Veteran Homelessness Research Articles

Local Bidirectional Data-Sharing Collaboration to End Veteran Homelessness: The Erie Model

Local Bidirectional Data-Sharing Collaboration to End Veteran Homelessness: The Erie Model

Veteran Returns to Homelessness following Exits from Permanent Supportive Housing: Health and Supportive Services Use Proximal to Exit

Permanent supportive housing (PSH) programs have been shown to increase housing retention for “hard to house” individuals and been used to address veteran homelessness. Departures from PSH (referred to as “exits”) can represent a positive outcome for some veterans, while others may return to homelessness. This study analyzed administrative and primary data to identify individual- and institutional-level factors associated with veterans' returns to homelessness following exits from a PSH program. Findings suggest that a number of factors increase the risk of a return to homelessness, including admissions to inpatient substance abuse and behavioral health treatment programs and emergency department visits both pre- and post-exit. Targeted interventions may reduce the likelihood of subsequent homelessness.

Homelessness among a nationally representative sample of US veterans: prevalence, service utilization, and correlates.

To examine the prevalence of lifetime homelessness among veterans and use of Veterans Affairs (VA) homeless services, as well as their association with sociodemographic and clinical characteristics. A nationally representative sample of 1533 US veterans was surveyed July-August 2015. Among all veterans, 8.5% reported any lifetime homelessness in their adult life, but only 17.2% of those reported using VA homeless services. Prevalence of homelessness and VA homeless service use did not significantly differ by gender. Being low income, aged 35-44, and having poor mental and physical health were each independently associated with lifetime homelessness. Veterans who were White or lived in rural areas were significantly less likely to have used VA homeless services. Homelessness remains a substantial problem across different generations of veterans. The low reported uptake of VA homeless services suggests there are barriers to care in this population, especially for veterans who live in rural areas. Governmental resources dedicated to veteran homelessness should be supported, and obtaining accurate prevalence estimates are important to tracking progress over time.

Screening for homelessness among individuals initiating medication-assisted treatment for opioid use disorder in the Veterans Health Administration.

To determine the prevalence of homelessness and risk for homelessness among veterans with opioid use disorder initiating treatment. Addiction treatment programs operated by the US Department of Veterans Affairs (VA). All veterans initiating treatment with methadone or buprenorphine for opioid use disorder between October 1, 2013 and September 30, 2014 (n = 2,699) who were administered the VA's national homelessness screener. Self-reported homelessness or imminent risk of homelessness. The prevalence of homelessness was 10.2 percent and 5.3 percent were at risk for homelessness. Compared to male veterans, women veterans were less likely to report homelessness (8.9 percent vs 10.3 percent) but more likely to be at risk (11.8 percent vs 4.9 percent). By age group, veterans aged 18-34 and 45-54 years most frequently reported homelessness (12.0 and 11.7 percent, respectively) and veterans aged 45-54 and 55-64 years most frequently reported risk for homelessness (6.5 and 6.8 percent, respectively). The prevalence of homelessness in this population is approximately 10 times that of the general veteran population accessing care at VA. Screening identified a substantial number of veterans who could benefit from VA housing assistance and had not received it recently. Programs to address veteran homelessness should engage with veterans seeking addiction treatment. Integration of homelessness services into addiction treatment settings may, in turn, improve outcomes.

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.

A cluster randomized Hybrid Type III trial testing an implementation support strategy to facilitate the use of an evidence-based practice in VA homeless programs

BackgroundThe Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program is one of the largest initiatives to end Veteran homelessness. However, mental health and substance use disorders continue to reduce client stability and impede program success. HUD-VASH programs do not consistently employ evidence-based practices that address co-occurring mental health and substance use disorders. This paper presents a study protocol to evaluate the implementation of an evidence-based, co-occurring disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking—Veterans Edition (MISSION-Vet) in HUD-VASH using an implementation strategy called Getting To Outcomes (GTO).Methods/designIn three large VA Medical Centers, this Hybrid Type III trial will randomize case managers and their clients by HUD-VASH sub-teams to receive either MISSION-Vet Implementation as Usual (IU—standard training and access to the MISSION-Vet treatment manuals) or MISSION-Vet implementation augmented by GTO. In addition to testing GTO, effectiveness of the treatment (MISSION-Vet) will be assessed using existing Veteran-level data from the HUD-VASH data monitoring system. This project will compare GTO and IU case managers and their clients on the following variables: (1) fidelity to the MISSION-Vet intervention; (2) proportion of time the Veteran is housed; (3) mental health, substance use, and functional outcomes among Veterans; and (4) factors key to the successful deployment of a new treatment as specified by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model.DiscussionThis project is an important step for developing an implementation strategy to increase adoption of evidence-based practice use in VA homeless programs, and to further examine efficacy of MISSION-Vet in HUD-VASH. This project has important implications for program managers, policy makers, and researchers within the homelessness field. VA Central IRB approval for this study was granted in October 2011. The three sites were trained on MISSION-Vet and GTO in the first half of 2013. The first GTO planning meetings began after training occurred, between January 2013 and November 2013, across the three sites. The data collection—via a fidelity measure embedded into the VA Computerized Patient Record System—began as each site initiated MISSION-Vet, between April 2013 and January 2014.Trial registrationClinicalTrials.gov: NCT01430741

THE ASSOCIATION BETWEEN HIV STATUS AND HOMELESSNESS AMONG VETERANS IN CARE

Veterans seeking care in the Department of Veterans Affairs Health Care System (VA) are more vulnerable to HIV infection and homelessness. However, there is little scholarship on the association between serostatus and homelessness among VA veterans. We examined this association in the Veterans Aging Cohort Study, a sample of 6,819 HIV-positive and HIV-negative veterans attending 8 VAs across the country. We utilized logistic models regressing shelter use in the last month on correlates. HIV and homelessness prevalence was higher than in general veteran populations. Being HIV-positive was protective against homelessness. Substance use, hazardous alcohol use, depression, schizophrenia, and being African American and male increased risk of homelessness. HIV-positive status reduced the homelessness risk posed by substance use, especially among African American substance users. However, women veterans with HIV were at higher risk of homelessness than noninfected women veterans. Implications for policies on veteran homelessness and housing for people with HIV are discussed.

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.

Making housing first happen: organizational leadership in VA's expansion of permanent supportive housing.

While most organizational literature has focused on initiatives that transpire inside the hospital walls, the redesign of American health care increasingly asks that health care institutions address matters outside their walls, targeting the health of populations. The US Department of Veterans Affairs (VA)'s national effort to end Veteran homelessness represents an externally focused organizational endeavor. Our aim was to evaluate the role of organizational practices in the implementation of Housing First (HF), an evidence-based homeless intervention for chronically homeless individuals. This was an interview-based comparative case study conducted across eight VA Medical Centers (VAMCs). Front line staff, mid-level managers, and senior leaders at VA Medical Centers were interviewed between February and December 2012. Using a structured narrative and numeric scoring, we assessed the correlation between successful HF implementation and organizational practices devised according to the organizational transformation model (OTM). Scoring results suggested a strong association between HF implementation and OTM practice. Strong impetus to house Veterans came from national leadership, reinforced by Medical Center directors closely tracking results. More effective Medical Center leaders differentiated themselves by joining front-line staff in the work (at public events and in process improvement exercises), by elevating homeless-knowledgeable persons into senior leadership, and by exerting themselves to resolve logistic challenges. Vertical alignment and horizontal integration advanced at sites that fostered work groups cutting across service lines and hierarchical levels. By contrast, weak alignment from top to bottom typically also hindered cooperation across departments. Staff commitment to ending homelessness was high, though sustainability planning was limited in this baseline year of observation. Key organizational practices correlated with more successful implementation of HF for homeless Veterans. Medical Center directors substantively influenced the success of this endeavor through their actions to foster impetus, demonstrate commitment and support alignment and integration.

VA Health Service Utilization for Homeless and Low-income Veterans

The US Department of Housing and Urban Development (HUD)-VA Supportive Housing (VASH) program-the VA's Housing First effort-is central to efforts to end Veteran homelessness. Yet, little is known about health care utilization patterns associated with achieving HUD-VASH housing. We compare health service utilization at the VA Greater Los Angeles among: (1) formerly homeless Veterans housed through HUD-VASH (HUD-VASH Veterans); (2) currently homeless Veterans; (3) housed, low-income Veterans not in HUD-VASH; and (4) housed, not low-income Veterans. We performed a secondary database analysis of Veterans (n=62,459) who received VA Greater Los Angeles care between October 1, 2010 and September 30, 2011. We described medical/surgical and mental health utilization [inpatient, outpatient, and emergency department (ED)]. We controlled for demographics, need, and primary care use in regression analyses of utilization data by housing and income status. HUD-VASH Veterans had more inpatient, outpatient, and ED use than currently homeless Veterans. Adjusting for demographics and need, HUD-VASH Veterans and the low-income housed Veterans had similar likelihoods of medical/surgical inpatient and outpatient utilization, compared with the housed, not low-income group. Adjusting first for demographics and need (model 1), then also for primary care use (model 2), HUD-VASH Veterans had the greatest decrease in incident rates of specialty medical/surgical, mental health, and ED care from models 1 to 2, becoming similar to the currently homeless, compared with the housed, not low-income group. Our findings suggest that currently homeless Veterans underuse health care relative to housed Veterans. HUD-VASH may address this disparity by providing housing and linkages to primary care.

Homelessness and money mismanagement in Iraq and Afghanistan veterans.

We examined the empirical link between money mismanagement and subsequent homelessness among veterans. We used a random sample of Iraq and Afghanistan War era veterans from the National Post-Deployment Adjustment Survey in 2009-2011. Veterans were randomly selected from a roster of all US military service members in Operation Iraqi Freedom or Operation Enduring Freedom who were separated from active duty or in the Reserves/National Guard. Veterans (n = 1090) from 50 states and all military branches completed 2 waves of data collection 1 year apart (79% retention rate). Thirty percent reported money mismanagement (e.g., bouncing or forging a check, going over one's credit limit, falling victim to a money scam in the past year). Multivariate analysis revealed money mismanagement (odds ratio [OR] = 4.09, 95% CI = 1.87, 8.94) was associated with homelessness in the next year, as were arrest history (OR = 2.65, 95% CI = 1.33, 5.29), mental health diagnosis (OR = 2.59, 95% CI = 1.26, 5.33), and income (OR = 0.30, 95% CI = 0.13, 0.71). Money mismanagement, reported by a substantial number of veterans, was related to a higher rate of subsequent homelessness. The findings have implications for policymakers and clinicians, suggesting that financial education programs offered by the US Departments of Defense and Veterans Affairs may be targeted to effectively address veteran homelessness.

Traumatic Stressor Exposure and Post-Traumatic Symptoms in Homeless Veterans

To better understand potential risk factors for post-traumatic stress disorder (PTSD) and homelessness in veterans, we studied trauma exposure and responses in archival data on 115 homeless veterans. Rates of exposure to military and a variety of civilian high magnitude stressor (HMS) and persistent post-traumatic distress (PPD) events and symptoms of post-traumatic stress were assessed. The relationships between frequency of different trauma types and symptoms of post-traumatic stress were examined. Exposure to both HMS and PPD events were extremely high in this sample, with particularly high exposure to adult (82%) and childhood (62%) interpersonal violence HMS events and HMS events during military service (53%). Exposure to both military and civilian PPD events was associated with significantly higher levels of PTSD symptoms than exposure to no PPD events or only civilian PPD events, and almost all HMS event types were significantly correlated with both PTSD and dissociation symptoms. Post-traumatic symptoms and military and civilian traumatic stressors of all types should be assessed in homeless veterans because they may be contributing to poor social and occupational functioning.

Perceptions of Homelessness in Older Homeless Veterans, VA Homeless Program Staff Liaisons, and Housing Intervention Providers

To understand the needs and challenges encountered by older homeless veterans. We conducted six focus groups of older veterans, two focus groups, and one semi-structured interview of VA staff liaisons, and two focus groups and one semi-structured interview of housing intervention providers. Major themes for older veterans: 1) negative homelessness experience; 2) benefits of the structured transitional housing program; 3) importance of peer outreach; and 4) need for age-tailored job placement programs. Major themes for VA staff liaison/housing intervention providers: 1) belief that the transitional housing program has made a positive change; 2) need for individualized criteria to address the unique needs of veterans; 3) distinct differences between older and younger homeless veterans; 4) outreach services; 5) permanent housing issues; and 6) coordination of services. Compared with younger veterans, older veterans have less social support, greater employment and health challenges, and, perhaps greater motivation to change.

Homelessness and Money Mismanagement in Iraq and Afghanistan Veterans

Homelessness and Money Mismanagement in Iraq and Afghanistan Veterans

Assessing the causal effect of Section 8 housing vouchers as the active ingredient for decreasing homelessness in veterans with mental illness

Estimating the causal effect of an active ingredient in a randomized treatment may be complicated when participants receive heterogeneous doses of the active ingredient. For example, homeless veterans with mental illness were randomized to receive either case management only, or case management plus special access to a Section 8 housing voucher. However, a quarter of those randomized to the housing voucher group did not actually use the voucher, while a few of those randomized to case management actually used a housing voucher. Our goal is to estimate the causal effect of the proposed active ingredient (i.e., using a housing voucher), as opposed to the effect of being randomized to the active ingredient. The proposed instrumental variable methodology assumes that the outcome is proportional to the dose of the active ingredient and tests the significance of the instrumental variable estimate using a permutation test such as the Hodges–Lehman aligned rank statistic proposed by Rosenbaum for pair-matched data (Rosenbaum, Observational studies, 2002; The design of observational studies, 2010). This method removes unmeasured confounding when the assumptions of monotonicity and the exclusion restrictions hold; however, in practice these assumptions may not hold perfectly. Consequently, we extend and strengthen this approach by incorporating optimal full matching on the propensity to use the active ingredient, to further reduce bias and variability in the IV estimation.

The Use of Data to Assist in the Design of a New Service System for Homeless Veterans in New York City

Operation Home is an agreement between the City of New York and the US Department of Veterans Affairs to design a new service system to help end veteran homelessness in New York City. The authors' task was to obtain data to inform the design of this new system. A variety of methods were used. The group reviewed relevant literature and data from street homeless survey samples, analyzed shelter data, and consulted with VA homeless program staff on the findings. We then surveyed case managers at a veterans' shelter regarding their clients and determined their housing eligibility using a standardized logic model, and led two focus groups of veterans at this shelter regarding their views of the current shelter system and services for homeless veterans and how these might be improved. Among those resident in shelters during 2006, 37.2% of self-identified veterans compared to 0.9% of others reported their prior residence as supported housing, suggesting the need for more intensive case management at veterans' supported housing sites to help them sustain their tenure. The lack of interconnectedness among the various information systems made it more difficult to collect and analyze pertinent data. To begin to address this, a data match was undertaken to estimate the proportion of veterans resident in the veterans' shelter who were not in receipt of VA benefits to which they may be entitled. The data obtained through collaboration between staff from NYC's Department of Homelessness Services, US Department of Veterans Affairs facilities in the New York/New Jersey region and Common Ground Community led to information that informed the evaluation design of the new system. The identification of gaps in available data on homeless veterans will lead to projects both to improve and share data.