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Homeless Veterans

 

Special Issue of Psychological Services - Homelessness Among Veterans

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Special Issue of Psychological Services - Homelessness Among Veterans

Special Issue: “Homelessness Among Veterans, Other Adults, and Youth”
Special Issue Cover

This page is dedicated to the recently published Special Issue of the American Psychological Association (APA) journal Psychological Services, Volume 14, Number 2, May 2017. The issue presents new and innovative measurement approaches, interventions, and study methodologies to help benefit and improve homeless services for Veterans specifically.

Thomas O'Toole and affiliated Center researcher Jack Tsai were the Special Issue Editors.  Dr. O'Toole is the Director of the National Center on Homelessness among Veterans and Dr. Tsai is one of the Center's researchers in addition to working as a researcher for the VISN 1 New England MIRECC. 

Please read the first article listed below, Homelessness as a Public Mental Health And Social Problem: New Knowledge and Solutions, which is an introduction to the special issue "Homelessness Among Veterans, Other Adults, and Youth."

Correspondence concerning this article should be addressed to: Jack Tsai, PhD / Jack.Tsai2@va.gov or Jack.Tsai@yale.edu.


Center Publications in the Special Issue Related to Homeless Veterans


Homelessness as a Public Mental Health and Social Problem: New Knowledge and Solutions

Tsai, J., O'Toole, T., Kearney, L. K.
Psychological Services, 14(2), 113–117. http://dx.doi.org/10.1037/ser0000164
May 2017
Full Article

Abstract

Homelessness is a major public health problem that has received considerable attention from clinicians, researchers, administrators, and policymakers in recent years. In 2016, 550,000 individuals were homeless in the United States (U.S. Department of Housing and Urban Development, 2016) with 4.2% of individuals in the United States experiencing homelessness for over 1 month sometime in their lives and 1.5% experiencing homelessness in the last year (Tsai, 2017). Homelessness remains a recalcitrant problem and a ripe area for study, particularly in addressing needs of individuals at high risk for homelessness and those from understudied populations. New and innovative measurement approaches, interventions, and study methodologies are presented in this special issue to shed light on how psychology can help benefit and improve homeless services. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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Housing First on a Large Scale: Fidelity Strengths and Challenges in the VA's HUD-VASH Program

Kertesz, S. G., Austin, E., L., Holmes, S. K., DeRussy, A. J., Van Deusen L. C., Pollio, D. E.
Psychological Services, 14(2), 118–128. http://dx.doi.org/10.1037/ser0000123
May 2017
Full Article 

Abstract

Housing First (HF) combines permanent supportive housing and supportive services for homeless individuals and removes traditional treatment-related preconditions for housing entry. There has been little research describing strengths and shortfalls of HF implementation outside of research demonstration projects. The U.S. Department of Veterans Affairs (VA) has transitioned to an HF approach in a supportive housing program serving over 85,000 persons. This offers a naturalistic window to study fidelity when HF is adopted on a large scale. We operationalized HF into 20 criteria grouped into 5 domains. We assessed 8 VA medical centers twice (1 year apart), scoring each criterion using a scale ranging from 1 (low fidelity) to 4 (high fidelity). There were 2 HF domains (no preconditions and rapidly offering permanent housing) for which high fidelity was readily attained. There was uneven progress in prioritizing the most vulnerable clients for housing support. Two HF domains (sufficient supportive services and a modern recovery philosophy) had considerably lower fidelity. Interviews suggested that operational issues such as shortfalls in staffing and training likely hindered performance in these 2 domains. In this ambitious national HF program, the largest to date, we found substantial fidelity in focusing on permanent housing and removal of preconditions to housing entry. Areas of concern included the adequacy of supportive services and adequacy in deployment of a modern recovery philosophy. Under real-world conditions, large-scale implementation of HF is likely to require significant additional investment in client service supports to assure that results are concordant with those found in research studies. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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Predictors of Homeless Services Re-Entry Within a Sample of Adults

Brown, M., Vaclavik, D., Watson, D. P., Wilka, E.
Psychological Services, 14(2), 129–140. http://dx.doi.org/10.1037/ser0000112 
May 2017
Full Article 

Abstract

Local and national evaluations of the federal Homelessness Prevention and Rapid Re-Housing Program (HPRP) have demonstrated a high rate of placement of program participants in permanent housing. However, there is a paucity of research on the long-term outcomes of HPRP, and research on rehousing and prevention interventions for single adults experiencing homelessness is particularly limited. Using Homeless Management Information System data from 2009 to 2015, this study examined risk of return to homeless services among 370 permanently housed and 71 non-permanently housed single adult HPRP participants in Indianapolis, Indiana. Kaplan-Meier survival curves were conducted to analyze time-to-service re-entry for the full sample, and the homelessness prevention and rapid rehousing participants separately. With an average follow-up of 4.5 years after HPRP exit, 9.5% of the permanently housed HPRP participants and 16.9% of those non-permanently housed returned to homeless services. By assistance type, 5.4% of permanently housed and 15.8% of non-permanently housed homelessness prevention recipients re-entered services, and 12.8% of permanently housed and 18.2% of non-permanently housed rapid rehousing recipients re-entered during the follow-up period. Overall, Veterans, individuals receiving rapid rehousing services, and those whose income did not increase during HPRP had significantly greater risk of returning to homeless services. Veterans were at significantly greater risk of re-entry when prevention and rehousing were examined separately. Findings suggest a need for future controlled studies of prevention and rehousing interventions for single adults, aiming to identify unique service needs among Veterans and those currently experiencing homelessness in need of rehousing to inform program refinement. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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No Wrong Door: Can Clinical Care Facilitate Veteran Engagement in Housing Services?

Abstract

E. E., Borgia, M., Rose, J., O'Toole, T. P.
Psychological Services, 14(2), 167-173. http://doi.apa.org/doi/10.1037/ser0000124
May 2017
Full Article 

It is well established that providing stable housing to homeless persons improves health outcomes. It is less clear whether engagement in clinical care facilitates housing outcomes. We present a post hoc analysis of a prospective, community-based randomized controlled trial of homeless Veterans not actively receiving or assigned to a primary care. Study subjects were interviewed at baseline, 1 month and 6 months and survey results were supplemented/verified by review of all notes in their VA electronic medical record for 6 months post-enrollment. A total of 142 subjects with complete data were included in this analysis: 82 (57.7%) were in a stable sheltering/housing arrangement (transitional housing, stably doubled-up, independent housing) at baseline and stayed stable; 36 (25.4%) started in an unstable sheltering arrangement (unsheltered, emergency sheltered, unstable doubled-up arrangement) and moved into stable sheltering/housing while 24 (17.0%) individuals either started in and stayed unstably sheltered or went from a stable to an unstable arrangement. Of 36 individuals who transitioned from unstable to stable sheltering/housing, 25 (69.4%) accessed primary care within 1 month compared with 37.5% of the persistently unstable sheltering group and 57.3% of the stably sheltered/housed group (p = .05). Of those with care within 1 month, their average time from unstable to stable housing was 84.8 days compared with 165.9 days for those who do not access care (p = .02). Of those receiving primary care within 1 month of enrollment, 88.9% were in stable sheltering at 6 months. These findings suggest an important role for clinical engagement in helping achieve housing stability for homeless Veterans. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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A National Evaluation of Homeless and Nonhomeless Veterans' Experiences With Primary Care

Jones, A. L., Hausmann, L. R. M., Haas, G. L., Mor, M. K., Cashy, J. P., Schaefer Jr., James H.; Gordon, A. J.
Psychological Services, 14(2), 174–183. http://dx.doi.org/10.1037/ser0000116
May 2017
Full Article 

Abstract

Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not access or receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons’ avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and non-homeless Veterans with MHSUDs receiving care in the Veterans Health Administration’s medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Health Care Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth “homeless”) were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 Veterans with MHSUDs (9.2% homeless). Compared with their non-homeless counterparts, homeless Veterans were younger, more likely to be non-Hispanic Black and nonmarried, had less education, and were more likely to live in urban areas. Homeless Veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless Veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than non-homeless Veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services. (PsycINFO Database Record (c) 2017 APA, all rights reserved)


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One-Year Incidence and Predictors of Homelessness Among 300,000 U.S. Veterans Seen in Specialty Mental Health Care

Tsai, J., Hoff, R. A., Harpaz-Rotem, I.
Psychological Services, 14(2), 203–207. http://dx.doi.org/10.1037/ser0000083
May 2017
Full Article 

Abstract

The Department of Veterans Affairs (VA) is committed to preventing and ending homelessness among U.S. Veterans, but there have been few estimates of the incidence of Veteran homelessness and prospective studies to identify predictors of homelessness. This study examines the 1-year incidence of homelessness among Veterans seen in VA specialty mental health clinics and identified sociodemographic and clinical predictors of homelessness. Using a retrospective cohort study design, data were extracted from the VA medical records of 306,351 Veterans referred to anxiety and posttraumatic stress disorder clinics across 130 VA facilities from 2008–2012 and followed for 1 year after referral. Homeless incidence was defined as new use of any VA homeless services or a documented International Classification of Diseases (9th rev.) V60.0 (lack of housing) code during the year. Of the total sample, 5.6% (7.8% for women and 5.4% for men) experienced homelessness within 1 year after referral to VA specialty mental health care. Veterans who were unmarried or diagnosed with a drug use disorder were more than twice as likely to become homeless; those who were Black or had annual incomes less than $25,000 were more than one and a half times as likely to become homeless. Together, these findings suggest a notable and important percentage of Veterans seen in VA specialty mental health clinics newly experience homelessness annually. Monitoring early signs of housing vulnerability and preventing homelessness in this vulnerable but treatment-engaged population may be important in the VA’s efforts to end Veteran homelessness. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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Characteristics and Service Utilization of Homeless Veterans Entering VA Substance Use Treatment

Cox, K. B., Malte, C. A., Saxon, A. J.
Psychological Services, 14(2), 208–213. http://doi.apa.org/doi/10.1037/ser0000133
May 2017
Full Article 

Abstract

This article compares characteristics and health care utilization patterns of homeless Veterans entering substance use disorder (SUD) treatment. Baseline self-report and medical record data were collected from 181 homeless Veterans participating in a randomized trial of SUD/housing case management. Veterans, categorized as newly (n = 45), episodically (n = 61), or chronically homeless (n = 75), were compared on clinical characteristics and health care utilization in the year prior to baseline. Between-groups differences were seen in stimulant use, bipolar, and depressive disorders. A significant majority accessed VA emergency department services, and nearly half accessed inpatient services, with more utilization among chronically versus newly homeless. A majority in all groups attended VA primary care (73.5%) and mental health (56.9%) visits, and 26.7% newly, 32.8% episodically, and 56.0% chronically homeless Veterans initiated multiple SUD treatment episodes (p = .002). A significant proportion of Veterans struggling with homelessness and SUDs appear to remain unstable despite high utilization of VA acute and preventative services. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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Engagement in Steps of Advance Health Care Planning by Homeless Veterans

Dubbert, P. M., Garner, K. K., Lensing, S., White, J. G., Sullivan, D. H.
Psychological Services, 14(2), 214–220. http://dx.doi.org/10.1037/ser0000147 
May 2017
Full Article 

Abstract

Communicating health care preferences in advance, so that wishes can be honored if the person becomes unable to participate in decision-making, is especially important for vulnerable populations such as homeless Veterans. Hospitals are required to inform patients of their rights to document their preferences, but completion rates for advance directives are low. Conceptualizing advance health care planning as a series of health behavior steps emphasizing communication is recommended for improving engagement in advance health care planning. The authors used program evaluation data from psychoeducational groups with 288 homeless Veterans to learn about their previous experience with different steps of advance health care planning and their personal goals for future steps. Results revealed a significant discrepancy between what these Veterans reported they have done and information available to health care providers in the medical record: Only 26% had an advance directive in the medical record, but 70% reported they had thought about the care they would want, and almost half reported they had talked with a trusted other or named someone to make decisions for them. The most frequent goal endorsed by Veterans attending groups was discussing advance health care planning with family or trusted others and/or naming someone to be a decision maker. These findings indicate a need for improved communication and documentation of Veteran preferences about emergency and end of life care. Results are also consistent with interventions tailored to varying readiness for different steps of advance health care planning. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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Risk Factors for Diabetic Retinopathy Among Homeless Veterans

Davis, J. A., Tsui, I., Gelberg, L., Gabrielian, S., Lee, M. L., Chang, E. T.
Psychological Services, 14(2), 221–228. http://doi.apa.org/doi/10.1037/ser0000148
May 2017
Full Article 

Abstract

Homeless patients have high rates of visual impairment and lower rates of glycemic control than housed patients. Although diabetic retinopathy (DR) is the most common cause of new visual impairment and legal blindness in the developed world, little is known about differential risk factors for and rates of DR in homeless versus housed populations. This study aimed to compare the rates of DR between homeless and housed patients with diabetes at the Greater Los Angeles Veterans Affairs Health care System (GLA) and identify clinical and psychosocial predictors of DR rates. We performed secondary database analyses of Veterans with diabetes who received care at GLA between October 1, 2013 and September 30, 2015. We described differences in demographic, clinical, and psychosocial characteristics associated with DR in homeless versus housed patients, and created a logistic regression model to identify independent predictors of DR. We found that diabetic Veterans who were homeless, as compared with those who were housed, had higher rates of substance use disorders and mental health diagnoses, more primary care and mental health visits, and were more likely to have had diabetic retinopathy eye screening according to guidelines. Multiple logistic regression modeling predicting having DR, revealed that having DR was independently associated with not being homeless (i.e., being housed), older age, having had retinal screening, anemia, higher systolic blood pressure, insulin use, microalbuminuria, and higher HbA1c. Homeless diabetic Veterans’ lower rates of DR may be due to the GLA VA’s tailored and intensive psychological and medical resources for homeless Veteran patients. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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Pathways into Homelessness Among Post-9/11-Era Veterans

Metraux, S., Cusack, M., Byrne, T. H., Hunt-Johnson, N., True, G.
Psychological Services, 14(2), 229–237. http://dx.doi.org/10.1037/ser0000136
May 2017
Full Article 

Abstract

Despite the scale of Veteran homelessness and government–community initiatives to end homelessness among Veterans, few studies have featured individual Veteran accounts of experiencing homelessness. Here we track Veterans’ trajectories from military service to homelessness through qualitative, semi-structured interviews with 17 post-9/11-era Veterans. Our objective was to examine how Veterans become homeless—including the role of military and postmilitary experiences—and how they negotiate and attempt to resolve episodes of homelessness. We identify and report results in 5 key thematic areas: transitioning from military service to civilian life, relationships and employment, mental and behavioral health, lifetime poverty and adverse events, and use of Veteran-specific services. We found that Veterans predominantly see their homelessness as rooted in nonmilitary, situational factors such as unemployment and the breakup of relationships, despite very tangible ties between homelessness and combat sequelae that manifest themselves in clinical diagnoses such as posttraumatic stress disorder. Furthermore, although assistance provided by the U.S. Department of Veterans Affairs (VA) and community-based organizations offer a powerful means for getting Veterans rehoused, Veterans also recount numerous difficulties in accessing and obtaining VA services and assistance. Based on this, we offer specific recommendations for more systematic and efficient measures to help engage Veterans with VA services that can prevent or attenuate their homelessness. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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Intimate Partner Violence, Unhealthy Alcohol Use, and Housing Instability Among Women Veterans in the Veterans Health Administration

Dichter, M. E., Wagner, Cl., Borrero, S., Broyles, L., Montgomery, A. E.
Psychological Services, 14(2), 246–249. http://dx.doi.org/10.1037/ser0000132
May 2017
Full Article 

Abstract

Women U.S. military Veterans face particularly high rates of homelessness, which may be associated with psychosocial experiences including unhealthy alcohol use and experience of intimate partner violence (IPV). In this study, we examined clinical social health screening data to assess the association between housing instability and (a) experience of past-year IPV victimization, and (b) unhealthy alcohol use among 554 women receiving primary care from the Veterans Health Administration. Approximately 12% of patients screened reported housing instability. Experience of past-year IPV was associated with increased risk of housing instability (OR = 2.10, 95% CI [1.16, 3.81]), with 1 in 5 women screening positive for IPV also reporting housing concern. There was no statistically significant association between current unhealthy alcohol use and housing instability. Findings hold implications for addressing potential housing concerns among women VA patients. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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Examining the Bidirectional Association Between Veteran Homelessness and Incarceration Within the Context of Permanent Supportive Housing 

Cusack, M., Montgomery, A. E.
Psychological Services, 14(2), 250–256. http://doi.apa.org/doi/10.1037/ser0000110
May 2017
Full Article

Abstract

Homelessness and incarceration share a bidirectional association: individuals experiencing homelessness are more likely to be incarcerated and former inmates are more likely to become homeless. Permanent supportive housing (PSH) programs have demonstrated positive outcomes for participants with criminal histories, yet participants continue to exit to jail or prison and experience subsequent homelessness. Using data on Veterans participating in a PSH program at 4 locations between 2011 and 2014 (N = 1,060), logistic regression was used to examine the risk factors for exiting PSH because of incarceration and returning to homelessness. Though exiting because of incarceration was uncommon, Veterans with a drug use disorder who decreased the frequency of related care over time had an increased risk for this outcome, and a history of incarceration increased Veterans’ risk of experiencing ongoing homelessness. Findings can inform housing and reentry interventions which should account for participant risk factors and service needs in an effort to end the cycle of homelessness and incarceration. (PsycINFO Database Record (c) 2017 APA, all rights reserved)

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