Special Issue of Psychological Services - Homelessness Among Veterans - Homeless Veterans
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Special Issue of Psychological Services - Homelessness Among Veterans

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December 2013 Issue of American Journal of Public Health (AJPH) - Center Publications
December 2013 AJPH Issue - Cover

 American Journal of Public Health 103, no. S2 (December 1, 2013)

The National Center on Homelessness among Veterans sponsored a special issue of the American Journal of Public Health in 2013 (Volume 103, issue S2), guest co-edited by Dennis Culhane (Research Director, National Center), Vincent Kane (Former Director, National Center), and Mark Johnston (HUD). Manuscripts were solicited and reviewed externally by reviewers selected and managed by the editorial staff at AJPH.

The issue featured articles that demonstrated the ongoing progress that is being made in research on homelessness, with an emphasis on Veteran homelessness. The research is also noteworthy in its focus on informing policy that ultimately seeks to end homelessness.

This page includes the following research articles by Center-affiliated researchers:


 EDITORIALS

Homelessness Research: Shaping Policy and Practice, Now and Into the Future
Dennis P. Culhane, PhD, Vincent Kane, MSS, and Mark Johnston “Homelessness Research: Shaping Policy and Practice, Now and Into the Future”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S181-S182.
DOI: 10.2105/AJPH.2013.301728                     PMID: 24148044

Application of Implementation Science for Homeless Interventions
Roger Casey, PhD, Colleen Clark, PhD, Paul Smits, MSW, and Roger Peters, PhD
. “Application of Implementation Science for Homeless Interventions”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S183-S184.
DOI: 10.2105/AJPH.2013.301729                      PMID: 24148045

Ending Homelessness—Then What?
Thomas O’Toole, MD, Lisa Pape, LISW, and Vincent Kane, MSS
. “Ending Homelessness—Then What?”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S185-S187.
DOI: 10.2105/AJPH.2013.301730                      PMID: 24148037



RESEARCH AND PRACTICE

Universal Screening for Homelessness and Risk for Homelessness in the Veterans Health Administration

Ann Elizabeth Montgomery, PhD, Jamison D. Fargo, PhD, Thomas H. Byrne, PhD, Vincent R. Kane, MSS, and Dennis P. Culhane. “Universal Screening for Homelessness and Risk for Homelessness in the Veterans Health Administration”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S210-S211.
DOI: 10.2105/AJPH.2013.301398                     PMID: 24148032

Abstract

We examined data for all Veterans who completed the Veterans Health Administration's national homelessness screening instrument between October 1, 2012, and January 10, 2013. Among Veterans who were not engaged with the US Department of Veterans Affairs homeless system and presented for primary care services, the prevalence of recent housing instability or homelessness was 0.9% and homelessness risk was 1.2%. Future research will refine outreach strategies, targeting of prevention resources, and development of novel interventions.



Challenges Associated with Screening for Traumatic Brain Injury Among US Veterans Seeking Homeless Services

Leah M. Russell, MA, et al. Maria D. Devore, MS, Sean M. Barnes, PhD, Jeri E. Forster, PhD, Trisha A. Hostetter, MPH, Ann Elizabeth Montgomery, PhD, Roger Casey, PhD, LCSW, Vincent Kane, MSS, and Lisa A. Brenner, PhD. “Challenges Associated with Screening for Traumatic Brain Injury Among US Veterans Seeking Homeless Services”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S211-S212.
DOI: 10.2105/AJPH.2013.301398                     PMID: 24148032

Abstract

We identified the prevalence of traumatic brain injury (TBI) among homeless Veterans and assessed the TBI-4, a screening tool created to identify TBI history. Between May 2010 and October 2011, 800 US Veterans from two hospitals, one eastern (n = 122) and one western (n = 678) completed some or all measures. Findings suggested that 47% of Veterans seeking homeless services had a probable history of TBI (data for prevalence obtained only at the western hospital). However, psychometric results from the screening measure suggested that this may be an underestimate and supported comprehensive assessment of TBI in this population.

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Housing Instability and Mental Distress among US Veterans

Robert M. Bossarte, PhD, John R. Blosnich, PhD, MPH, Rebecca I. Piegari, MS, Lindsay L. Hill, BA, and Vincent Kane, MSS. “Housing Instability and Mental Distress among US Veterans”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S213-S216.
DOI: 10.2105/AJPH.2013.301277                     PMID: 24148047

Abstract

Evidence has suggested increased risk for homelessness and suicide among US Veterans, but little is known about the associations between housing instability and psychological distress (including suicidal ideation). We examined frequent mental distress (FMD) and suicidal ideation among a probability-based sample of 1767 Nebraska Veterans who participated in the 2010 Behavioral Risk Factor Surveillance Survey who had and had not experienced housing instability in the past 12 months. Veterans experiencing housing instability had increased odds of FMD and suicidal ideation.


 


When Health Insurance Is Not a Factor: National Comparison of Homeless and Nonhomeless US Veterans Who Use Veterans Affairs Emergency Departments

Jack Tsai, PhD, Kelly M. Doran, MD, and Robert A. Rosenheck, MD. “When Health Insurance Is Not a Factor: National Comparison of Homeless and Nonhomeless US Veterans Who Use Veterans Affairs Emergency Departments”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S225-S231.
DOI:10.2105/AJPH.2013.301307                      PMID: 24148061

Abstract

OBJECTIVES: We examined the proportion of homeless Veterans among users of Veterans Affairs (VA) emergency departments (EDs) and compared sociodemographic and clinical characteristics of homeless and nonhomeless VA emergency department users nationally.

METHODS: We used national VA administrative data from fiscal year 2010 for a cross-sectional study comparing homeless (n = 64,091) and nonhomeless (n = 866,621) ED users on sociodemographics, medical and psychiatric diagnoses, and other clinical characteristics.

RESULTS: Homeless Veterans had 4 times the odds of using EDs than nonhomeless Veterans. Multivariate analyses found few differences between homeless and nonhomeless ED users on the medical conditions examined, but homeless ED users were more likely to have been diagnosed with a drug use disorder (odds ratio [OR] = 4.12; 95% confidence interval [CI] = 3.97, 4.27), alcohol use disorder (OR = 3.67; 95% CI = 3.55, 3.79), or schizophrenia (OR = 3.44; 95% CI = 3.25, 3.64) in the past year.

CONCLUSIONS: In a national integrated health care system with no specific requirements for health insurance, the major differences found between homeless and nonhomeless ED users were high rates of psychiatric and substance abuse diagnoses. EDs may be an important location for specialized homeless outreach (or "in" reach) services to address mental health and addictive disorders.

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Elderly Homeless Veterans in Los Angeles: Chronicity and Precipitants of Homelessness

Carissa van den Berk-Clark, PhD, MSW, and James McGuire, PhD, LCSW. “Elderly Homeless Veterans in Los Angeles: Chronicity and Precipitants of Homelessness”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S232-S238.
DOI: 10.2105/AJPH.2013.301309                    PMID: 24148059

Abstract

OBJECTIVES: We compared the characteristics of chronically homeless and acutely homeless elderly Veterans to better understand precipitants of homelessness.

METHODS: We conducted interviews with 33 chronically and 26 acutely homeless Veterans aged 65 years and older receiving transitional housing services in Los Angeles, California, between 2003 and 2005. We asked questions regarding their sociodemographic characteristics and other social status measures. Other precipitants of homelessness were acquired via observation and open-ended and structured questions.

RESULTS: Both Veterans’ groups were more similar than different, with substantial levels of physical, psychiatric, and social impairment. They differed significantly in homelessness history, with chronically homeless Veterans having more homelessness episodes and more total time homeless. They were also less educated and had smaller social networks. In response to open-ended questioning, elderly homeless Veterans revealed how health and substance use issues interacted with loss of social support and eviction to exacerbate homelessness.

CONCLUSIONS: Assessment of a range of factors is needed to address risk factors and events leading to homelessness. Further research with larger samples is needed to confirm the characteristics and needs of the elderly homeless Veteran population.


 


Latent Homeless Risk Profiles of a National Sample of Homeless Veterans and Their Relation to Program Referral and Admission Patterns

Jack Tsai, PhD, Wesley J. Kasprow, PhD, MPH, and Robert A. Rosenheck, MD. “Latent Homeless Risk Profiles of a National Sample of Homeless Veterans and Their Relation to Program Referral and Admission Patterns”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S239-S247.
DOI: 10.2105/AJPH.2013.301322                   PMID: 24148048

Abstract

OBJECTIVES:
We identified risk and need profiles of homeless Veterans and examined the relation between profiles and referrals and admissions to Department of Veterans Affairs (VA) homeless service programs.

METHODS: We examined data from the VA's new Homeless Operations Management and Evaluation System on 120,852 Veterans from 142 sites nationally in 2011 and 2012 using latent class analyses based on 9 homeless risk factors. The final 4-class solution compared both referral and admission to VA homeless services.

RESULTS: We identified 4 latent classes: relatively few problems, dual diagnosis, poverty-substance abuse-incarceration, and disabling medical problems. Homeless Veterans in the first group were more likely to be admitted to the VA's permanent supportive housing program, whereas those in the second group were more likely to be admitted to more restrictive VA residential treatment. Homeless Veterans in the third group were more likely to be admitted to the VA's prisoner re-entry program, and those in the fourth group were more likely to be directed to VA medical services.

CONCLUSIONS: The heterogeneous risk and need profiles of homeless Veterans supported the diversity of VA homeless services and encouraged the development of specialized services to meet their diverse needs.

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Risk Factors for Becoming Homeless Among a Cohort of Veterans Who Served in the Era of the Iraq and Afghanistan Conflicts

Stephen Metraux, PhD, Limin X. Clegg, PhD, John D. Daigh, MD, Dennis P. Culhane, PhD, and Vincent Kane, MSS. “Risk Factors for Becoming Homeless Among a Cohort of Veterans Who Served in the Era of the Iraq and Afghanistan Conflicts”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S255-S261.
DOI: 10.2105/AJPH.2013.301432                    PMID: 24148066

Abstract

OBJECTIVES:
In this population-based cohort study, we assessed baseline risk factors for homelessness, including the role of service in the Iraq or Afghanistan conflicts, among a large cohort of recent Veterans.

METHODS: Data for this study came from administrative records for 310,685 Veterans who separated from active military duty from July 1, 2005, to September 30, 2006. We used survival analysis methods to determine incidence rates and risk factors for homelessness, based on baseline data for military factors, demographic characteristics, and diagnoses of behavioral health disorders and traumatic brain injury.

RESULTS: Service in Iraq or Afghanistan and, more specifically, posttraumatic stress disorder among Veterans deployed there, were significant risk factors of modest magnitude for homelessness, and socioeconomic and behavioral health factors provided stronger indicators of risk. Gender was not a significant indicator of differential risk.

CONCLUSIONS: Although service in Iraq and Afghanistan was significant, socioeconomic and behavioral health indicators show more promise in efforts to use administrative data to inform prevention efforts by identifying Veterans who are at elevated risk for becoming homeless upon their return to civilian life.


 


Relationship Among Adverse Childhood Experiences, History of Active Military Service, and Adult Outcomes: Homelessness, Mental Health, and Physical Health

Ann Elizabeth Montgomery, PhD, J. J. Cutuli, PhD, Michelle Evans-Chase, PhD, Dan Treglia, MPP, and Dennis P. Culhane, PhD. “Relationship Among Adverse Childhood Experiences, History of Active Military Service, and Adult Outcomes: Homelessness, Mental Health, and Physical Health”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S262-S268.
DOI: 10.2105/AJPH.2013.301474                    PMID: 24148064

Abtsract

OBJECTIVES:
We determined whether a report of adverse childhood experiences predicts adult outcomes related to homelessness, mental health, and physical health and whether participation in active military service influences the relationship between childhood and adult adversity.

METHODS: Using data from the 2010 Washington State Behavioral Risk Factor Surveillance System, we tested by means of logistic regression the relationship between adverse childhood experiences and 3 adult outcomes--homelessness, mental health, and physical health--as well as differences among those with a history of active military service.

RESULTS: Adverse childhood experiences separately predicted increased odds of experiencing homelessness as an adult and mental health and physical health problems. Childhood adversity increased the likelihood of adult homelessness and poor physical health among individuals with no history of active military service and the likelihood of mental health problems among individuals with a history of active military service.

CONCLUSIONS: The relationship between childhood adversity and adult adversity changes in degree when history of active military service is controlled, which has implications for Armed Forces recruitment strategies and postmilitary service risk assessment.

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Community-Level Characteristics Associated with Variation in Rates of Homelessness Among Families and Single Adults

Jamison D. Fargo, PhD, Ellen A. Munley, PhD, Thomas H. Byrne, PhD, Ann Elizabeth Montgomery, PhD, and Dennis P. Culhane, PhD. “Community-Level Characteristics Associated With Variation in Rates of Homelessness Among Families and Single Adults”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S340-S347.
DOI: 10.2105/AJPH.2013.301619                    PMID: 24148057

Abstract

OBJECTIVES:
We modeled rates of family and single-adult homelessness in the United States in metropolitan and nonmetropolitan regions and as a function of community-level demographic, behavioral, health, economic, and safety net characteristics.

METHODS: We entered community-level characteristics and US Department of Housing and Urban Development point-in-time counts for a single night in January 2009 into separate mixed-effects statistical analyses that modeled homelessness rates for 4 subpopulations: families and single adults in metropolitan and nonmetropolitan regions.

RESULTS: Community-level factors accounted for 25% to 50% of the variance in homelessness rates across models. In metropolitan regions, alcohol consumption, social support, and several economic indicators were uniquely associated with family homelessness, and drug use and homicide were uniquely associated with single-adult homelessness. In nonmetropolitan regions, life expectancy, religious adherence, unemployment, and rent burden were uniquely associated with family homelessness, and health care access, crime, several economic indicators, and receipt of Supplemental Security Income were uniquely associated with single-adult homelessness.

CONCLUSIONS: Considering homeless families and single adults separately enabled more precise modeling of associations between homelessness rates and community-level characteristics, indicating targets for interventions to reduce homelessness among these subpopulations.


 


Evaluating the Impact of Dental Care on Housing Intervention Program Outcomes Among Homeless Veterans

Elizabeth Nunez, DMD MST, Gretchen Gibson, DDS, MPH, Judith A. Jones, DDS, DScD, MPH, and John A. Schinka, PhD. “Evaluating the Impact of Dental Care on Housing Intervention Program Outcomes Among Homeless Veterans”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S368-S373.
DOI: 10.2105/AJPH.2012.301064                    PMID: 23678921

Abtsract

OBJECTIVES:
In this retrospective longitudinal cohort study, we examined the impact of dental care on outcomes among homeless Veterans discharged from a Department of Veterans Affairs (VA) transitional housing intervention program.

METHODS: Our sample consisted of 9870 Veterans who were admitted into a VA homeless intervention program during 2008 and 2009, 4482 of whom received dental care during treatment and 5388 of whom did not. Primary outcomes of interest were program completion, employment or stable financial status on discharge, and transition to permanent housing. We calculated descriptive statistics and compared the 2 study groups with respect to demographic characteristics, medical and psychiatric history (including alcohol and substance use), work and financial support, and treatment outcomes.

RESULTS: Veterans who received dental care were 30% more likely than those who did not to complete the program, 14% more likely to be employed or financially stable, and 15% more likely to have obtained residential housing.

CONCLUSIONS: Provision of dental care has a substantial positive impact on outcomes among homeless Veterans participating in housing intervention programs. This suggests that homeless programs need to weigh the benefits and cost of dental care in program planning and implementation.

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New to Care: Demands on a Health System When Homeless Veterans Are Enrolled in a Medical Home Model

Thomas P. O’Toole, MD, et al. Claire Bourgault, RN, Erin E. Johnson, BA, Stephen G. Redihan, BA, Matthew Borgia, MA, Riccardo Aiello, MPA, and Vincent Kane, MSS. “New to Care: Demands on a Health System When Homeless Veterans Are Enrolled in a Medical Home Model”, American Journal of Public Health 103, no. S2 (December 1, 2013): pp. S374-S379.
DOI: 10.2105/AJPH.2013.301632                     PMID: 24148042

Abstract

OBJECTIVES: We compared service use among homeless and nonhomeless Veterans newly enrolled in a medical home model and identified patterns of use among homeless Veterans associated with reductions in emergency department (ED) use.

METHODS: We used case-control matching with a nested cohort analysis to measure 6-month health services use, new diagnoses, and care use patterns in Veterans at the Providence, Rhode Island, Veterans Affairs Medical Center from 2008 to 2011.

RESULTS: We followed 127 homeless and 106 nonhomeless Veterans. Both groups had similar rates of chronic medical and mental health diagnoses; 25.4% of the homeless and 18.1% of the nonhomeless group reported active substance abuse. Homeless Veterans used significantly more primary, mental health, substance abuse, and ED care during the first 6 months. Homeless Veterans who accessed primary care at higher rates (relative risk ratio [RRR] = 1.46; 95% confidence interval [CI] = 1.11, 1.92) or who used specialty and primary care (RRR = 10.95; 95% CI = 1.58, 75.78) had reduced ED usage. Homeless Veterans in transitional housing or doubled-up at baseline (RRR = 3.41; 95% CI = 1.24, 9.42) had similar reductions in ED usage.

CONCLUSIONS: Homeless adults had substantial health needs when presenting for care. High-intensity primary care and access to specialty care services could reduce ED use.

 

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