Combat stress, psychosocial adjustment, and service use among homeless Vietnam veterans.

Clinical data were gathered on 627 homeless Vietnam veterans evaluated in a Department of Veterans Affairs clinical program for homeless mentally ill veterans. More than two-fifths (43 percent) of the 627 veterans showed evidence of combat stress that was associated with more severe psychiatric and substance abuse problems, although not with greater social dysfunction. In comparison with Vietnam veterans assessed in a national epidemiological study, homeless veterans were severely socially and vocationally dysfunctional. While homeless mentally ill veterans with combat stress used VA mental health services more frequently than did homeless mentally ill Vietnam veterans with other disorders, many received no mental health services. Combat stress appears to be a significant problem among homeless mentally ill Vietnam veterans.     

Factors predicting choice of provider among homeless veterans with mental illness

OBJECTIVE: Homeless persons with serious mental illness are especially likely to lack access to comprehensive medical and psychiatric care. This study examined the relative importance of predisposing factors, illness factors, and enabling factors as determinants of the use of Veterans Affairs (VA) health care services by mentally ill homeless veterans seeking services from a non-VA program. Predisposing factors included demographic characteristics and wartime service; illness factors were related to the type of medical problem and the need to seek medical care; and enabling factors included entitlement to VA medical services and location of VA facilities. METHODS: Logistic regression analysis was used to analyze data for 698 homeless veterans with mental illness who were enrolled in the Access to Community Care and Effective Services and Supports (ACCESS) program. RESULTS: About 56 percent of the mentally ill homeless veterans had used VA services at some time in their lives. Homeless veterans were almost twice as likely as other poor veterans to use VA services; those with a dual diagnosis were also more likely to use VA services. Enabling factors were more important than either predisposing or illness factors in predicting VA service use. Veterans most likely to use VA services were those who received VA benefits that gave them priority access to VA services and those who lived near a VA medical center. CONCLUSIONS: Specific characteristics of the service system and of veterans' entitlement were more important than clinical needs or predisposing factors in predicting service use.     

Health status,service use,and costs among veterans receiving outreach services in jail or community settings

OBJECTIVE: This study compared client characteristics, service use, and health care costs of two groups of veterans who were contacted by outreach workers: a group of veterans who were contacted while incarcerated at the Los Angeles jail and a group of homeless veterans who were contacted in community settings. METHODS: Between May 1, 1997, and October 1, 1999, a total of 1,676 veterans who were in jail and 6,560 community homeless veterans were assessed through a structured intake procedure that documented their demographic, clinical, and social adjustment characteristics. Data on the use and costs of health services during the year after outreach contact were obtained from national databases of the Department of Veterans Affairs (VA). Chi square and t tests were used for statistical comparisons. RESULTS: The veterans who were contacted in jail obtained higher scores on several measures of social stability (marital status and homelessness status) but had higher rates of unemployment. They had fewer medical problems but higher levels of psychiatric and substance use problems, although the rate of current substance use was lower among these veterans than among the community homeless veterans. One-year service access for the jailed veterans was half that of the community homeless veterans. No differences were observed in the intensity of use of mental health services among those who used services, but the jailed outreach clients used fewer residential, medical, and surgical services. Total health care expenditures for the veterans who received outreach contact in jail were $2,318 less, or 30 percent less, than for those who were contacted through community outreach. CONCLUSIONS: Specialized outreach services appear to be modestly effective in linking veterans who become incarcerated with VA health care services. Although it is clinically challenging to link this group with services, the fact that the rate of current substance use is lower during incarceration may provide a window of opportunity for developing linkages between inmates and community rehabilitative services.     

Predictors of homeless veterans' irregular discharge status from a domiciliary care program

This study addresses the relationship of homeless veterans' discharge status from a domiciliary care program to biopsychosocial characteristics presented at admission into the program. Hypotheses were that younger age, less education, and substance abuse or psychiatric disorder would predict an irregular discharge. Research participants were 367 homeless male veterans who had been admitted to a domiciliary care program at the West Los Angeles Veterans Affairs Medical Center for treatment of medical, psychiatric, or substance disorders. Status of veterans' program discharge (regular or irregular) served as the outcome measure. Logistic regression analysis revealed that irregular discharge from the program was more likely among veterans who were black, who had poor employment histories, or who had problems with alcohol. Results are discussed in light of the need to maintain homeless veterans in treatment programs so that they can achieve maximum benefit from available programs.     

Homelessness in a National Sample of Incarcerated Veterans in State and Federal Prisons

The Veterans Health Administration (VHA) has been increasing efforts to reach out to assist incarcerated veterans. While previous studies have shown strong associations between incarceration and homelessness, few studies have examined distinctive characteristics of incarcerated homeless and non-homeless veterans. National administrative data on 30,348 incarcerated veterans served by the Health Care for Re-entry Veterans (HCRV) program were analyzed. Incarcerated veterans were classified into four groups based on their history of past homelessness: not homeless, transiently homeless, episodically homeless, and chronically homeless. Multinomial logistic regression was used to compare groups on sociodemographic characteristics, criminal justice status, clinical status, and their interest in using VHA services. Of the sample, 70 % were classified as not homeless, 8 % as transiently homeless, 11 % as episodically homeless, and 11 % as chronically homeless. Thus, 30 % of the sample had a homeless history, which is five times the 6 % rate of past homelessness among adult men in the general population. Compared to non-homeless incarcerated veterans, all three homeless groups reported significantly more mental health problems, more substance abuse, more times arrested in their lifetime, more likely to be incarcerated for a non-violent offense, and were more interested in receiving VHA services after release from prison. Together, these findings suggest re-entry programs, like HCRV, can address relevant mental health-related service needs, especially among formerly homeless veterans and veterans in need of services are receptive to the offer of assistance.     

Psychiatric illness and substance abuse among homeless Asian-American veterans

OBJECTIVES: This study examined the proportion of Asian Americans among homeless veterans and among veterans in the general population to calculate the relative risk of homelessness among Asian-American veterans. It also examined differences in rates of psychiatric and substance use disorders between homeless racial and ethnic subgroups. METHODS: Data were gathered between 1997 and 2001 from the Health Care for Homeless Veterans program and included data from administrative intake, patients' self-reports, and clinicians' diagnostic assessments of substance use disorders and psychiatric illness. RESULTS: Data were examined for 67,441 veterans. Asian-American veterans had a significantly lower risk of homelessness than veterans of other ethnic groups. Alcohol abuse was significantly and consistently less prevalent among Asian Americans compared with blacks and Hispanics. However, drug abuse was less prevalent among Asian Americans than among blacks and Hispanics, but rates were similar to those of whites. CONCLUSIONS: Lower rates of alcohol abuse may protect Asian-American veterans from becoming homeless.     

Cost-effectiveness of supported housing for homeless persons with mental illness

BACKGROUND: Supported housing, integrating clinical and housing services, is a widely advocated intervention for homeless people with mental illness. In 1992, the US Department of Housing and Urban Development (HUD) and the US Department of Veterans Affairs (VA) established the HUD-VA Supported Housing (HUD-VASH) program. METHODS: Homeless veterans with psychiatric and/or substance abuse disorders or both (N = 460) were randomly assigned to 1 of 3 groups: (1) HUD-VASH, with Section 8 vouchers (rent subsidies) and intensive case management (n = 182); (2) case management only, without special access to Section 8 vouchers (n = 90); and (3) standard VA care (n = 188) Primary outcomes were days housed and days homeless. Secondary outcomes were mental health status, community adjustment, and costs from 4 perspectives. RESULTS: During a 3-year follow-up, HUD-VASH veterans had 16% more days housed than the case management-only group and 25% more days housed than the standard care group (P<.001 for both). The case management-only group had only 7% more days housed than the standard care group (P =.29). The HUD-VASH group also experienced 35% and 36% fewer days homeless than each of the control groups (P<.005 for both). There were no significant differences on any measures of psychiatric or substance abuse status or community adjustment, although HUD-VASH clients had larger social networks. From the societal perspective, HUD-VASH was 6200 US dollars (15%) more costly than standard care. Incremental cost-effectiveness ratios suggest that HUD-VASH cost 45 US dollars more than standard care for each additional day housed (95% confidence interval, -19 US dollars to 108 US dollars). CONCLUSIONS: Supported housing for homeless people with mental illness results in superior housing outcomes than intensive case management alone or standard care and modestly increases societal costs.     

Who is served by programs for the homeless? Admission to a domiciliary care program for homeless veterans

Demographic and clinical data are presented on 4,138 veterans assessed in the 20-site Department of Veterans Affairs (VA) Domiciliary Care for Homeless Veterans program during its first year of operation. More than two-thirds of the veterans who were screened had been hospitalized in VA medical centers during the year before assessment, and 34 percent were hospitalized at the time of assessment. Compared with veterans who were not admitted for residential treatment, veterans who were admitted were more likely to be previously involved in mental health treatment, literally homeless rather than at risk for homelessness, and without public financial support. Specialized service programs for the homeless such as the VA domiciliary care program may also be called on to play a broader role in the discharge and rehabilitative efforts of public mental health service systems.     

Homeless veterans' satisfaction with residential treatment

OBJECTIVE: Because little is known about homeless individuals' satisfaction with mental health services or the association between satisfaction and measures of treatment outcome, the study examined those issues in a group of homeless veterans. METHODS: Demographic and clinical data were obtained from intake assessments conducted before veterans' admission to residential treatment facilities under contract with the Department of Veterans Affairs Health Care for Homeless Veterans program, a national outreach and case management program. Clients completed a satisfaction survey and the Community-Oriented Programs Environment Scale, which asks them to rate dimensions of the treatment environment. Outcome data came from discharge outcome summaries completed by VA case managers. RESULTS: Overall satisfaction with residential treatment services was high among the 1,048 veterans surveyed. Greater satisfaction was associated with more days of drug abuse and more days spent institutionalized in the month before intake and with an intake diagnosis of drug abuse. Regression analyses indicated that satisfaction was most strongly related to clients' perceptions of several factors in the treatment environment. Policy clarity, clients' involvement in the program, an emphasis on order, a practical orientation, and peer support were positively related to satisfaction; staff control and clients' expression of anger were negatively related. Satisfaction was significantly associated with case managers' discharge ratings of clinical improvement of drug problems and psychiatric problems. CONCLUSIONS: Homeless veterans are more satisfied in environments they perceive to be supportive, orderly, and focused on practical solutions. The results indicate that client satisfaction is not related to treatment outcomes strongly enough to serve as a substitute for other outcome measures.     

Implementing Peer-Assisted Case Management to Help Homeless Veterans with Mental Illness Transition to Independent Housing

Formerly homeless mentally ill veterans are at an important crossroads when they move from living in an institutional setting such as a shelter or supportive residential facility to independent living. We hypothesized that peer advisors, veterans with severe mental illness who had been homeless previously, graduated from a Healthcare for Homeless Veterans program, and subsequently maintained independent, stable housing could assist other veterans make a successful transition to independent living. Pilot data suggests that participants who received peer advisors were more likely to follow up with assessments than were controls. In this report, we describe a pilot peer advisor program, its implementation, and pilot data on program administration.     

Impact of work therapy on health status among homeless,substance-dependent veterans: a randomized controlled trial

BACKGROUND: Little is known about the health outcomes of clinician-supervised, performance-based, abstinence-contingent therapeutic work programs on homeless persons with addiction disorders. This study examined the effect of the Department of Veterans Affairs compensated work therapy program (CWT) on nonvocational outcomes. With mandatory urine screenings and adherence to addiction treatment schedules, CWT provided work opportunities (wages, hours, and responsibilities) with jobs created from Veterans Affairs contracts competitively obtained from private industry. METHODS: Homeless, substance-dependent veterans (N = 142) from 4 Department of Veterans Affairs medical centers were randomized, assessed at baseline, and reassessed at 3-month intervals for 1 year. Both CWT and control groups had access to comprehensive rehabilitation, addictions, psychiatric, and medical services. Data were analyzed to determine an immediate CWT effect after treatment and rates of change during 1 year. RESULTS: Compared with control subjects, patients in the CWT program were more likely to (1) initiate outpatient addictions treatment, (2) experience fewer drug and alcohol problems, (3) report fewer physical symptoms related to substance use, (4) avoid further loss of physical functioning, and (5) have fewer episodes of homelessness and incarceration. No effect on psychiatric outcomes was found. CONCLUSION: Work therapy can enhance nonvocational outcomes of addiction treatment for homeless persons, although long-term gains remain unknown.     

Mortality among homeless and nonhomeless mentally ill veterans

This study directly compared mortality risk in homeless and nonhomeless mentally ill veterans and compared mortality rates in these groups with the general U.S. population. The study used a retrospective cohort design to assess mortality over a 9-year period in homeless (N = 6,714) and nonhomeless (N = 1,715) male veterans who were treated by Department of Veterans Affairs specialized mental health programs. The study showed that mortality rates in all homeless members of the cohort were significantly higher than the general U.S. population. Relative to nonhomeless cohort members, significant increases in mortality risk were observed in cohort members who at baseline were age 45 to 54 and had been homeless 1 year or less (RR = 1.55, 95% CI = 1.02, 2.36) and those age 55 and older who had been homeless 1 year or less (RR = 1.83, 95% CI = 1.33, 2.52). Similar, but nonsignificant trends were observed in cohort members who had been homeless more than 1 year at baseline. Additionally, medical problems at baseline and history of prior hospitalization for alcohol problems elevated mortality risk. Employment at baseline and minority group membership reduced mortality risk. The study suggests that mentally ill veterans served by specialized VA mental health programs are at elevated risk of mortality, relative to the general population. Homelessness increases this risk, particularly in older veterans, and this difference does not abate after entry into a health care system.     

Use of psychiatric and medical health care by veterans with severe mental illness

Risk behaviors and health care use among 396 initially hospitalized veterans with severe mental illnesses were examined. Health care use was abstracted from Veterans Affairs databases (March 1998 to June 2000) for one year after hospital discharge. Lifetime intravenous drug use was related to increased use of outpatient services, and current alcohol use was related to decreased health care use. Patients with posttraumatic stress disorder had greater use of medical outpatient services than patients with schizophrenia-spectrum disorders, although they had longer hospital stays. These results highlight that veterans with severe mental illness receive more treatment in medical than psychiatric health clinics.     

Age differences in posttraumatic stress disorder, psychiatric disorders, and healthcare service use among veterans in Veterans Affairs primary care clinics.

OBJECTIVE: To expand our understanding of posttraumatic stress disorder (PTSD) prevalence, its psychiatric characteristics, and service use among elderly veterans in Veterans Affairs (VA) primary care clinics. METHODS: A cross-sectional, epidemiological design (N = 745) incorporating self-report measures, structured interviews, and chart reviews was used to obtain relevant information for analyses. RESULTS: The oldest group of veterans (>or=65 years; N = 318) had lower prevalence of most psychiatric diagnoses than the youngest (18-44 years; N = 69) and middle-aged (45-64 years; N = 358) groups. Despite having higher rates of combat exposure, veterans in the oldest group (6.3%) had one-third the prevalence of PTSD than those in the middle-aged group (18.6%). A similar pattern was found across other psychiatric diagnoses. For example, those in the oldest group (7.5%) had one-third the prevalence of major depression as those in the two younger groups (21.7% and 22.9%). These differences were maintained after controlling for relevant demographic covariates (race, sex). Results from examination of VA health care service use across the three groups were consistent with the findings that the oldest veteran group is functioning significantly better across mental health domains. CONCLUSION: Elderly veterans who use VA primary care services evidence lower rates of PTSD and other psychiatric disorders, and they use significantly less VA mental health services. They also do not appear to show evidence of worse physical health functioning or use VA health care services or disability benefits at a meaningfully higher rate than their younger counterparts.     

Factors Associated with Receipt of Pension and Compensation Benefits for Homeless Veterans in the VBA/VHA Homeless Outreach Initiative

Public support payments may facilitate exit from homelessness for persons with mental illness. We examined data from 10,641 homeless veterans contacted from October 1, 1995 to September 30, 2002 in a collaborative outreach program designed to facilitate access to Department of Veterans Affairs (VA) disability benefits. Those who were awarded benefits (22% of contacted veterans) were more likely to report disability, poor to fair self-rated health, and were more likely to have used VA services in the past. Thus, this program achieved only modest success and was most successful with veterans who were already receiving VA services and who might have received benefits even without the outreach effort.     

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

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.     

Outcomes of critical time intervention case management of homeless veterans after psychiatric hospitalization

OBJECTIVE: This study evaluated a modification of the critical time intervention (CTI) community case management model for homeless veterans with mental illness who were leaving Department of Veterans Affairs (VA) inpatient care. CTI offers time-limited intensive case management designed to negotiate transitions from institutional settings to community living. METHODS: CTI was implemented at eight VA medical centers through a training program that used primarily teleconference-based case review. A comparison cohort (phase 1) of 278 participants was recruited before CTI was implemented, and a treatment cohort (phase 2) of 206 participants was recruited after implementation and offered CTI. Mixed-regression models were used to compare outcomes in phase 1 and phase 2 and controlled for baseline differences between participants in the two phases. RESULTS: Measures of client service delivery show that CTI was successfully implemented at most sites. Phase 1 veterans had a better work history and more drug use at baseline than phase 2 clients had. Controlling for these differences, veterans in phase 2 on average had 19% more days housed in each 90-day reporting period over the one-year follow-up (p<.002) and 14% fewer days in institutional settings (p=.041). Veterans in phase 2 also had 19% lower Addiction Severity Index (ASI) alcohol use scores (p<.001), 14% lower ASI drug use scores (p=.003), and 8% lower ASI psychiatric problem scores (p=.001). CONCLUSIONS: A sustained training program can be used to implement CTI in systems that have little past experience with this approach and can yield improved housing and mental health outcomes.     

Impact of supported housing on clinical outcomes: analysis of a randomized trial using multiple imputation technique

In 1992, the US Department of Housing and Urban Development (HUD) and the US Department of Veterans Affairs (VA) established the HUD-VA Supported Housing (HUD-VASH) Program to provide integrated clinical and housing services to homeless veterans with psychiatric and/or substance abuse disorders at 19 sites. At four sites, 460 subjects were randomly assigned to one of the three groups: (1) HUD-VASH, with both Section 8 vouchers and intensive case management; (2) case management only; and (3) standard VA care. A previous publication found HUD-VASH resulted in superior housing outcomes but yielded no benefits on clinical outcomes. Since many participants missed prescheduled visits during the follow-up period and follow-up rates were quite different across the groups, we reanalyzed these data using multiple imputation statistical methods to account for the missing observations. Significant benefits were found for HUD-VASH in drug and alcohol abuse outcomes that had not previously been identified.     

Patient and Program Predictors of 12-Month Outcomes for Homeless Veterans Following Discharge from Time-Limited Residential Treatment

The U.S. Department of Veterans Affairs provides transitional residential treatment to homeless veterans through three types of programs: VA-staffed Domiciliary care, and two types of community-based treatment (one funded through locally managed contracts and the other through national grants). This study compared treatment process and outcomes in these three programs and also sought to identify differences in outcome between dually diagnosed veterans, veterans with substance abuse problems or psychiatric problems alone, and those with no psychiatric diagnoses. Altogether, 1,338 veterans admitted to the 3 types of program were recruited to participate in a prospective naturalistic study which evaluated housing, clinical and community adjustment outcomes during the year following discharge. Data on 1,003 veterans for whom psychiatric diagnostic, social climate and length of stay data were available were used to compare participants in the three program types at baseline. Regression models were used to compare outcomes across program and diagnostic types net of baseline differences between study participants, and of differences in social climate and length of stay. The overall follow-up rate across all time points was 72%. Significant differences across programs were observed on only 2 baseline measures as well as on several baseline values of the outcome measures, length of stay and a measure of social climate. Adjusting for veteran baseline differences alone there were no differences in outcomes by program after correction for multiple comparisons. Dually diagnosed veterans had poorer mental health and overall quality of life outcomes. Longer length of stay and more positive social climate were associated with superior outcomes on several measures. The adjusted mean estimate of the proportion of veterans housed at 12 months follow-up was 78%, similar to published outcomes for supported housing. Length of stay, rather than program funding configuration or diagnostic group, was the strongest predictor of outcomes in time-limited residential treatment programs in which 1-year housing was similar to those in direct-placement supported housing programs.     

Prevalence of Hepatitis C virus infection in a sample of homeless veterans

OBJECTIVE: This study measures the prevalence of Hepatitis C Virus (HCV) infection in a sample of homeless veterans treated in a Domiciliary Care for Homeless Veterans (DCHV) program in Massachusetts. We also examine risk factors and correlates for HCV infection, including substance abuse and service in Vietnam. METHODS: Patients admitted to the DCHV program over a 5-year period (n=418) were systematically tested for HCV infection. Blood test data were merged with standardized data collection forms to assess socio-demographic characteristics, military history, and medical and psychiatric history. RESULTS: The overall prevalence rate of HCV infection was 44.02%, a rate more than ten times higher than the national rate for men age 20-59 and more than twice as high as other VA patient samples. Adjusting for age, significant risk factors in this sample included a history of substance abuse (OR=6.86, p<0.0001) and service during the Vietnam era (OR=4.66, p=0.01). Comparisons of the tested sample with other homeless veterans treated in 34 similar programs nationally indicated that this sample did not significantly differ from other treated homeless veterans with respect to demographics or HCV risk factors. CONCLUSIONS: We found a high prevalence of HCV infection in this population that is not likely to be geographically unique, and may indicate particularly high risk for homeless men. Substance abuse is the most important risk factor, and we hypothesize that the effect of Vietnam-era service is a proxy for unreported drug use. We advise an increase in screening and education for all homeless populations, particularly those with a history of injection drug use. Public systems of care, including the VA, should expect increasing costs of care related to HCV infection as prevalent cases develop serious medical sequelae of HCV infection.