Homeless Veterans Research Articles

The association of military discharge variables with smoking status among homeless Veterans

ObjectiveThere is a dearth of research examining the health correlates of tobacco use within the homeless population, particularly with respect to homeless Veterans. An aim of the present study was to compare homeless Veteran and homeless non-Veteran smokers across a series of socio-demographic and health variables, and to determine whether any of these variables were independently associated with Veteran status. A subsequent aim was to compare the socio-demographic and health profiles of Veteran smokers and Veteran nonsmokers, and to determine whether any of these variables were independently associated with current smoking. MethodsData were obtained from the 2009 Homelessness in Minnesota survey conducted by the Wilder Research Foundation. The final sample included 4750 homeless individuals living throughout Minnesota. ResultsThe prevalence of smoking was greater among homeless Veterans (74%) than homeless non-Veterans (70%). The prevalence of physical and mental health problems was higher among homeless Veteran smokers than homeless non-Veteran smokers, although these variables were not independently associated with Veteran status after controlling for socio-demographics. Analyses of the homeless Veteran sample indicated that receipt of Veterans' benefits, type of discharge, and alcohol and/or chemical dependence were independently associated with current smoking. ConclusionHomeless Veteran smokers exhibit heightened rates of physical and mental health problems compared to homeless non-Veteran smokers. Military service and discharge characteristics may contribute to this high smoking prevalence. Future efforts should focus on increasing Veterans' access to and knowledge of Veterans' health resources, and on developing innovative strategies to boost cessation in this population.

Needing Primary Care But Not Getting It: The Role of Trust, Stigma and Organizational Obstacles reported by Homeless Veterans.

We describe data from a multi-center community-based survey of homeless veterans who were not accessing available primary care to identify reasons for not getting this care as well as for not seeking health care when it was needed. Overall, 185 homeless veterans were interviewed: The average age was 48.7 years (SD 10.8), 94.6% were male, 43.2% were from a minority population. The majority identified a recent need for care and interest in having a primary care provider. Reasons for delaying care fell into three domains: 1) trust; 2) stigma; and 3) care processes. Identifying a place for care (OR 3.3; 95% CI: 1.4-7.7), having a medical condition (OR 5.5; 95% CI 1.9-15.4) and having depression (OR 3.4; 95% CI: 1.4-8.7) were associated with receiving care while not being involved in care decisions was associated with no care (OR 0.7; 95% CI 0.5-0.9). Our findings support the importance of considering health access within an expanded framework that includes perceived stigma, inflexible care systems and trust issues.

Preliminary needs assessment of mobile technology use for healthcare among homeless veterans.

Background. Homeless veterans have complex healthcare needs, but experience many barriers to treatment engagement. While information technologies (IT), especially mobile phones, are used to engage patients in care, little is known about homeless veterans’ IT use. This study examines homeless veterans’ access to and use of IT, attitudes toward health-related IT use, and barriers to IT in the context of homelessness.Methods. Qualitative interviews were conducted with 30 homeless veterans in different housing programs in Boston, MA, ranging from emergency shelters to supportive transitional housing that allow stays of up to 2 years. Interviews were conducted in person, audio recorded and then transcribed. Three researchers coded transcripts. Inductive thematic analysis was used.Results. Most participants (90%) had a mobile phone and were receptive to IT use for health-related communications. A common difficulty communicating with providers was the lack of a stable mailing address. Some participants were using mobile phones to stay in touch with providers. Participants felt mobile-phone calls or text messages could be used to remind patients of appointments, prescription refills, medication taking, and returning for laboratory results. Mobile phone text messaging was seen as convenient, and helped participants stay organized because necessary information was saved in text messages. Some reported concerns about the costs associated with mobile phone use (calls and texting), the potential to be annoyed by too many text messages, and not knowing how to use text messaging.Conclusion. Homeless veterans use IT and welcome its use for health-related purposes. Technology-assisted outreach among this population may lead to improved engagement in care.

Smoking cessation in homeless veterans.

aRalph H. Johnson VA Medical Center, Charleston, South Carolina. *Corresponding author: Mark B. Hamner, MD, Ralph H. Johnson VA Medical Center, 109 Bee Street, Charleston, SC 29401-5799 (mark.hamner@va.gov). J Clin Psychiatry 2015;76(7):e911–e912 dx.doi.org/10.4088/JCP.14com09726 © Copyright 2015 Physicians Postgraduate Press, Inc. S is likely much higher in the homeless than in the general population. It is likely higher still in the mentally ill homeless. The effect of veteran status on smoking in the homeless is unclear. However, there is no reason to think that smoking rates would be different as a function of veteran status in this population. For example, homeless veterans are much more likely to have nicotine dependence than veterans who are not homeless.1 Few studies have investigated the treatment of smoking in the homeless, despite the fact that the majority of smokers seem to want to quit. In this issue of the Journal, Carpenter and colleagues2 report an open trial of a multicomponent smoking cessation program for 20 homeless veterans. A novel feature of the study was the development of a smartphone application to facilitate mobile contingency management (mCM) therapy. The smoking cessation program utilized in the study included 4 weeks of using mCM, 4 counseling sessions, nicotine replacement therapy, and bupropion if medically appropriate. Participants could earn up to $815 ($480 for mCM, $100 for verified abstinence at 3 follow-up visits, and $35 for equipment return). This approach was a success in this pilot study. Abstinence as verified by carbon monoxide concentrations ≤ 6 ppm was 50% at the 4-week endpoint. Follow-up bioverified abstinence was 55% at 3 months and 45% at 6 months. Not surprisingly, there was a high rate of psychiatric comorbidity in this sample including posttraumatic stress disorder, major depressive disorder, and lifetime alcohol or substance dependence. This study further suggests that the intervention may be effective despite other psychiatric conditions that are thought to limit successful abstinence. The interpretation of this study, as the authors note appropriately, is limited by the small sample size and the lack of a control group. Nonetheless, the results are promising and should be further explored using a randomized controlled trial design.

Identifying Homelessness among Veterans Using VA Administrative Data: Opportunities to Expand Detection Criteria.

Researchers at the U.S. Department of Veterans Affairs (VA) have used administrative criteria to identify homelessness among U.S. Veterans. Our objective was to explore the use of these codes in VA health care facilities. We examined VA health records (2002-2012) of Veterans recently separated from the military and identified as homeless using VA conventional identification criteria (ICD-9-CM code V60.0, VA specific codes for homeless services), plus closely allied V60 codes indicating housing instability. Logistic regression analyses examined differences between Veterans who received these codes. Health care services and co-morbidities were analyzed in the 90 days post-identification of homelessness. VA conventional criteria identified 21,021 homeless Veterans from Operations Enduring Freedom, Iraqi Freedom, and New Dawn (rate 2.5%). Adding allied V60 codes increased that to 31,260 (rate 3.3%). While certain demographic differences were noted, Veterans identified as homeless using conventional or allied codes were similar with regards to utilization of homeless, mental health, and substance abuse services, as well as co-morbidities. Differences were noted in the pattern of usage of homelessness-related diagnostic codes in VA facilities nation-wide. Creating an official VA case definition for homelessness, which would include additional ICD-9-CM and other administrative codes for VA homeless services, would likely allow improved identification of homeless and at-risk Veterans. This also presents an opportunity for encouraging uniformity in applying these codes in VA facilities nationwide as well as in other large health care organizations.

Correlates of Initiation of Treatment for Chronic Hepatitis C Infection in United States Veterans, 2004-2009.

We describe the rates and predictors of initiation of treatment for chronic hepatitis C (HCV) infection in a large cohort of HCV positive Veterans seen in U.S. Department of Veterans Affairs (VA) facilities between January 1, 2004 and December 31, 2009. In addition, we identify the relationship between homelessness among these Veterans and treatment initiation. Univariate and multivariable Cox Proportional Hazards regression models with time-varying covariates were used to identify predictors of initiation of treatment with pegylated interferon alpha plus ribavirin. Of the 101,444 HCV treatment-naïve Veterans during the study period, rates of initiation of treatment among homeless and non-homeless Veterans with HCV were low and clinically similar (6.2% vs. 7.4%, p<0.0001). For all U.S. Veterans, being diagnosed with genotype 2 or 3, black or other/unknown race, having Medicare or other insurance increased the risk of treatment. Veterans with age ≥50 years, drug abuse, diabetes, and hemoglobin < 10 g/dL showed lower rates of treatment. Initiation of treatment for HCV in homeless Veterans is low; similar factors predicted initiation of treatment. Additionally, exposure to treatment with medications for diabetes predicted lower rates of treatment. As newer therapies become available for HCV, these results may inform further studies and guide strategies to increase treatment rates in all U.S. Veterans and those who experience homelessness.

IDENTIFYING MENTAL AND PHYSICAL HEALTH CORRELATES OF HOMELESSNESS AMONG FIRST-TIME AND CHRONICALLY HOMELESS VETERANS

This study examined four categories of self-reported health and mental health factors and their association with recurrent or chronic homelessness in a sample of homeless Veterans presenting for care for the first time. These factors and their relationship to housing status were examined in a cross-sectional analysis comparing first-time or single episode homeless Veterans to chronic or repeat emergency sheltered or unsheltered homeless Veterans. Results revealed that while Veterans with a history of chronic or recurrent homelessness were more likely to self-report diagnoses of substance abuse problems, any mental health problems, and bipolar disorder, those who were homeless for the first time in their adult life were more likely to report a variety of physical health conditions, economic causes of homelessness, and some other mental health problem. These findings suggest that further work should be undertaken to determine how clinical interventions for Veteran homelessness address different risk profiles and treatment needs based on lifetime homeless history.

Characteristics and Use of Services Among Literally Homeless and Unstably Housed U.S. Veterans With Custody of Minor Children.

The study examined the number of homeless veterans with minor children in their custody ("children in custody"), compared sociodemographic and clinical characteristics among homeless veterans with and without children in custody, and observed differences in referral and admission patterns among veterans with and without children in custody for a variety of U.S. Department of Veterans Affairs (VA) programs for homeless veterans. Data were obtained from the VA Homeless Operations Management and Evaluation System for 89,142 literally homeless and unstably housed veterans. Sociodemographic, housing, health, and psychosocial characteristics of veterans were analyzed. Among literally homeless veterans, 9% of men and 30% of women had children in custody; among unstably housed veterans, 18% of men and 45% of women had children in custody. Both male and female veterans with children in custody were younger and less likely to have chronic general medical conditions and psychiatric disorders compared with other veterans, but, notably, 11% of homeless veterans with children in custody had psychotic disorders. Veterans with children in custody were more likely than other veterans to be referred and admitted to the VA's permanent supported housing program, and women were more likely than men to be admitted to the program. A substantial proportion of homeless veterans served by the VA have severe mental illness and children in custody, which raises concerns about the parenting environment for their children. Particular focus should be directed at VA's supported-housing program, and the practical and ethical implications of serving homeless parents and their children need to be considered.

Effects of self-compassion workbook training on trauma-related guilt in a sample of homeless veterans: a pilot study.

The present pilot study examined the effects of a 4-week-long self-administered self-compassion training on trauma-related guilt and compared it to a stress inoculation control group. A total of 47 homeless male veterans who were living in transitional housing facilities volunteered to participate in this study. Participants were randomly assigned to either a self-compassion (N = 13) or a stress inoculation (N = 14) group and were asked to complete pre-, mid-, and postintervention assessments measuring changes in self-compassion, trauma-related guilt, and posttraumatic stress disorder severity. Participants in both interventions reported increased levels of self-compassion and equal reductions in trauma-related guilt. No other significant changes were noted. The results from this pilot study provide preliminary evidence for the use of self-compassion and stress inoculation trainings as effective interventions for trauma-related guilt. The findings also suggest that self-administered trainings in the form of workbooks may be a viable, cost-effective form of intervention for disadvantaged populations, such as homeless veterans in transitional housing, who may lack resources or access to professionals or paraprofessionals. The effects of both self-compassion training and stress inoculation training on the study variables and directions for future research on self-compassion and trauma-related guilt are discussed.

VA Disability Compensation and Money Spent on Substance Use Among Homeless Veterans: A Controversial Association.

There has long been concern that public support payments are used to support addictive behaviors. This study examined the amount of money homeless veterans spend on alcohol and drugs and the association between public support income, including VA disability compensation, and expenditures on alcohol and drugs. Data were from 1,160 veterans from 19 sites on entry into the Housing and Urban Development-Veterans Affairs Supportive Housing program. Descriptive statistics and nonparametric analyses were conducted. About 33% of veterans reported spending money on alcohol and 22% reported spending money on drugs in the past month. No significant association was found between public support income, VA disability compensation, and money spent on alcohol and drugs. A substantial proportion of homeless veterans spend some income on alcohol and drugs, but disability income, including VA compensation, does not seem to be related to substance use or money spent on addictive substances.

Challenges of Providing End-of-Life Care for Homeless Veterans.

To describe challenges of caring for homeless veterans at end of life (EOL) as perceived by Veterans Affairs Medical Center (VAMC) homeless and EOL care staff. E-mail survey. Homelessness and EOL programs at VAMCs. Programs and their ratings of personal, structural, and clinical care challenges were described statistically. Homelessness and EOL program responses were compared in unadjusted analyses and using multivariable models. Of 152 VAMCs, 50 (33%) completed the survey. The VAMCs treated an average of 6.5 homeless veterans at EOL annually. Lack of appropriate housing was the most critical challenge. The EOL programs expressed somewhat more concern about lack of appropriate care site and care coordination than did homelessness programs. Personal, clinical, and structural challenges face care providers for veterans who are homeless at EOL. Deeper understanding of these challenges will require qualitative study of homeless veterans and care providers.

Tailoring Outreach Efforts to Increase Primary Care Use Among Homeless Veterans: Results of a Randomized Controlled Trial.

Homeless individuals often have significant unmet health care needs that are critical to helping them leave homelessness. However, engaging them in primary and mental health care services is often elusive and difficult to achieve. We aimed to increase health-seeking behavior and receipt of health care among homeless Veterans. This was a multi-center, prospective, community-based, two-by-two randomized controlled trial of homeless Veterans. Homeless Veterans not receiving primary care participated in the study. An outreach intervention that included a personal health assessment and brief intervention (PHA/BI), and/or a clinic orientation (CO) was implemented. We measured receipt of primary care within 4 weeks of study enrollment. Overall, 185 homeless Veterans were enrolled: the average age was 48.6 years (SD 10.8), 94.6% were male, 43.0% were from a minority population, 12.0% were unsheltered, 25.5% were staying in a dusk-to-dawn emergency shelter, 26.1% were in transitional housing, while 27.7% were in an unstable, doubled-up arrangement. At one month, 77.3% of the PHA/BI plus CO group accessed primary care and by 6 months, 88.7% had been seen in primary care. This was followed by the CO-only group, 50.0% of whom accessed care in the first 4 weeks, the PHI/BI-only arm at 41.0% and the Usual Care arm at 30.6%. Chi-squared tests by group were significant (p < 0.001) at both 4 weeks and 6 months. There was no difference in attitudes about care at baseline and 6 months or in use patterns once enrolled in care. Our findings suggest that treatment-resistant/avoidant homeless Veterans can be effectively engaged in primary and other clinical care services through a relatively low intensity, targeted and tailored outreach effort.

Mental health and quality of life among veterans employed as peer and vocational rehabilitation specialists.

The study compared employment experiences, mental health recovery, and quality of life among peer specialists and vocational rehabilitation (VR) specialists hired by the U.S. Department of Veterans Affairs (VA), the VR specialists under the Homeless Veterans Supported Employment Program. Employment characteristics associated with mental health recovery were examined. The study was a national, observational survey of 152 peer specialists and 222 VR specialists across 138 VA health care systems in 49 states. The survey, administered over the Internet, included measures describing participant characteristics, employment factors, mental health, and quality of life. The two cohorts were compared by using t tests or chi square tests. Multiple regression analysis controlling for participant characteristics was used to identify employment factors associated with mental health and quality of life. Peer specialists were more likely than VR specialists to share recovery stories, serve as a role model or mentor, and advocate for veterans. Activities by VR specialists tended to focus more narrowly on job skills. Overall, after adjusting for multiple comparisons, the analysis found high levels of mental health and average quality of life for both cohorts, with no significant differences between the groups. Satisfaction with amount of supervision was consistently associated with aspects of mental health recovery, including work-related and helping-related quality of life, for both cohorts. The results highlight the value of work and the importance of supervision in realizing both the adoption of recovery-oriented services and the promotion of mental health in a community of veterans serving each other.

Risk factors for homelessness among US veterans.

Homelessness among US veterans has been a focus of research for over 3 decades. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this is the first systematic review to summarize research on risk factors for homelessness among US veterans and to evaluate the evidence for these risk factors. Thirty-one studies published from 1987 to 2014 were divided into 3 categories: more rigorous studies, less rigorous studies, and studies comparing homeless veterans with homeless nonveterans. The strongest and most consistent risk factors were substance use disorders and mental illness, followed by low income and other income-related factors. There was some evidence that social isolation, adverse childhood experiences, and past incarceration were also important risk factors. Veterans, especially those who served since the advent of the all-volunteer force, were at greater risk for homelessness than other adults. Homeless veterans were generally older, better educated, and more likely to be male, married/have been married, and to have health insurance coverage than other homeless adults. More studies simultaneously addressing premilitary, military, and postmilitary risk factors for veteran homelessness are needed. This review identifies substance use disorders, mental illness, and low income as targets for policies and programs in efforts to end homelessness among veterans.

Staff perceptions of homeless veterans’ needs and available services at community-based outpatient clinics.

Staff perceptions of homeless veterans’ needs and available services at community-based outpatient clinics.

Estimating PTSD prevalence in US veterans: considering combat exposure, PTSD checklist cutpoints, and DSM-5.

Despite the outstanding methodology, this study will no doubt generate questions and debate, like most veteran studies, concerning sample representativeness and interpretation in the context of other research related to the Iraq and Afghanistan wars, PCL validity, or diagnostic changes between DSM-IV and DSM-5. Questions concerning representativeness stem from the observation that veterans account for > 9% of US adults (2010 census5) but were identified in less than 4% of households in Wisco and colleagues’ study sampling frame.1 Nevertheless, this remains one of the only national samples with a high response rate, and the demographic weighting using census figures increases the likelihood that results are nationally representative. Homeless veterans account for 30%,6,7 not useful for projecting health care needs. Such a wide range has been particularly notable when comparing UK and US personnel after Iraq or Afghanistan deployments, with prevalences in UK personnel consistently at the lowest end of the spectrum, though some US studies, such as the Millennium Cohort,8 have produced similarly low estimates. Reasons for the striking differences across studies have been extensively debated, to include differences in demographics, exposure to combat, time between deployments, strategies in sampling, case criteria, level of anonymity of questionnaires, proportion of reservists to active members, and even the possibility of cultural differences.6,7 However, one meta-analysis9 largely resolved this debate by showing that there is much greater consistency across studies than first recognized, provided that studies are suitably grouped. Studies involving stratified random sampling of all deployed personnel, including the large proportion in support roles (eg, UK and Millennium Cohort), yielded a weighted PTSD prevalence of 5.5% (95% CI, 5.4–5.6), comparable to nondeployed personnel, whereas the large body of research focused on combat infantry personnel (mostly US studies) yielded a weighted prevalence of 13.2% (95% CI, 12.8–13.7),9 numbers nicely framing Wisco and colleagues’ overall veteran estimate.1 A follow-up study that directly linked UK and US data confirmed that level of combat exposure largely explained UK/US PTSD prevalence differences.10 H an accurate estimate of the prevalence of posttraumatic stress disorder (PTSD) is critically important for projecting health care needs for veterans now and in coming years. However, prevalence studies in US veterans have produced widely varying estimates, due in large part to lack of representative samples of the entire population, including those who deployed to war zones as well as the large proportion with service not involving war zone deployment. The article by Wisco et al1 in this issue of the Journal of Clinical Psychiatry provides the most comprehensive estimate to date of PTSD prevalence in a national veteran sample, as well as other important findings on trauma exposure, risk factors, and comorbidities useful to clinicians, researchers, and health care administrators. The 4.8% current and 8.0% lifetime prevalence of PTSD reported by Wisco et al1 in veterans overall, based on a stringent score (≥ 50) on the PTSD Checklist (PCL), is not dissimilar to the 3.5% 12-month and 6.8% lifetime National Comorbidity Study-Replication estimates in the general population,2,3 although this comparison is limited due to marked demographic and methodological differences. More similar is the 9.1%, 8.2%, and 7.1% current (30-day) PTSD prevalence in veterans aged 21–29, 30–44, and 45–59 years, respectively, reported by Wisco and colleagues, compared with 8.6% in 1 representative sample of Army personnel (both samples obtained in 2011), although this comparison too is limited by the failure to use the PCL or another wellestablished tool in the Army study.4 Consistent with other research, Wisco et al1 found strong associations of PTSD with number of lifetime traumas, combat exposure, and draft enlistment and strong protective effects of social connectedness and other psychosocial factors (measures related to resilience, optimism, gratitude, curiosity, purpose in life, and community integration). Nearly 90% of veterans reported a lifetime traumatic event (mean = 3.4), with 34% reporting combat exposure. Events carrying highest conditional probability of PTSD (≥ 25%) included sexual assault and high combat exposure (“moderate to heavy” or “heavy” in 7% of participants). The study also confirmed the strong comorbidity of PTSD with other psychiatric conditions.

VA Health Service use for homeless and low-income veterans: A spotlight on Los Angeles’ VA Supportive Housing program

VA Health Service use for homeless and low-income veterans: A spotlight on Los Angeles’ VA Supportive Housing program

A quality improvement innovation to establish a PCMH tailored to homeless veterans who utilize the ED

Knowledge is increasing regarding effective models of HCV care for people who inject drugs (PWID). However, examples implementing such models in primary care are lacking, leaving a gap in our applied understanding of how practically we best scale-up such care: this is critical and urgent if the benefits of treatment advances are to be realized for PWID.The Cool Aid Community Health Centre (CHC) provides HCV programming for PWID, putting recent advances into practice. A case study of the CHC's HCV programming describes the practice experience and outcomes of its novel, multidisciplinary, primary care, inner-city HCV treatment program for PWID. This paper describes how this model of care functions to address the many barriers to treatment and successfully facilitate adherence to treatment.Medical advances for HCV will be ineffectual without effective management of complex barriers to care related to substance use, mental health, trauma, poverty, homelessness, criminalization, cultural issues, stigma and marginalization. HCV treatment for PWIDs benefits from low-threshold settings which are culturally appropriate and where trusting relationships between clients and providers are nurtured. Public investment in primary care treatment for PWID living with HCV, including investments in supports that address the social barriers faced by these vulnerable populations would build on existing evidence and improve HCV outcomes for PWID.

Receipt of opioid therapy guideline- concordant care among HIV+ and HIV− veterans

s / Drug and Alcohol Dependence 146 (2015) e118–e201 e119 VASH may enable needed service use for homeless Veterans, through links to housing and primary care. Financial support: VAGLA CSHIIP. http://dx.doi.org/10.1016/j.drugalcdep.2014.09.241 Receipt of opioid therapy guidelineconcordant care among HIV+ and HIV− veterans J.R. Gaither1, E. Edelman1, W. Becker1,2, S. Crystal4, K. Gordon2, J. Goulet1,2, R. Kerns1,2, M. Skanderson3, D. Weisberg1, K. Bryant5, A. Justice1,2, D. Fiellin1 1 Yale University, New Haven, CT, United States 2 VA CT HCS, New Haven, CT, United States 3 VA Pittsburgh HCS, New Haven, CT, United States 4 Rutgers University, New Brunswick, NJ, United States 5 NIH/NIAAA, Bethesda, MD, United States Aims: To determine whether HIV+ and HIV− patients initiating opioid therapy (OT) are equally likely to receive care concordant with American Pain Society/American Academy of Pain Medicine opioid clinical practice guidelines. Methods: We performed a nested prospective cohort study on 17,961 patients from the Veterans Aging Cohort Study who initiated long-termOT (≥90-days) between 1999 and 2009. Unadjusted and adjusted models were used to evaluate associations between HIV status and outcomes on 12 indicators derived from national OT guidelines. We calculated summary scores (i.e., number of recommended indicators received per patient/number for which they were eligible×100) and examined trends in the receipt of individual indicators over time. Results: Receipt of guideline-concordant care was low for both patient groups. HIV+ patients (n=5,677) were more likely than HIV− patients (n=12,284) to receive a primary care provider (PCP) visit within 1 month (51% vs. 31%; p< .001); PCP follow-up within 6 months (89% vs. 73%; p< .001); urine drug tests (UDTs) within 1 month (8% vs. 6%; p< .001) and 6 months (18% vs. 14%; p< .001); a bowel regimen (31% vs. 25%; p< .001); and concurrent non-opioid pain medications (50% vs. 46%; p< .001). However, HIV+ patients were less likely to receive physical rehabilitation (24% vs. 31%; p< .001) or counseling (30% vs. 33%; p< .01) and more likely to receive sedative co-prescriptions (22% vs. 18%; p< .001). Overall, patients received no more than 35% of recommended care. Over time, we observed an increase in UDTs (10–19%; p for trend <.001) and a decrease in sedative co-prescriptions (22–17%; p for trend <.001). Conclusions: Strategies to increase the provision of OT guideline-concordant care are needed as the majority of HIV+ and HIV− patients receiving incident long-term OT did not receive recommended care and there were few clinically meaningful quality improvements over time. Financial support: F31DA035567, U24AA020794. http://dx.doi.org/10.1016/j.drugalcdep.2014.09.242 Prevalence of illicit drug use among patients of community health centers in East Los Angeles and Tijuana Marianna Garcia1, Melvin Rico1, John Scholtz1, Mani Vahidi1, Guillermina Natera3, Ronald Andersen2, Ietza Bojorquez4, Julia Yacenda1, Miriam Arroyo3, Mario Gonzalez5, Lillian Gelberg1,2 1 Family Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, United States 2 UCLA School of Public Health, Los Angeles, CA, United States 3 National Institute of Psychiatry Ramon de la Fuente Muniz, Mexico City, Mexico 4 El Colegio de la Frontera Norte Department of Population Studies, Tijuana, Mexico 5 National Commission Against Addictions, Mexico

The effects of homelessness on Veterans' health care service use: an evaluation of independence from comorbidities

ObjectivesThis study evaluates the prevalence of Multiple Comorbid Chronic Disease (MCCD) within homeless and non-homeless Veterans and the association between MCCD and inpatient medical care. MethodsAll individuals seen in the VA North Texas Health Care System between October 1, 2009 and September 30, 2010 (n = 102,034) were evaluated. Homelessness during the year and the number of common chronic diseases were evaluated for an association with likelihood of medical and psychiatric hospitalizations, bed days of care, inpatient substance treatment, rehabilitation admissions, and emergency department visits. ResultsHomeless Veterans had higher all-cause mortality rates and rates of use of almost all resources after controlling for chronic disease burden using the Charlson Comorbidity Index, psychiatric illnesses, substance use disorders, and demographic variables. ConclusionsHomelessness Veterans are vulnerable to a high use of resources and mortality, independent of medical and psychiatric conditions. This finding should focus additional attention on reducing homelessness.