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Homeless Veterans

 

Homelessness Screening Clinical Reminder

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Background: To prevent and end homelessness among Veterans, the U.S. Department of Veterans Affairs (VA) has refined its programming and policies to focus on ending chronic homelessness and preventing new episodes of homelessness. To support the latter, VA has allocated close to one billion dollars toward homelessness prevention services since Federal Fiscal Year (FFY) 2011 through the Supportive Services for Veteran Families (SSVF) program. To assist in the identification of Veterans in need of homelessness prevention or rapid rehousing, the National Center on Homelessness among Veterans (the Center) developed the Homelessness Screening Clinical Reminder (HSCR), a two-question universal screener that assesses housing instability and risk among Veterans who present for outpatient care and are not already engaged with VA Homeless Programs. During FFY 2014, 3,623,446 Veterans accessing outpatient health services through the Veterans Health Administration (VHA) responded to the HSCR. Among those screened, 0.74% reported current homelessness and 0.68% reported imminent risk. Veterans who screen positive are offered a referral for further assessment and intervention; of note is the community-based SSVF program, which provides supportive services and temporary financial assistance to quickly end or prevent episodes of homelessness.

Ann Elizabeth Montgomery, an investigator at the Center, has received a three-year, one-million dollar HSR&D grant to continue work around the HSCR. The study is also funded as part of a multi-million dollar settlement reached by the New York Attorney General after an investigation into direct mail fundraising abuses at one of the country's largest Veterans' charities. This settlement is to be used on behalf of disabled Veterans, specifically to advance the science in the areas of mental healthcare for Veterans, Veteran homelessness, improving the quality of Veteran healthcare, and healthcare for women Veterans:

http://www.hsrd.research.va.gov/news/research_news/settlement-070214.cfm.

Objectives: This study will evaluate VA’s efforts at identifying Veterans at risk of homelessness and linking them with services of their choosing that are both efficient and effective. The objectives are:

  • To validate the HSCR and assess prevalence and risk factors for homelessness and imminent risk among Veteran users of VHA healthcare services.
  • To assess the effectiveness of the HSCR at linking Veterans who screen positive for homelessness or risk with subsequent services.
  • To evaluate the psychometric properties and efficacy of an existing instrument (SSVF Instrument) used by the SSVF program to quantify risk of homelessness among Veterans.

Methods: The study will employ a mixed methods approach, using a combination of data from existing VA data sources and primary data collection. The evaluation and validation of the two instruments identified here—the HSCR and SSVF Instrument—will use secondary data collected during regular VA operations. To assess the effectiveness of the HSCR at linking Veterans to needed services, the study team will use a mixed methods explanatory sequential design whereby initial analysis of secondary quantitative data will be followed by primary qualitative data collection.

Anticipated Impact on Veteran’s Healthcare: The existing body of research related to homelessness prevention is limited in terms of its practical application to policies and programs; the primary contribution of this study will be the examination and refinement of the current set of policies and practices to identify, refer, and intervene with Veterans who are experiencing homelessness or are at risk. This study will have an immediate impact on the system of care by informing and guiding more efficient and effective use of homelessness prevention resources.

Highlights for FY 2014:

  • 3,623,446 Veterans responded to the HSCR; 0.72% screened positive for homelessness and 0.67% screened positive for risk.
  • Rates of positive screens for either type of housing instability were significant higher among Veterans who were screened in Substance Use or Mental Health clinics compared with Primary Care.
  • Veterans who were aged 51–60 years, male, and white comprised the majority of positive screens.
  • The majority of Veterans who screened positive and requested follow-up received services—most frequently provided by Social Work and the Health Care for Homeless Veterans program—within 30 days: 71.5% of those who screened positive for homelessness and 64.6% of those who screened positive for risk.
  • 83.3% of Veterans who initially screened positive for either homelessness or risk and responded to a rescreen at least 6 months later resolved their housing instability.

Contact: Ann Elizabeth Montgomery, PhD / Ann.Montgomery2@va.gov

See below for Research Briefs and Published Articles related to the Homelessness Screening Clinical Reminder:

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Example of VA’s Homelessness Screening Clinical Reminder

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

Russell, L. M., Devore, M. D., Barnes, S. M., Forster, J. E., Hostetter, T.A., Montgomery, A. E., Casey, R. J., Kane, V., & Brenner, L.
American Journal of Public Health, published online ahead of print October 22, 2013: e1–e2. doi:10.2105/AJPH.2013.301485
2013
Read Full Article: http://jn2qk7ta8c.search.serialssolutions.com/?V=1.0&sid=PubMed:LinkOut&pmid=24148060

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.

Contact: Lisa Brenner, PhD / Lisa.Brenner@va.gov

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Development and Validation of an Instrument to Assess Imminent Risk of Homelessness among Veterans

Montgomery, A. E., Fargo, J. D., Kane, V., & Culhane, D. P.
Public Health Reports, 129(5), 439–447
September - October 2014
Read Full Article:  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4116370/

Abstract

OBJECTIVES: Veterans are overrepresented within the homeless population compared with their non-Veteran counterparts, particularly when controlling for poverty. The U.S. Department of Veterans Affairs (VA) aims to prevent new episodes of homelessness by targeting households at greatest risk; however, there are no instruments that systematically assess Veterans' risk of homelessness. We developed and tested a brief screening instrument to identify imminent risk of homelessness among Veterans accessing VA health care.

METHODS: The study team developed initial assessment items, conducted cognitive interviews with Veterans experiencing homelessness, refined pilot items based on Veterans’ and experts' feedback and results of psychometric analyses, and assigned weights to items in the final instrument to indicate a measure of homelessness risk.

RESULTS: One-third of Veterans who responded to the field instrument reported imminent risk of homelessness (i.e., housing instability in the previous 90 days or expected in the next 90 days). The reliability coefficient for the instrument was 0.85, indicating good internal consistency. Veterans who had a recent change in income, had unpaid housing expenses, were living temporarily with family and friends, needed help to get or keep housing, and had poor rental and credit histories were more likely to report a risk of homelessness than those who did not.

CONCLUSION: This study provides the field with an instrument to identify individuals and households at risk of or experiencing homelessness, which is necessary to prevent and end homelessness. In addition, it supports VA's investment in homelessness prevention and rapid rehousing services for Veterans who are experiencing or are at risk for homelessness.

Contact: Ann Elizabeth Montgomery, PhD / ann.montgomery2@va.gov

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Needles in a Haystack: Screening and Healthcare System Evidence for Homelessness

Fargo, J. D., Montgomery, A. E., Byrne, T., Brignone, E., Cusack, M., Gundlapalli, A., V.
Studies in Health Technology and Informatics; 129(5), 235:574-578.
doi: 10.3233/978-1-61499-753-5-574
2017
Read Full Article:  https://www.ncbi.nlm.nih.gov/pubmed/28423858 or http://ebooks.iospress.nl/publication/46406 (PDF)

Abstract

OBJECTIVES: Effectiveness of screening for homelessness in a large healthcare system was evaluated in terms of successfully referring and connecting patients with appropriate prevention or intervention services. Screening and healthcare services data from nearly 6 million U.S. military Veterans were analyzed. Veterans either screened positive for current or risk of housing instability, or negative for both. Current living situation was used to validate results of screening. Administrative evidence for homelessness-related services was significantly higher among positive-screen Veterans who accepted a referral for services compared to those who declined. Screening for current or risk of homelessness led to earlier identification, which led to earlier and more extensive service engagement.

METHODS
Homelessness Screening Clinical Reminder
To assist in the identification of Veterans in need of homelessness prevention, the National Center on Homelessness Among Veterans in Philadelphia, PA, USA, developed the HSCR, a two-question universal screener that assesses housing instability and risk among Veterans who present for outpatient care and are not already engaged with VHA homeless programs. The two questions are:
   1. In the past 2 months, have you been living in stable housing that you own, rent, or stay in as part of a household? [“No” indicates Veteran is positive for current housing instability]
   2. Are you worried or concerned that in the next 2 months you may NOT have stable housing that you own, rent, or stay in as part of a household? [“Yes” indicates Veteran is positive for risk of housing instability]
Veterans who screen positive to either question are then asked where they have lived for most of the previous two months and whether they want to be referred for services. In conjunction with the Veteran’s self-reported living situation, results of screening were used to form three major groups [6]: 1) positive screen for housing instability, 2) positive screen for risk of housing instability, 3) negative screen for housing instability or risk; and then group 1 was further subdivided into two groups: 1a) positive screen for housing instability with a current homeless living situation (i.e., shelter, on the street, with a family member or friend [doubled-up], or in a motel/hotel) and 1b) positive screen for housing instability without a current homeless living situation (i.e., subsidized or unsubsidized housing, or in an institution). Group 1a represented the most stringent classification for current housing instability or homelessness. Veterans whose current living situation was “Other” at the time of screening were not included in groups 1a or 1b.
Data
Veterans Informatics and Computing Infrastructure (VINCI) provides secure access to VA data sources through an integrated suite of databases in a secure, high-performance-computing environment [7]. VINCI houses data on over 21 million Veterans nationwide. Data available on VINCI for this study included Veterans’ demographic, military, and healthcare characteristics (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes, clinic stop codes, inpatient treatment specialty codes, and National Homeless Registry data [longitudinal data for Veterans who have experienced homelessness]). Homelessness was defined as receiving a clinical diagnostic code (ICD-9 v60.0) indicative of housing instability, participation in a VA homelessness-related clinical service or treatment specialty, and/or participation in a VHA homeless program within 90 days of initial HSCR response [8]. Results of the HSCR were matched with demographic, military service, and healthcare data.
Sample
A total of 5,845,937 Veterans were asked to complete the HSCR between October 1, 2012 through September 30, 2014. However, 74,441 (1.3%) were excluded or not screened because they 1) reported that they were already receiving housing assistance (n=11,020), 2) declined screening (n=2,656), 3) were a nursing home resident (n=1,202), 4) were unable to perform screening (n=148), 5) used a VHA homeless program in the 6 months prior to screening (n=57,356), or 6) were missing screening results (n=2,059). This resulted in a final sample of 5,771,496 Veterans with HSCR results. A majority of the sample was male (92.8%, n=5,356,442), White (76.2%, n=4,396,989), had served in the Army (53.0%, n=3,060,863), and had served in conflicts other than operations in Iraq or Afghanistan (88.8%, n=5,126,393); mean age was 61.1 years (SD=16.6; median = 64.0).
Evaluation
Descriptive statistics were computed for demographic and HSCR variables, including current living situation and referral acceptance in cases of positive screens. The criterion validity of the HSCR was evaluated by comparing the positive screens for current or risk of housing instability with the current living situation. Among Veterans who screened positive for current or risk of housing instability, presence of administrative evidence for homelessness was compared between those who accepted or declined a referral for services using logistic regression analyses in order to evaluate screening and referral effectiveness in connecting Veterans to services.

RESULTS (of the HSCR):  Results of initial screening showed that 0.8% (n=45,282) were positive for current housing instability, 1.0% (n=54,882) were positive for risk of housing instability, and 98.2% (n=5,671,332) screened negative (see Table 1). Among those who screened positive for housing instability, 61.9% were living in a homelessness situation, 24.5% were not; for those who screened positive for risk, 25.1% were living in a homeless situation, 65.3% were not. Results were similar whether we excluded or retained Veterans without a current homeless living situation from the group that screened positive for housing instability. Administrative evidence for homelessness significantly varied depending on whether Veterans accepted or declined a referral for services, with 61.3% of positive screens for housing instability who accepted services showing administrative evidence for homelessness as compared to only 19.0% who declined (p<.01); a similar difference was observed for other groups (p<.01).

CONCLUSION: The results of this study of almost 6 million records from a healthcare system suggests that screening for current housing instability and risk can lead to earlier identification, which can then lead to earlier referral for service provision. If such referrals are accepted, service provision is more likely to occur, as evidenced by administrative documentation of homelessness prevention and intervention services.

Contact: Jamison Fargo, PhD / Jamison.Fargo@va.gov

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Receipt of Social Services Following a Positive Screen for Homelessness among Veteran Outpatients

Montgomery, A. E., Dichter, M. E., Thomasson, A. M., Roberts, C. B.
American Journal of Preventative Medicine, 50(3):336-343. doi: 10.1016/j.amepre.2015.06.035
March, 2016
Read Full Article:  http://www.ncbi.nlm.nih.gov/pubmed/?term+Receipt+of+social+services+following+a+positive+screen+for+homelessness+among+Veteran+outpatients

Abstract

OBJECTIVES: The Veterans Health Administration seeks to reduce homelessness among Veterans by identifying, and providing prevention and supportive services to, patients with housing concerns. The objectives of this study were to assess the proportion of Veterans Health Administration patients who received homeless or social work services within 6 months of a positive screen for homelessness or risk in the Veterans Health Administration and the demographic and clinical characteristics that predicted services utilization.

METHODS: Data were from a cohort of 27,403 Veteran outpatients who screened positive for homelessness or risk between November 1, 2012 and January 31, 2013. During 2013, AORs were calculated using a mixed-effects logistic regression to estimate the likelihood of patients' receipt of VHA homeless or social work services based on demographic and clinical characteristics.

RESULTS: The majority of patients received services within 6 months post-screening; predictors of services utilization varied by gender. Among women, diagnosis of drug abuse and psychosis predicted receipt of services, being unmarried increased the odds of using services among those screening positive for homelessness, and a diagnosis of post-traumatic stress disorder increased the odds of receiving services for at-risk women. Among men, being younger, unmarried, not service-connected/Medicaid-eligible, and having a medical or behavioral health condition predicted receipt of services.

CONCLUSION: Receipt of housing support services among Veterans post-homelessness screening differs by patient demographic and clinical characteristics. Future research should investigate the role that primary and secondary prevention interventions play in Veterans' resolution of risk for homelessness and experience of homelessness

Contact: Ann Elizabeth Montgomery, PhD / ann.montgomery2@va.gov

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Screening for Homelessness and Risk in a National Healthcare System: Monitoring Housing Stability through Repeat Screening and Exploring Profiles of Risk

Byrne, T.H., Fargo, J. D., Montgomery, A. E., Roberts, C. B., Culhane, D. P., Kane, V.
Public Health Reports, 130(6):684-692.
November - December 2015
Read Full Article:  http://www.ncbi.nlm.nih.gov/pubmed/26556940

Abstract

OBJECTIVES: This study examined Veterans' responses to the Veterans Health Administration's (VHA's) universal screen for homelessness and risk of homelessness during the first 12 months of implementation.

METHODS: The study team calculated the baseline annual frequency of homelessness and risk of homelessness among all Veterans who completed an initial screen during the study period. The study team measured changes in housing status among Veterans who initially screened positive and then completed a follow-up screen, assessed factors associated with such changes, and identified distinct risk profiles of Veterans who completed a follow-up screen.

RESULTS: More than 4 million Veterans completed an initial screen; 1.8% (N=77,621) screened positive for homelessness or risk of homelessness. Of those who initially screened positive for either homelessness or risk of homelessness and who completed a second screen during the study period, 85.0% (N=15,060) resolved their housing instability prior to their second screen. Age, sex, race, VHA eligibility, and screening location were all associated with changes in housing stability. Four distinct risk profiles were identified for Veterans with ongoing housing instability.

CONCLUSION: To address homelessness among Veterans, efforts should include increased and targeted engagement of Veterans experiencing persistent housing instability.

Contact: Ann Elizabeth Montgomery, PhD / ann.montgomery2@va.gov

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

Montgomery, A. E., Fargo, J.D., Byrne, T.H, Kane, V., & Culhane, D.P.
American Journal of Public Health, published online ahead of print October 22, 2013: e1–e2. doi:10.2105/AJPH.2013.301398
2013
Read Article:  http://www.ncbi.nlm.nih.gov/pubmed/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.

Contact: Ann Elizabeth Montgomery, PhD / Ann.Montgomery2@va.gov

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Universal Screening for Homelessness and Risk among Veterans: Monitoring Housing Stability and Exploring Profiles of Risk through Repeated Screening

Jamison Fargo, PhD, Thomas Byrne, PhD, Ann Elizabeth Montgomery, PhD, Christopher B. Roberts
Research Brief
June 2014

Abstract

The U.S. Department of Veterans Affairs (VA) has developed a comprehensive plan for preventing and ending homelessness among Veterans, emphasizing prevention-oriented strategies including the Supportive Services for Veteran Families (SSVF) program. First operationalized in 2011, SSVF provides services and temporary financial assistance intended to intervene early to prevent homelessness or quickly re-house Veterans who become homeless. These efforts have made a real impact; the number of Veterans experiencing homelessness on a given night nationwide decreased by 24% between 2009 and 2013.

Identifying Veterans who are at risk of homelessness, or experiencing homelessness, but are not accessing VA services, is of crucial importance for continued progress toward ending homelessness among Veterans. To improve the ability to identify these Veterans and refer them to appropriate services, VA implemented a universal, two-question screener for current homelessness and imminent risk—the Homelessness Screening Clinical Reminder (HSCR)—that is administered at all VA healthcare facilities.

This brief builds on a previous report that summarized findings from the first year of HSCR implementation. The focus here is on Veterans who had an initial positive screen for homelessness or risk and subsequently completed a second screen, or were rescreened, during the year. Specifically, this brief assesses changes in housing stability for Veterans who initially screened positive and completed a rescreen and identifies risk profiles of Veterans who are experiencing persistent housing instability upon rescreening.

For the full research brief, please contact:  Ann Elizabeth Montgomery, PhD / Ann.Montgomery2@va.gov.

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Using a Universal Screener to Identify Veterans Experiencing Housing Instability

Ann Elizabeth Montgomery
Research Brief
March 2014

Abstract

Ending Veteran homelessness is a high priority for the U.S. Department of Veteran Affairs (VA). To improve VA’s ability to identify Veterans who are at risk of homelessness—or experiencing homelessness but not accessing services—the VA National Center on Homelessness among Veterans, in collaboration with the VA National Clinical Reminders Committee, developed a two-stage Homelessness Screening Clinical Reminder (HSCR) to conduct an ongoing, universal screen for homelessness and risk among Veterans accessing healthcare services.

The objective of this national, health system-based screening instrument is to enhance the rapid identification of Veterans who have very recently become homeless or are at imminent risk of homelessness, and to ensure that they are referred for the appropriate assistance to stabilize their housing crisis or to rapidly rehouse them if they have fallen into homelessness.

Data for this research brief were collected during the first year of implementation of the HSCR: October 1, 2012 through September 30, 2013. During this period, more than 4.3 million Veterans accessing outpatient healthcare services through the Veterans Health Administration (VHA) responded to the HSCR. Veterans who were already engaged with VHA homeless services and those receiving palliative or long-term care were excluded from the screening.

Among those screened during this period, 0.8% reported current homelessness and 1.0% reported imminent risk. In addition to the prevalence of homelessness and risk across the entire VA system, this brief presents prevalence by age and gender as well as geographic location. The brief also provides information about the current living situation of Veterans who screened positive for homelessness, and for those Veterans who responded to the HSCR twice during FY 2013, whether their homelessness or risk were resolved.

For the full research brief, please contact: Ann Elizabeth Montgomery, PhD / Ann.Montgomery2@va.gov.

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