Multivariable Cox regression was applied for homelessness and psychiatric disorders as predictor of suicide deaths, sequentially controlling for demographic, clinical, substance use, and mental health characteristics. Four-way decomposition analysis was used to calculate proportions of suicide deaths mediated and/or moderated by homelessness, substance use, and mental health disorders. The relationship between homelessness and suicide-specific mortality risk was reduced from 40 % greater risk in unadjusted to 9 % greater risk in fully-adjusted models. Nearly 26 % of the total effect of homelessness on suicide-specific mortality risk was mediated by substance use disorders, whereas 49 % was mediated and 36 % was moderated by mental health disorders. In conclusion, excess suicide-specific mortality risk in homeless veterans is partly explained by substance use and mental health disorders, highlighting the importance of wrap-around health and social services for homeless veterans in mitigating suicide risk.

A thematic analysis of perceptions of VHA emergency care and suicide risk assessment among Veterans experiencing homelessness

ABSTRACT Introduction: Veterans who are homeless are at elevated risk for suicide, and often access Veterans Health Administration (VHA) emergency services to address their health needs. We sought to explore experiences of homeless Veterans utilizing these services, and barriers and facilitators to suicide prevention engagement. Methods: Semi-structured interviews with 25 Veterans who self-reported past 12-month history of homelessness and accessed VHA emergency services. Interviews explored perceptions of VHA emergency care and suicide risk assessment. Results: Interviewees described a complex array of factors contributing to housing instability. Participants detailed challenges navigating interrelated, yet at times disconnected, systems of healthcare and homeless services. Veterans’ experiences receiving care and suicide risk screening in VHA emergency services were generally positive. However, some described rare, striking experiences, feeling stigmatized for “being homeless”. Services following discharge tended to be fragmented. Given numerous contextual factors (e.g. transportation difficulties, timeliness of referrals) complicated by homelessness, individuals tended to routinely rely upon VHA emergency service for future acute care needs. Conclusions: Overall, perceptions of emergency services, including suicide risk screening in this setting, were largely positive and deemed acceptable. However, findings illustrate multiple avenues for optimizing service delivery, including post-discharge services, among homeless Veterans accessing VHA emergency services.

Digital access among a national sample of currently and formerly homeless veterans in 2022.

Background: Digital technologies are essential for connecting to the Internet and communicating with others. Methods: This study used data from the 2022 Project Community Homelessness Assessment, Local Education and Networking Groups (CHALENG) survey, which surveyed a national sample of 1992 homeless-experienced veterans (HEV) about use of cell phones, smart phones, computers, laptops, and the Internet. Data were analyzed to compare currently and formerly homeless veterans on digital access and to identify characteristics associated with never using the Internet. Results: Over 75% of HEV reported having a cellphone and over 65% reported having a smartphone. Internet use was common among HEV as 74% of currently homeless veterans and 77% of formerly homeless veterans reported using the Internet. Among HEV who used the Internet, over 70% used the Internet at least weekly. There was no significant difference between currently and formerly homeless veterans on their Internet use in the total sample and subsamples of only black and only Hispanic veterans. Overall, HEV who were older, black non-Hispanic, and living in the Southeast were more likely to never use the Internet. Conclusions: These findings highlight the potential for technology-based interventions among HEV, and suggest a digital divide based on age, race, and geography.

First Decade of Supportive Services for Veteran Families Program and Homelessness, 2012-2022.

As homelessness remains an urgent public health crisis in the United States, specific programs in the US Department of Veterans Affairs (VA) system may serve as a roadmap for addressing it. We examine lessons learned from the first decade (2012-2022) of the Supportive Services for Veteran Families (SSVF) program, a cornerstone in the VA continuum of homeless services aimed at both preventing homelessness among those at risk and providing rapid rehousing for veterans and their families who are currently experiencing homelessness. Drawing on information from annual reports and other relevant literature, we have identified 3 themes of SSVF that emerged as features to comprehensively deliver support for homeless veterans and their families: (1) responsiveness and flexibility, (2) coordination and integration, and (3) social resource engagement. Using these strategies, SSVF reached nearly three quarters of a million veterans and their families in its first decade, thereby becoming one of the VA's most substantial programmatic efforts designed to address homelessness. We discuss how each feature might apply to addressing homelessness in the general population as well as future research directions. (Am J Public Health. 2024;114(6):610-618. https://doi.org/10.2105/AJPH.2024.307625).

Suicide risk screening and evaluation among patients accessing VHA services and identified as being newly homeless.

To evaluate universal suicide risk screening and evaluation processes among newly homeless Veterans. Not applicable. Examination of Veterans Health Administration (VHA) using newly homeless patients' health record data in Calendar Year 2021. Not applicable. Health record data. Most patients received suicide risk screening and/or evaluation in the year prior to and/or following homeless identification (n = 49,505; 87.4%). Smaller percentages of patients were screened and/or evaluated in close proximity to identification (n = 7358; 16.0%), 1-30 days prior to identification (n = 12,840; 39.6%), or 1-30 days following identification (n = 14,263; 34.3%). Common settings for screening included primary care, emergency and urgent care, and mental health services. Of positive screens (i.e., potentially elevated risk for suicide), 72.6% had a Comprehensive Suicide Risk Evaluation (CSRE) completed in a timely manner (i.e., same day or within 24 h). Age, race, and sex were largely unrelated to screening and/or evaluation. Although many newly identified homeless patients were screened and/or evaluated for suicide risk, approximately 13% were not screened; and 27% of positive screens did not receive a timely CSRE. Continued efforts are warranted to facilitate suicide risk identification to ensure homeless patients have access to evidence-based interventions.

Growing Concern About Unsheltered Homelessness Among Veterans: Clinical Characteristics and Engagement in Health Care Services.

Veteran homelessness has declined in the past decade, but the proportion of unsheltered homeless veterans has increased. We identified characteristics of unsheltered homelessness in a large contemporary veteran cohort and examined outpatient and inpatient encounters before and after intake to US Department of Veterans Affairs (VA) homeless programs. National data from the Homeless Operations Management Evaluation System (HOMES) database and the Corporate Data Warehouse were analyzed on 191 204 veterans experiencing housing instability from January 2018 through December 2021. We used hierarchical multivariate logistic regressions to model associations between sheltered status and veteran correlates. Repeated-measures analysis of variance assessed changes in care utilization after intake in homeless programs. Age <50 years (odds ratio [OR] = 1.3; 95% CI, 1.2-1.4), Hispanic ethnicity (OR = 1.2; 95% CI, 1.1-1.3), some college education (OR = 1.1; 95% CI, 1.0-1.1), and a bachelor's degree (OR = 1.2; 95% CI, 1.1-1.2) were associated with veteran unsheltered homelessness. Unsheltered veterans were more likely to have a VA service-connected disability (OR = 1.4; 95% CI, 1.4-1.5), military sexual trauma (OR = 1.1; 95% CI, 1.0-1.1), and/or combat exposure (OR = 1.1; 95% CI, 1.0-1.1). Unsheltered and sheltered homeless veterans had an increase in outpatient encounters and a decrease in inpatient care after intake to the VA homeless program. Contemporary unsheltered homeless veterans are younger and Hispanic with some college education. Innovative public health approaches that better engage and reduce barriers to entry need to be tested for a diverse unsheltered homeless population.

Changes in mental health services in response to the COVID-19 pandemic in high-income countries: a rapid review

BackgroundSevere deterioration in mental health and disrupted care provision during the COVID-19 increased unmet needs for mental health. This review aimed to identify changes in mental health services for patients in response to the pandemic and understand the impact of the changes on patients and providers.MethodsFollowing the Cochrane guidance for rapid reviews, Cochrane CENTRAL, MEDLINE, Embase and PsycInfo were searched for empirical studies that investigated models of care, services, initiatives or programmes developed/evolved for patients receiving mental health care during COVID-19, published in English and undertaken in high-income countries. Thematic analysis was conducted to describe the changes and an effect direction plot was used to show impact on outcomes.Results33 of 6969 records identified were included reporting on patients’ experiences (n = 24), care providers’ experiences (n = 7) and mixed of both (n = 2). Changes reported included technology-based care delivery, accessibility, flexibility, remote diagnostics and evaluation, privacy, safety and operating hours of service provision. These changes had impacts on: (1) care access; (2) satisfaction with telehealth; (3) comparability of telehealth with face-to-face care; (4) treatment effectiveness; (5) continuity of care; (6) relationships between patients and care providers; (7) remote detection and diagnostics in patients; (8) privacy; (9) treatment length and (10) work-life balance.ConclusionsA shift to telecommunication technologies had a significant impact on patients and care providers’ experiences of mental health care. Improvements to care access, flexibility, remote forms of care delivery and lengths of operating service hours emerged as crucial changes, which supported accessibility to mental health services, increased attendance and reduced dropouts from care. The relationships between patients and care providers were influenced by service changes and were vastly depending on technological literacy and context of patients and availability and care access ranging from regular contact to a loss of in-person contact. The review also identified an increase in care inequality and a feeling of being disconnected among marginalised groups including homeless people, veterans and ethic minority groups. Telehealth in mental care could be a viable alternative to face-to-face service delivery with effective treatment outcomes. Further research is needed to better understand the impact of the changes identified particularly on underserved populations.

What We Know About Homeless Veterans With Other-than-honorable and Punitive Discharges: Data From the Grant and Per Diem (GPD) Program.

The U.S. DVA Grant and Per Diem (GPD) program funds community agencies to provide housing and case management services to Veterans experiencing homelessness. GPD is one of the few VA programs that can enroll Veterans with Other-than-Honorable (OTH) military discharges. The characteristics of OTH Veterans and their outcomes in GPD are unknown. We linked the Homeless Operations and Management Evaluation System database and VA Corporate Data Warehouse to identify Veterans with complete GPD enrollment and discharge data between 2018 and 2020. We categorized Veterans into three military discharge groups: Honorable, OTH, or Punitive. We evaluated key GPD process and outcomes measures: days enrolled in GPD, use of VA-funded emergency department care while in GPD, and whether a Veteran was successfully discharged from GPD, their housing status at program exit, employment status at program exit, and connection to mental health and substance abuse treatment at discharge. We conducted multivariable regressions to determine the adjusted association (controlling for demographics and comorbidities) between military discharge status and process and outcome measures. Among 21,646 Veterans in the GPD program, 20,517 (95%) were honorably discharged; 811 (4%) had an OTH discharge; and 318 (1%) had a Punitive discharge. There was no difference in GPD length of enrollment by discharge status. Compared to honorably discharged veterans, OTH and Punitive discharged Veterans were less likely to successfully exit GPD, more likely to be homeless and employed at program exit, and were less likely to have a VA-funded emergency department visit while in GPD and less likely to be connected to mental health care or substance use treatment at program exit. The GPD program serves hundreds of homeless Veterans with OTH and Punitive discharges every year, but they seem to be at greater risk for negative health and psychosocial outcomes and do not have the same access to VA services as other Veterans. These findings may inform policy considerations about expanding VA care and opportunities for community providers to serve Veterans with OTH and Punitive discharges.

Cost-effectiveness of Supported Housing for Homeless Veterans With Mental Illness

Cost-effectiveness of Supported Housing for Homeless Veterans With Mental Illness

Taps

Do you have the right, or even the obligation, to disobey laws that you find personally unjust? In this work of philosophical short story fiction, John, a retired music teacher who fled to Canada during the Vietnam War, grapples with his past choices as he plays taps at the funeral of a homeless veteran. Through his reflections and encounters, including a conversation with the veteran's sister and a rereading of Plato's "Crito," John confronts his guilt and seeks redemption for the sacrifices he didn't make. The story delves into themes of duty, sacrifice, and the enduring impact of war on those who lived through it.

Testing an implementation package in a housing skills training pilot for homeless-experienced persons with serious mental illness.

Evidence-based practices (EBPs) improve housing and health for persons who have experienced homelessness with serious mental illness (PEH-SMI) but are challenging to implement. We tested a strategy to support pilot implementation of a 12-session housing skills training intervention for PEH-SMI, tailored from effective social skills training interventions. We aimed to optimize the implementation strategy and intervention prior to an implementation trial. We provided training and technical assistance to nine providers to support pilot implementation of this intervention to six groups of PEH-SMI (n = 35) engaged in VA Greater Los Angeles' homeless services. We used scales and semi-structured interviews with 14 PEH-SMI and all interventionists to inform implementation strategy adaptations, identify factors that impacted implementation, and assess perceptions of the intervention. Attendance was tracked and we observed a random sample of each interventionist's groups to assess treatment fidelity. Interventionists perceived the implementation strategy and the intervention favorably. However, interventionists often lacked physical space, staff, and resources (e.g., computers) to conduct the intervention. Interventionists found the content valuable for participants and a few suggested that group engagement should be a prerequisite for obtaining housing services. PEH-SMI were interested in the intervention's content and receptive to the group-based format. Participants attended a mean of 4 ± 3/12 groups; all groups observed had acceptable fidelity. Problems with intervention retention were described, suggesting challenges maintaining group participation when participants transitioned between VA homeless services. To support the implementation of an EBP for PEH-SMI in homeless programs, these data suggest the value of training/technical assistance and strategies that enhance program-level buy-in to address resource concerns. Intervention adaptations, e.g., using a drop-in, open group format, in community-based settings that are easily accessible to PEH-SMI, may also increase adoption. This project was registered as "Improving Housing Outcomes for Homeless Veterans" Trial registration NCT03646149, registered 8/24/2018.

AGING IN THE RIGHT PLACE: TEMPORARY SUPPORTIVE HOUSING FOR OLDER MALE VETERANS IN CALGARY, CANADA

Abstract In 2019 an estimated 1.6% of emergency shelter users in Canada were veterans (1,905 individuals), which is consistent with the proportion of veterans in the general population (1.7%). However, veterans tend to be older, male, and cite an illness or medical condition as a contributing factor to their homelessness, than their non-veteran counterparts. As part of the Aging in the Right Place (AIRP) study, we sought to understand the housing and support needs of older male military veterans (age 50+) living in a congregate temporary supportive housing in Calgary, Alberta. This exploratory, multi-methods study used: (1) de-identified document review, (2) environmental audit, (3) in-depth qualitative key informant interviews with service providers and (4) in-depth qualitative and Photovoice interviews with older shelter residents to understand the shelter needs of older homeless veterans. The data was collected between February and June 2023. Interviews were transcribed, managed with NVivo 1.6.1, and team-based flexible coding was employed on the key informant (n=5) and shelter resident (n=5) interviews to determine older male veterans’ shelter needs. In this presentation we share the findings of the study and offer recommendations for shelter and services designed to assist older housing insecure veterans to age in the right place.

Rates and Predictors of Returns to Homelessness Among Veterans, 2018–2022

IntroductionThe progress made by the U.S. Department of Veterans Affairs (VA) towards ending veteran homelessness requires attention be paid to preventing returns to homelessness. MethodsUsing national VA data on 293,820 exits from a VA homeless program to a permanent housing destination between January 2018 thru December 2022, rates and predictors of returns to homelessness among veterans were examined. Analyses were conducted June-August 2023. A return to homelessness was operationally defined as a return encounter with a VA homeless program. Results5.8% of successful exits to permanent housing resulted in a return to homelessness within 6 months, 10.2% return within 12 months, and 16.7% return within 24 months. In the total sample, veterans who were male (hazard ratio [HR]= 1.47), widowed (HR= 1.29), had diagnoses of drug use disorder (HR= 1.40) or psychotic disorder (HR= 1.20), and had used more inpatient or urgent care services in the year prior (HR= 1.05-1.15) were at significantly greater risk of returning to homelessness. Many of these predictors remained significant in subgroup analyses of female veterans, veterans aged 65 or older, and veterans in the Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program. ConclusionsMost homeless veterans served by VA who exit to permanent housing do not return to homelessness within 2 years. The most critical period seems to be the first year, when 1 in 10 veterans return to homelessness. Knowledge of these risk factors may be important in planning secondary and tertiary prevention efforts for homelessness.

Risk of ESKD and Death Among Homeless Veterans with Incident CKD

Risk of ESKD and Death Among Homeless Veterans with Incident CKD

Benzodiazepine Prescriptions for Homeless Veterans Affairs Service Users With Mental Illness.

Despite elevated risk for substance use disorder and overdose death in the homeless population, benzodiazepine prescribing for this population has not been examined. In this study, the authors used data from the U.S. Department of Veterans Affairs (VA) health care system to examine benzodiazepine prescribing and risky and potentially inappropriate benzodiazepine prescribing practices for homeless VA service users. Using national VA administrative data (2018-2019), the authors conducted logistic regression to compare likelihood of benzodiazepine prescribing and t tests to compare indicators of risky and potentially inappropriate benzodiazepine prescribing patterns for homeless service users with mental illness (N=244,113) and their housed peers (N=2,763,513). Unadjusted analyses showed that benzodiazepines were prescribed for 7.5% of homeless VA service users with mental illness, versus 9.4% of their housed peers (p<0.001). Analyses adjusted for sociodemographic and clinical characteristics and health care utilization showed that homeless service users were less likely than their housed peers to receive a benzodiazepine prescription (AOR=0.70, 99% CI=0.68-0.72). However, compared with their housed peers, homeless service users received higher rates of risky and potentially inappropriate benzodiazepine prescriptions, including multiple concurrent benzodiazepine prescriptions (9.4% vs. 7.0%, p<0.001) and concurrent prescriptions for benzodiazepines and opioids (36.9% vs. 31.2%, p<0.001) or sedatives (61.9% vs. 45.9%, p<0.001). Although homeless VA service users with mental illness were less likely than their housed peers to receive a benzodiazepine prescription, benzodiazepine prescriptions for these service users had more characteristics of risky and potentially inappropriate prescribing.

Perspectives of homeless veterans living with substance use disorders (SUD) and mental illness

Upon returning home from the military, America's veterans face complex challenges such as homelessness and substance use disorders (SUD). Veterans who have experienced SUDs and homelessness are more likely to struggle with depression and suicidal behaviors. This study aims to understand homeless veterans' lived experiences of their everyday life and social interactions. We used semi-structured interviews to conduct a phenomenological study of 14 homeless veterans with known SUDs living in the Baltimore-Washington D.C. Metropolitan area. A Social-Ecological Model (SEM) was used to create themes, a priori, then used open coding analytic methods to identify emerging themes. Two-thirds of veterans used illicit drugs or abused alcohol, and nearly all reported a history of depression or anxiety. Suicidal behaviors were present in a third of all veterans. We found that veteran homelessness and substance use are strongly associated with emotional and physical trauma suffered while on active duty. Consequently, once homeless, a veteran's community may encourage and exacerbate SUDs, thus impeding a path toward sobriety. Homeless veterans who have struggled with SUDs and later experience a death in their family often relapse to substance use. Deeply exploring a veteran's relationships with family, friends, and their immediate community may reveal opportunities to address these issues using healthcare and community interventions.

Female Veterans’ risk factors for homelessness: A scoping review

LAY SUMMARY Homelessness is a problem among female Canadian Veterans. Approximately 15% of the Canadian Veteran population is female, yet female Veterans constitute approximately 30% of the homeless Canadian Veteran population. In response, the Standing Committee on Veterans Affairs has called for the investigation of homelessness among female Canadian Veterans to address this research gap. A scoping review was conducted on the lived experiences of homeless female Veterans to identify factors associated with homelessness. This review was the initial step in a larger research framework to investigate the lived experiences of homeless Canadian female Veterans. Fifteen articles met the inclusion criteria and were included for synthesis. Four themes were identified, corresponding with the period in which they occurred (pre-military service, post-military service, during military service, and across the lifespan). Several implications are clear. First, Canadian research on female Veteran homelessness is needed. Second, future research must use a framework that accounts for multifactorial and multi-dimensional issues, as well as a sex- and gender-based analysis lens.

A Sanctioned Encampment as a Strategy for Increasing Homeless Veterans' Access to Housing and Healthcare During the COVID-19 Pandemic.

The COVID-19 pandemic intersected with a housing crisis for unsheltered Veterans experiencing homelessness (VEHs); congregate settings became high risk for viral spread. The VA Greater Los Angeles responded by creating the Care, Treatment, and Rehabilitation Service (CTRS), an outdoor, low-barrier-to-entry transitional housing program on VA grounds. This novel emergency initiative offered a protected outdoor environment ("sanctioned encampment") where VEHs lived in tents and had access to three meals a day, hygiene resources, and health and social services. To identify contextual factors that supported and impeded CTRS participants' access to healthcare and housing services. Multi-method, ethnographic data collection. VEHs residing at CTRS, CTRS staff. Over 150hours of participant observation were conducted at CTRS and at eight town hall meetings; semi-structured interviews were conducted with 21 VEHs and 11 staff. Rapid turn-around qualitative analysis was used to synthesize data, engaging stakeholders in iterative participant validation. Content analysis techniques were used to identify key factors that impacted access to housing and health services among VEHs residing in CTRS. Staff varied in their interpretation of CTRS' mission. Some conceptualized access to health services as a central tenet, while others viewed CTRS as an emergency shelter only. Regardless, staff burnout was prevalent, which lead to low morale, high turnover, and worsened access to and quality of care. VEHs endorsed trusting, long-term relationships with CTRS staff as paramount for facilitating access to services. Though CTRS addressed basic priorities (food, shelter, etc.) that traditionally compete with access to healthcare, some VEHs needed on-site healthcare services, at their tents, to access care. CTRS provided VEHs access to basic needs and health and housing services. To improve access to healthcare services within encampments, our data suggest the value of longitudinal trusting relationships, adequate staff support, and on-site health services.

Chronically homeless veterans with gambling disorder: Epidemiology, clinical correlates, and traumatic experiences

BackgroundGambling disorder (GD) is often a concern for people living in poverty. Although GD has been correlated with homelessness, there has been no study of factors related to chronic homelessness among veterans with GD. MethodThis study used data from specialized homeless programs from the U.S. Department of Veterans Affairs Homeless Operations Management System to explore prevalence and correlates of chronic homelessness among veterans with GD in this program and to describe initial descriptive epidemiology. Chi-square tests, analyses of variance, and logistic regressions were conducted to examine differences in sociodemographic, military, clinical, and behavioral characteristics between veterans with versus without chronic homelessness. ResultOf 6053 veterans with GD, 1733 (28.6%) had chronic homelessness. Veterans with versus without chronic homelessness were more likely to be older, male, unemployed, and of low educational attainment and report having spent fewer years in the military. Chronic homelessness was associated with elevated odds of mental health and medical diagnoses, traumatic experiences, incarceration, and suicidal thoughts. Veterans with versus without chronic homelessness more frequently reported needing substance use, medical and psychiatric treatments but expressed low interest in participation in psychiatric treatment. ConclusionVeterans with GD and chronic homelessness have more clinical and behavioral concerns and needs for treatment, but participate in treatment at lower rates. It may be important to address both chronic homelessness and GD concurrently in order to effectively support veterans facing these challenges.