Homeless Veterans Research Articles

Interprofessional collaboration and housing resource groups increase access to care for homeless veterans

Abstract The Veterans Administration Palo Alto Health Care System (VAPAHCS) is leading change and transforming the lives of homeless veterans served by combining two evidenced-based practice models to improve overall outcomes for ending veteran homelessness. To increase access to and quality of care for homeless veterans, a structure including Interprofessional Collaboration (IPC) regional teams and Housing Resource Groups (HRGs) was developed, to provide coordinated assistance in the communities where veterans reside. This paper reports the results of a longitudinal, repeated measures program evaluation. Outcome measures of the combined practice models indicated increased access to care for homeless veterans, and provider self-report of increased collaboration, coordination, and communication of stakeholders.

Disparities in Access to Medications for Opioid Use Disorder in the Veterans Health Administration.

A variety of patients - including women, older, racial/ethnic minority, rural, homeless, and justice-involved patients - are vulnerable to experiencing poor healthcare access and quality, such as lower quality substance use disorder treatment, than other populations. The current study examined receipt of medications for opioid use disorder by vulnerable populations within Veterans Health Administration (VHA) facilities to determine whether there are patient and facility factors that are associated with disparities in care. Using national VHA clinical/administrative data from Fiscal Year 2017, we calculated receipt of medications for opioid use disorder using the American Society for Addiction Medicine quality measure specifications. A mixed-effects logistic regression model tested whether patient vulnerability (ie, women, older age, racial/ethnic minority, rural residence, homeless, and justice-involved) and facility (eg, regional location, availability of a methadone clinic) characteristics were associated with medication receipt. Among the 53,568 veterans at VHA facilities diagnosed with opioid use disorder in Fiscal Year 2017, vulnerable populations - including women, older, Black, rural, homeless, and justice-involved veterans - had lower odds of receiving medications for opioid use disorder than their nonvulnerable counterparts. Veterans had higher odds of receiving medications at facilities with a higher proportion of patients with opioid use disorder, but lower odds of receiving medications at facilities in the Southern region compared to the Northeast region of the United States. Quality improvement efforts targeted at vulnerable populations are needed at the VHA to ensure these groups receive the same quality of substance use disorder treatment as other veterans.

Program Effectiveness of Life Skills Classes for Homeless Veterans

Abstract Date Presented 03/28/20 This quasiexperimental study determined whether four homeless male veterans who partook in life-skills classes in a transitional housing program reported increased satisfaction and improved life skills according to the Canadian Occupational Performance Measure (COPM). Results of paired t-tests indicated no statistically significant change; however, all participants reported a self-perceived change of two or more points, which is clinically significant and could inform future programs and OT practice. Primary Author and Speaker: David LeVan Contributing Authors: Allison Blatt, Colleen Cummings, Morgan Demyanovich, Emily Tomer, Jennifer Weightman

Examination of potential disparities in suicide risk identification and follow-up care within the Veterans Health Administration.

To improve the identification and intervention of suicide risk, the Veterans Health Administration implemented the use of electronic patient record flags (PRF) to indicate when a veteran is identified as high risk for suicide and to increase the clinical contacts made with the veteran. The current study utilized an intersectional approach to assess potential disparities in the likelihood of receiving a PRF and the likelihood of receiving post-PRF follow-up care among veterans with substance use disorders (SUDs). Among 458,092 veterans who received a SUD diagnosis in 2012, Black veterans were less likely to receive a PRF, although Black-disabled veterans and Black-female veterans were more likely to receive a PRF. Homelessness was related to greater likelihood of receiving a PRF and post-PRF care. Hispanic/Latinx veterans who experienced homelessness were more likely to receive post-PRF care, while disabled veterans who experienced homelessness were less likely. Hispanic/Latinx, female veterans, and Black-disabled veterans were significantly less likely to receive post-PRF care. Overall, few marginalized or intersecting identities were associated with decreased PRF or decreased follow-up care. There are opportunities for specific strategies that promote engagement in VA follow-up services for veterans identifying as Hispanic/Latinx women, disabled Black veterans, and disabled homeless veterans.

How many Australian veterans are homeless? Reporting prevalence findings and method from a national study

AbstractThis article presents findings from an Australian study of veteran homelessness (Hilferty, Katz et al. 2019). The AHURI Inquiry into Homelessness Amongst Australian Veterans was funded by the Department of Veterans' Affairs (DVA) to estimate the number of homeless veterans and to examine veterans' pathways into homelessness, service usage patterns and ways that service responses may be improved. This article presents the prevalence findings and describes the method employed by the research team. Drawing on primary data and extrapolating results to a larger sample of veterans, the researchers estimate that approximately 5,800 contemporary veterans experience homelessness over a 12‐month period in Australia. This estimate – the first ever to be based on primary data – indicates that veteran homelessness is a much larger problem than previously estimated and deserves priority attention from policymakers and sectoral representatives.

Cumulative Trauma Exposure and Chronic Homelessness Among Veterans: The Roles of Responses to Intrusions and Emotion Regulation.

Veterans with mental health problems and a history of interpersonal and military trauma exposure are at increased risk for chronic homelessness. Although studies have examined posttraumatic stress disorder (PTSD) as a predictor of homelessness, there is limited understanding of specific mechanisms related to cumulative trauma exposure. We sought to elucidate how cumulative interpersonal and military trauma exposure may be linked to homelessness chronicity by examining the role of factors that influence trauma recovery and functional impairment. Specifically, we examined the indirect association of cumulative trauma exposure with homelessness chronicity through distress and responses to trauma-related intrusions and emotion regulation problems in a sample of 239 veterans in community-based homeless programs. Participants completed measures of trauma exposure, responses to intrusions, intrusion distress, difficulties with emotion regulation, and duration and episodes of homelessness. Structural equation modeling was used to test a serial indirect effect model in which cumulative trauma exposure was indirectly associated with homelessness chronicity through distress from and responses to intrusions as well as emotion regulation problems. The results supported the hypothesized sequential indirect effect for episodes of homelessness, indirect effect odds ratio (IE ORs) = 1.12-1.13, but not for current episode duration, IE OR = 1.05. Overall, the present findings elucidate specific trauma-related factors that may be particularly relevant to episodic patterns of homelessness and interfere with efforts to remain housed. These findings represent an important step toward shaping policy and program development to better meet mental health care needs and improve housing outcomes among homeless veterans.

Establishing a pharmacist-managed outreach clinic at a day shelter for homeless veterans.

IntroductionThe US Department of Veterans Affairs (VA) has developed a homeless patient aligned care team (H-PACT) model to provide clinical outreach to homeless veterans. This model has not been implemented by the VA Sierra Nevada Health Care System; however, a day shelter for homeless veterans does exist. Currently, clinical staff at the shelter consists of licensed clinical social workers.MethodsA half day per week pharmacy clinic was established and managed by a postgraduate year-2 psychiatric pharmacy resident. Data regarding provider and emergency department (ED) visits, psychotropic medication adherence, and interventions made during visits were collected and analyzed to provide support for need of additional clinical staff and the establishment of an H-PACT at the Reno VA.ResultsOver 5 months, 52 veterans were seen, including some over multiple visits, with a total of 77 encounters. There were an average of 4 visits per clinic day. Total interventions equaled 205 and included medication review, patient education, and adverse drug reaction detection among other interventions. Provider visits and psychotropic medication possession prior to and following clinic visits were tracked.DiscussionThis pharmacist-managed outpatient clinic provided a comfortable walk-in environment for homeless veterans. The difference in provider visits, medication possession, and ED visits before and after walk-in clinic visits provided clinical significance with 205 documented interventions, and the clinic was well received by veterans.

Motivational and cognitive factors linked to community integration in homeless veterans: study 1 - individuals with psychotic disorders.

Little is known about the determinants of community integration (i.e. recovery) for individuals with a history of homelessness, yet such information is essential to develop targeted interventions. We recruited homeless Veterans with a history of psychotic disorders and evaluated four domains of correlates of community integration: perception, non-social cognition, social cognition, and motivation. Baseline assessments occurred after participants were engaged in supported housing services but before they received housing, and again after 12 months. Ninety-five homeless Veterans with a history of psychosis were assessed at baseline and 53 returned after 12 months. We examined both cross-sectional and longitudinal relationships with 12-month community integration. The strongest longitudinal association was between a baseline motivational measure and social integration at 12 months. We also observed cross-sectional associations at baseline between motivational measures and community integration, including social, work, and independent living. Cross-lagged panel analyses did not suggest causal associations for the motivational measures. Correlations with perception and non-social cognition were weak. One social cognition measure showed a significant longitudinal correlation with independent living at 12 months that was significant for cross-lagged analysis, consistent with a causal relationship and potential treatment target. The relatively selective associations for motivational measures differ from what is typically seen in psychosis, in which all domains are associated with community integration. These findings are presented along with a partner paper (Study 2) to compare findings from this study to an independent sample without a history of psychotic disorders to evaluate the consistency in findings regarding community integration across projects.

Changing demography of homeless adult populations.

As the demographic characteristics of the US population have changed over the past decade, the characteristics of different homeless populations have changed as well. This study tracked changes in demographic characteristics of homeless adult, veteran, and healthcare service user populations against general adult and veteran populations from 2007-2017. The results showed that changing demographics of homeless populations largely reflected broader trends in the general population, and attention is needed on the clinical needs of aging homeless populations. There may be some unique changes in the demography of some homeless populations, such as younger homeless veterans seeking healthcare services.

Motivational and cognitive factors linked to community integration in homeless veterans: Study 2 - clinically diverse sample.

In an initial study (Study 1), we found that motivation predicted community integration (i.e. functional recovery) 12 months after receiving housing in formerly homeless Veterans with a psychotic disorder. The current study examined whether the same pattern would be found in a broader, more clinically diverse, homeless Veteran sample without psychosis. We examined four categories of variables as potential predictors of community integration in non-psychotic Veterans: perception, non-social cognition, social cognition, and motivation at baseline (after participants were engaged in a permanent supported housing program but before receiving housing) and a 12-month follow-up. A total of 82 Veterans had a baseline assessment and 41 returned for testing after 12 months. The strongest longitudinal association was between an interview-based measure of motivation (the motivation and pleasure subscale from the Clinical Assessment Interview for Negative Symptoms) at baseline and measures of social integration at 12 months. In addition, cross-lagged panel analyses were consistent with a causal influence of general psychiatric symptoms at baseline driving social integration at 12 months, and reduced expressiveness at baseline driving independent living at 12 months, but there were no significant causal associations with measures of motivation. The findings from this study complement and reinforce those in Veterans with psychosis. Across these two studies, our findings suggest that motivational factors are associated at baseline and at 12 months and are particularly important for understanding and improving community integration in recently-housed Veterans across psychiatric diagnoses.

Increasing the Numbers of Homeless Veterans Served by the Veterans Health Administration from 2008 to 2015: maintaining focus on the intended target population and on sustaining service intensity

ABSTRACT In 2009, the Department of Veterans Affairs (VA) set a goal of ending veteran homelessness by expanding health care and housing services. The process of expanding programs on a large scale can lead to erosion of focus on program goals, especially if it involves serving a target population that is challenging to assist and that may require delivery of services at a high level of intensity. This study examined changes from 2008 to 2015 in the numbers of homeless veterans served; changes in in the target population served (socio-demographic and diagnoses treated); and changes in the intensity of services provided (number of mental health contacts per veteran annually). The number of homeless veterans served increased 125% (by over 134,000/year) as compared to only 15% for non-homeless veterans. Housing subsidies provided through HUD vouchers increased 75-fold from less than 1000 to almost 60,000. These large expansions were accomplished with little evidence of changes in sociodemographic characteristics or diagnoses among those treated, or reductions in the numbers of mental health services provided per veteran. These data demonstrate a large expansion of services for homeless veterans, especially supported housing, and successful maintenance of focus on the intended target population.

Homeless Veterans: It Takes a Community

Veterans’ Voices is a unique space for the contributions of veterans, active military, and military family members to voice their perspectives and experiences with areas of military or veteran life of interest to Journal of Veterans Studies readership and veterans studies scholars. Authors connect their experiences or perspectives with issues (explored or not yet explored) in applicable research, academic, or teaching fields. Veterans’ Voices submissions are vetted by members of the Journal of Veterans Studies editorial board.

An Interprofessional Team Performance Training Program for the Care of Vulnerable Patients in the Ambulatory Setting

Abstract Health professions trainees often want to care for vulnerable populations, but their good intentions can be tested by patients’ complex medical, psychological, and social needs. Well-functioning care teams can respond to these challenges through communication, coordination and supportive relationships, but this requires teams to train together. In this paper, we describe a year-long ambulatory curriculum that trains post-graduate primary care and mental health trainees in key aspects of teamwork and relationship-centered care as they care for patients with complex biopsychosocial problems. The curriculum was developed and implemented with two cohorts of trainees from primary care, mental health and pharmacy disciplines (n =31) that were immersed in an interprofessional team caring for homeless Veterans in a patient-centered medical home (PCMH). Our curriculum is relevant for any clinical site seeking to improve team-based care for patients with complex conditions. It is grounded in an evidence-derived team performance framework that addresses three key aspects of well-performing teams: meeting practices (standardizing time and processes for collaborative care using checklists), taskwork (understanding team members' roles and responsibilities, and how to improve care), and teamwork (building humanistic relationships with patients and team members, and communicating respectfully). The curriculum is experiential and requires trainees to work on an existing patient care team and participate in team-based care processes (e.g. huddles, team meetings, panel management). We address stakeholder engagement, faculty and team development, culture building and logistics. Using two previously validated instruments to assess trainee perceptions of team performance and personal burnout at 6 and 12 months, we found that the program led to improvements in trainees’ perspectives of team performance, their relationship skills, and the effectiveness of their meeting practices, while also avoiding burnout. Key factors contributing to the success of the program are co-locating the professions, faculty role-modeling of team practice and communication behaviors, promotion of a relationship-centered culture, regularly scheduled workplace learning activities and planned IP learning sessions that support team-based practice.

Impact of Peer Specialist Services on Residential Stability and Behavioral Health Status Among Formerly Homeless Veterans With Cooccurring Mental Health and Substance Use Conditions.

This study tested the impacts of peer specialists on housing stability, substance abuse, and mental health status for previously homeless Veterans with cooccurring mental health issues and substance abuse. Veterans living in the US Housing and Urban Development-Veterans Administration Supported Housing (HUD-VASH) program were randomized to peer specialist services that worked independently from HUD-VASH case managers (ie, not part of a case manager/peer specialist dyad) and to treatment as usual that included case management services. Peer specialist services were community-based, using a structured curriculum for recovery with up to 40 weekly sessions. Standardized self-report measures were collected at 3 timepoints. The intent-to-treat analysis tested treatment effects using a generalized additive mixed-effects model that allows for different nonlinear relationships between outcomes and time for treatment and control groups. A secondary analysis was conducted for Veterans who received services from peer specialists that were adherent to the intervention protocol. Treated Veterans did not spend more days in housing compared with control Veterans during any part of the study at the 95% level of confidence. Veterans assigned to protocol adherent peer specialists showed greater housing stability between about 400 and 800 days postbaseline. Neither analysis detected significant effects for the behavioral health measures. Some impact of peer specialist services was found for housing stability but not for behavioral health problems. Future studies may need more sensitive measures for early steps in recovery and may need longer time frames to effectively impact this highly challenged population.

Motivational and cognitive correlates of community integration in homeless veterans entering a permanent supported housing program.

Homelessness is a major public health problem, and serious mental illness (SMI) is highly prevalent in the homeless population. Although supported housing services-which provide permanent housing in the community along with case management-improve housing outcomes, community integration typically remains poor, and little is known about the underlying determinants of poor community integration postresidential placement. The general SMI literature has indicated that motivational and cognitive ability factors are key determinants of successful community integration, which provides a foundation for examining this issue. This study evaluated whether interview- and performance-based assessments of motivation, nonsocial and social-cognitive ability, and psychiatric symptoms were associated with community integration indices in 2 samples of homeless veterans either with (N = 96) or without (N = 80) a psychotic disorder who had recently been admitted to a supported housing program but who had not yet attained housing. Motivation indices, including experiential negative symptoms and defeatist performance attitudes, stood out as the most robust correlates (rs = -.30 to -.69) of community integration across both samples, particularly for social role participation. Demographics, general psychiatric symptoms, and nonsocial cognition showed generally weak relations with community integration, though social cognition showed a few relations. The consistent findings across samples point to the importance of motivational factors for understanding the determinants of poor community integration in this complex population. Further, interventions that target motivational challenges may have widespread usefulness for enhancing community integration outcomes beyond obtaining housing. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Implementation of HIV Preexposure Prophylaxis in a Homeless Primary Care Setting at the Veterans Affairs.

Objective: Oral preexposure prophylaxis (PrEP) is highly effective in preventing HIV-1 acquisition, yet it is underutilized among at-risk populations. In this pilot quality improvement (QI) initiative, we sought to identify barriers to PrEP implementation and create interventions to improve access to PrEP in a primary care clinic for homeless veterans. Methods: The setting was a large homeless primary care clinic at the Veterans Affairs in an urban area with high HIV prevalence. A root cause analysis was performed to identify barriers to PrEP expansion in the primary care clinic. Targeted interventions to improve provider knowledge and patient access to PrEP were implemented by the QI team. Results: Root cause analysis revealed 3 primary barriers to PrEP expansion in the primary care clinic: institutional limitations for prescribing PrEP, inconsistent screening and recognition of eligible patients by clinic staff, and lack of clinic workflow processes to support PrEP prescription. A multidisciplinary focus group found low levels of PrEP awareness and knowledge, with only 22% of providers reporting comfort discussing PrEP with patients. This improved to 40% of providers following targeted clinic educational interventions. The QI team also developed a pathway for primary care providers to obtain institutional PrEP prescribing privileges and used work groups to develop clinic workflows and protocols for PrEP. At the end of the intervention, at least 50% of primary care providers in the clinic had initiated PrEP in a new patient. Conclusions: We describe a multidisciplinary QI model to implement PrEP within a primary care setting serving Veterans and persons experiencing homelessness. Our program successfully addressed provider knowledge deficits and improved primary care capacity to prescribe PrEP. The primary care clinic can be a viable and important clinical setting to improve access to PrEP for HIV prevention, especially for vulnerable populations.

Health Care Utilization Among Homeless Veterans in Chicago.

The U.S. Department of Veterans Affairs (VA), the single largest health care system in the United States, provides comprehensive medical and behavioral health services to more than 9 million Veterans. The size and scope of the VA's system of care allow health care providers, policymakers, and community stakeholders to conduct detailed analyses of health care utilization among Veterans; however, these analyses do not include health care encounters that occur outside VA. Although many Veterans obtain care in non-VA settings, understanding health care utilization among vulnerable populations of Veterans, including those who are homeless or at risk of becoming homeless, is needed to identify potential opportunities to enhance access and reduce fragmentation of care. VA administrative data were merged with data from the Chicago HealthLNK Data Repository to identify Veterans eligible for VA services who were homeless, or at risk of becoming homeless, in the greater Chicago metropolitan area for the years 2010-2012. During the 3-year study period, about 208,554 Veterans were registered for care at two VA medical centers located in the City of Chicago and an adjacent suburb. Of those, 13,948 were identified as homeless or at risk of becoming homeless. Results suggest that 17% (n=2,309) of Veterans in this sample received some or all of their care in the community. Much of the care these Veterans received was for chronic health conditions, substance use, and mental health disorders. Veterans eligible for VA servicers who are homeless, or at risk of becoming homeless, frequently sought care in the community for a variety of chronic health conditions. Health information exchanges and partner-based registries may represent an important tool for identifying vulnerable Veteran populations while reducing duplication of care.

Providers' perceptions on barriers and facilitators to prescribing naloxone for patients at risk for opioid overdose after implementation of a national academic detailing program: A qualitative assessment.

Academic detailing is an educational outreach program that aligns providers' prescribing with evidence-based practice. The U.S. Department of Veterans Affairs (VA) Opioid Overdose Education and Naloxone Distribution (OEND) Program partnered with the VA Pharmacy Benefits Management National Academic Detailing Service to deliver naloxone education to providers who cared for patients at risk of opioid overdose. In this pilot study, we interviewed providers' who received academic detailing to capture their perceptions of facilitators and barriers to prescribing naloxone. To identify providers' perceptions of facilitators and barriers to prescribing naloxone for patients at risk for opioid overdose after implementation of a national academic detailing program. This was a hybrid inductive-deductive qualitative pilot using semi-structured interviews with VA providers to explore constructs associated with facilitators and barriers to prescribing take-home naloxone to patients at risk for opioid overdose from August 2017 to April 2018. Eleven participants were interviewed, six physicians, three clinical psychiatric pharmacists, and two nurse practitioners. Participants identified patient-level barriers (social stigma and lack of homeless patient support), poor data integration, and burden of data validation as barriers to prescribing naloxone. However, they also identified patient lists, repeat visits, and face-to-face/one-on-one video conferencing visits as important facilitators for naloxone prescribing. Academic detailing will need to address issues of social stigma regarding naloxone, educate providers about existing support systems for homeless veterans, and develop tools for data integration to improve naloxone access for veterans at risk for an opioid overdose.

An examination of physical illness and health service use in homeless veterans with PTSD, major depressive disorder, anxiety disorder, and/or bipolar disorder in Nebraska

ABSTRACT This study examined physical health problems and health service use among homeless veterans with a reported mental health diagnosis. The current sample included a total of 156 homeless male veterans living in Nebraska. Each participant completed a single structured interview with questions pertaining to sociodemographics, clinical characteristics, and use of health services. The results showed that veterans with mental health diagnoses endorsed several physical health problems not endorsed by veterans without such a diagnosis. Participants with a mental health diagnosis were also more likely to report the use of several health services for treatment of medical, mental health, and substance abuse problems. These findings highlight the association of mental illness with physical health problems among homeless veterans and suggest that further work may be needed to address the unique health care needs of this population.

Exploring Community Integration Among Formerly Homeless Veterans in Project-Based Versus Tenant-Based Supportive Housing.

Community integration-an individual's embeddedness in his/her community-impacts mental and physical health. This study aimed to understand factors affecting community integration among Veterans in the Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) program. Semi-structured interviews and focus groups were conducted with HUD-VASH staff (n = 14) and persons residing in project-based (n = 9) and tenant-based (n = 9) housing at VA Greater Los Angeles. Participants identified neighborhood safety concerns as a limitation to community integration. Participants were reluctant to connect with HUD-VASH peers living nearby because they wanted to focus on their own recovery (e.g., from substance use); and many were dissatisfied with the location of their apartments. Staff valued community integration but saw it as secondary to housing retention. Increased access to safe neighborhoods (e.g., through relationship building with landlords) and the addition of staff dedicated to improving community integration (e.g., peer-support specialists) would enhance community integration in the HUD-VASH program.