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.     

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.     

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.     

Health care utilization and receipt of cholesterol testing by veterans with and those without mental illness

OBJECTIVE: We examined the relationship between mental illness, health care utilization and rates of cholesterol testing. METHODS: We conducted a retrospective cohort study using Veterans Affairs (VA) administrative data on 64,490 United States veterans who used VA New England Health Care System outpatient services between January 1998 and June 2001. A total of 10,100 veterans (15.7%) had a mental illness treated with medication. We examined the interaction between mental illness and outpatient service utilization with respect to the likelihood of receiving a cholesterol test, adjusting for major demographic and clinical covariates. RESULTS: Among veterans using VA outpatient services infrequently, those with mental illness were less likely than non-mentally ill control subjects to receive a cholesterol test during the study period (first quartile adjusted OR=0.45, 95% CI=0.37-0.54; second quartile adjusted OR=0.50, 95% CI=0.45-0.57). Mentally ill subjects with more frequent utilization of VA services were as likely as (third quartile adjusted OR=1.01, 95% CI=0.91-1.13) or more likely than (fourth quartile adjusted OR=2.73, 95% CI=2.46-3.03) non-mentally ill subjects to receive cholesterol testing. CONCLUSIONS: Mental illness was associated with a lower likelihood of cholesterol testing in subjects who used fewer VA outpatient services. The observed disparity attenuated at higher levels of service utilization.     

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.     

Outcomes of Supported Housing for Homeless Veterans with Psychiatric and Substance Abuse Problems

This study examines the effect of previous participation in time limited residential treatment and other factors on treatment outcomes among homeless veterans with serious mental illness placed into permanent supported housing. The sample consisted of 655 veterans placed into supported housing at 18 sites through the VA's Healthcare for Homeless Veterans (HCHV) Supported Housing Program during the period 1993-2000. Data on client and program characteristics, and treatment outcomes, were documented by HCHV case managers staffing these programs. Data on use of VA services, including time limited residential treatment received 6 months prior to entry into supported housing, were extracted from VA administrative files. The relationship of prior residential treatment, as well as other measures of client characteristics, service use, and program characteristics, to outcomes were assessed using both bivariate and multivariate Cox proportional hazards regression and logistic regression. After adjusting for client characteristics, service use, and program characteristics, no differences in outcomes were found between clients who had received prior residential treatment and those placed directly into permanent supported housing. Prior residential treatment appears to have little effect on treatment outcomes among formerly homeless veterans placed into permanent supported housing programs providing indirect support for the direct placement supported housing model.     

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.     

Outpatient medical and mental healthcare utilization models among military veterans: results from the 2001 National Survey of Veterans

Using Andersen's (1995) [Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? Journal of Health and Social Behavior 1995;36:1-10] behavioral model of healthcare use as our theoretical framework, we examined predisposing (i.e., sociodemographic), enabling (i.e., access resources), and need (i.e., illness) models of outpatient medical and mental healthcare utilization among a national sample of US veterans. Participants were 20,048 nationally representative participants completing the 2001 National Survey of Veterans. Outcomes were healthcare use variables for the past year, including the number of Veterans Affairs (VA) and non-VA outpatient healthcare visits, and whether VA and non-VA mental health treatment was used. Univariate results demonstrated that numerous predisposing, enabling and need variables predicted both VA and non-VA healthcare use intensity and mental healthcare use. In multivariate analyses, predisposing, enabling and need variables demonstrated significant associations with both types of healthcare use, but accounted for more variance in mental healthcare use. Need variables provided an additive effect over predisposing and enabling variables in accounting for medical and mental healthcare use, and accounted for some of the strongest effects. The results demonstrate that need remains an important factor that drives healthcare use among veterans and does not seem to be overshadowed by socioeconomic factors that may create unfair disparities in treatment access.     

Effects of an outreach intervention on use of mental health services by veterans with posttraumatic stress disorder

OBJECTIVE: The study examined the effectiveness of an outreach intervention designed to increase access to mental health treatment among veterans disabled by chronic posttraumatic stress disorder (PTSD) and identified patient-reported barriers to care associated with failure to seek the treatment offered. METHODS: Participants were 594 male Vietnam veterans who were not enrolled in mental health care at a Department of Veterans Affairs (VA) medical center but who were receiving VA disability benefits for PTSD. Half the sample was randomly assigned to an outreach intervention, and the other half was assigned to a control group. Veterans in the intervention group received a mailing that included a brochure describing PTSD treatment available at an urban VA medical center, along with a letter informing them about how to access care. Participants in the intervention group were subsequently telephoned by a study coordinator who encouraged them to enroll in PTSD treatment and who administered a survey assessing barriers to care. RESULTS: Veterans in the intervention group were significantly more likely than those in the control group to schedule an intake appointment (28 percent versus 7 percent), attend the intake (23 percent versus 7 percent), and enroll in treatment (19 percent versus 6 percent). Several patient-identified barriers were associated with failure to seek VA mental health care, such as personal obligations that prevented clinic attendance, inconvenient clinic hours, and current receipt of mental health treatment from a non-VA provider. CONCLUSIONS: Utilization of mental health services among underserved veterans with PTSD can be increased by an inexpensive outreach intervention, which may be useful with other chronically mentally ill populations.     

Homeless mentally ill patients in the community: Results of a general hospital emergency room study

Previous inattention to the specific circumstances of homeless mentally ill individuals in general hospital settings is discussed. Homeless mentally ill individuals who presented for emergency psychiatric care in a public general hospital setting exhibited distinctive patterns of service utilization and showed evidence of being a uniquely disabled, rootless, and impoverished subgroup of mentally ill individuals. The characteristics of homeless users of general hospital psychiatric services may provide some important clues to system-wide deficits in community-based care for the members of this population.     

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.     

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.     

The impact of managed care on cross-system use of mental health services by veterans in Colorado

OBJECTIVES: Some state mental health systems have implemented capitated managed care as a strategy for lowering mental health care costs. There has been concern that this strategy has left vulnerable populations at risk of not being able to obtain adequate care. This study examined whether the advent of managed care in Colorado resulted in lower rates of use of both state and Department of Veterans Affairs (VA) mental health care services (cross-system use). METHODS: A cohort of 10,950 veterans who had used VA mental health services between 1995 and 1997 were studied to determine whether veterans who lived in counties that had implemented managed care were less likely to be cross-system users over time. VA data were matched with state mental health data to determine who was using both types of services. RESULTS: Rates of cross-system use were generally low. Veterans who lived in a county that had implemented managed care were less likely to be cross-system users than veterans who lived in other counties. However, the proportions of cross system users in managed care counties and in other counties did not change significantly over time. Veterans who were cross-system users were more likely to be younger, to live farther away from a VA hospital and closer to a non-VA hospital, and to have received inpatient VA care. CONCLUSIONS: The implementation of managed care in Colorado did not appear to have affected rates of cross-system use of state and VA mental health care.     

Pathways to homelessness among the mentally ill

  Background: Persons with mental illness are over-represented among the homeless relative to the general population, and mental illness is most likely one of many vulnerabilities that confer risk for homelessness. Method: This paper elucidates the pathways to homelessness for persons with mental illness by comparing and contrasting groups of mentally ill homeless persons, non-mentally ill homeless persons, and housed mentally ill persons drawn from RAND's Course of Homelessness (COH) study and the Epidemiological Catchment Area (ECA) survey. Results: Homeless persons share childhood histories of economic and social disadvantage. The mentally ill homeless appear to have a “double dose” of disadvantage: poverty with the addition of childhood family instability and violence. Among the mentally ill homeless, those who became homeless prior to becoming mentally ill have the highest levels of disadvantage and disruption; while those who become homeless after becoming ill have an especially high prevalence of alcohol dependence. Conclusions: Mental illness may play a role in initiating homelessness for some, but is unlikely in and of itself to be a sufficient risk factor for homelessness. In addition to outreach and treatment programs for adult mentally ill homeless persons, emphasis should be placed on interventions with children and on addressing more pervasive causes of homelessness. Accepted: 14 June 2000     

Mental health status and community adjustment after treatment in a residential treatment program for homeless veterans.

OBJECTIVE: An uncontrolled outcome study was conducted to examine clinical improvement and the relationship of psychiatric and substance abuse problems, community adjustment, and housing status among homeless veterans who participated in a multisite residential treatment program. METHOD: The study was performed at three U.S. Department of Veterans Affairs medical centers in Florida, Ohio, and California. Baseline, discharge, and 3-month postdischarge follow-up data were collected for 255 veterans admitted to the Domiciliary Care for Homeless Veterans Program. Multiple dimensions of outcome were examined, including psychiatric symptoms, alcohol abuse, drug abuse, social contacts, income, employment, and housing. RESULTS: Program participation was found to be associated with improvement in all areas of mental health and community adjustment. Improvement in psychiatric symptoms was associated with superior housing outcomes and improvement in community adjustment. When correlates of improvement in alcohol and drug abuse were examined, only one of eight possible relationships was found to be significant: improvement in alcohol problems was positively associated with improvement in employment. CONCLUSIONS: Homeless mentally ill veterans derive clear benefits from participation in a multidimensional residential treatment program. Improvement in mental health problems, however, is weakly linked to improvement in other areas, suggesting that treatment programs may have to attend separately to multiple domains of life adjustment.     

Medical service utilization by veterans seeking help for posttraumatic stress disorder

OBJECTIVE: Posttraumatic stress disorder (PTSD) has been associated with higher rates of health complaints and medical conditions diagnosed by physicians, yet research examining the relationship between PTSD and health care utilization has been limited. This study compared the health service use of veterans with PTSD to that of help-seeking veterans without PTSD. The relationship between severity of PTSD and service utilization was also examined. METHOD: Data were collected from 996 veterans seeking an evaluation at a Veterans Affairs (VA) Medical Center specialty PTSD clinic in the southeastern United States between March 1992 and September 1998. Data included sociodemographic characteristics, severity of PTSD, and disability status. The outcome variable, VA health service utilization, was prospectively assessed 1 year from the date of the initial PTSD assessment. RESULTS: Although the use of VA mental health services by patients with PTSD was substantial (a median of seven clinic stops), these patients used more services in general physical health clinics that provided predominantly nonmental health services (a median of 18 clinic stops). Negative binomial regression models revealed that younger veterans with PTSD had greater health care utilization than those without PTSD who also sought services. Greater severity of PTSD was related to higher rates of mental and physical health service use among veterans without a service-connected disability. CONCLUSIONS: PTSD is associated with substantial health service use. The results highlight the importance of increased collaboration between primary care and mental health specialists, given that patients with PTSD are more likely to receive treatment in nonmental health clinics.     

Homelessness and mental illness: a literature review and a qualitative study of perceptions of the adequacy of care

BACKGROUND: Homelessness and mental illness together confer significant morbidity and mortality because of physical health problems. Healthcare provision is undergoing significant review, and, as part of the Department of Health's policy reforms, the service user's view is central to the future restructuring of NHS services. MATERIAL: A literature review of homeless service users' perceptions of services for homeless mentally ill people was supplemented by a qualitative in-depth survey of 10 homeless people. This article reports on their views about the services they receive. Mismatch between expectations and provision, disputes with healthcare providers, dissatisfaction with the degree to which they have choice in their care, and suspicions about the intentions of health professionals demonstrate the extent to which powerlessness and social exclusion are replicated in healthcare economies. The inadequacy of hostels and their staff are also emphasised, with some recommendations for services. DISCUSSION AND CONCLUSIONS: There are few data on homeless people's perceptions of services for mental health problems. Homeless people have strong views about the adequacy of services to meet their needs. They were particularly concerned about stigma, prejudice and the inadequacy and complexity of services that they have to use. This article reports their recommendations for change.     

Homelessness among persons with serious mental illness in an enhanced community-based mental health system

OBJECTIVE: Homelessness and patterns of service use were examined among seriously mentally ill persons in an area with a well-funded community-based mental health system. METHODS: The sample consisted of 438 individuals referred between 1990 and 1992 to an extended acute care psychiatric hospital after a stay in a general hospital. Those experiencing an episode of homelessness, defined as an admission to a public shelter between 1990 and 1993, were compared with those who were residentially stable. Data from a longitudinal integrated database of public mental health and medical services were used to construct service utilization measures to test the mediating effect of outpatient mental health care on preventing homelessness. RESULTS: A homelessness rate of 24 percent was found among the 438 persons with serious mental illness. Those who experienced homelessness were more likely to be African American, receive general assistance, and have a comorbid substance abuse problem. They used significantly more inpatient psychiatric, emergency, and health care services than the subjects who did not become homeless. Forty to 50 percent of the homeless group received outpatient care during the year before and after their shelter episode. The number of persons who received intensive case management services increased after shelter admission. CONCLUSIONS: An enhanced community-based mental health system was not sufficient to prevent homelessness among high-risk persons with serious mental illness. Eleven percent of this group experienced homelessness after referral to an extended acute care facility. Strategies to prevent homelessness should be considered, perhaps at the time of discharge from the referring community hospital or extended acute care facility.     

Predictors of mental health service utilization by people using resources for homeless people in Canada

OBJECTIVE: This study used Pescosolido's network episode model to examine mental health service utilization among impoverished people accessing resources for the homeless in Canada's universal health care setting. METHODS: The sample consisted of 439 people who met DSM-IV criteria for affective or psychotic disorders who were assessed as part of a larger study of resources for homeless or impoverished people in Montreal and Quebec City. Interviews were organized into the framework of four network episode model concepts: sociodemographic characteristics, illness characteristics, illness history, and social network. These blocks of variables were then analyzed in terms of their accuracy in predicting mental health service utilization. RESULTS: Eighty-four percent of the sample were male, the mean+/-SD age was 41+/-12 years, and 36% were homeless at the time of the interview, but nearly half (48%) of the population had been homeless previously. The research shows that each network episode model concept except illness history significantly predicted utilization of mental health services. Female gender, youth, never being homeless (sociodemographic characteristics), presence of antisocial personality disorders within the preceding year, past or current alcohol-related disorders (illness characteristics), hospitalization before the preceding year (illness history), and a larger social support network were related to utilization of mental health services. CONCLUSIONS: In the absence of economic barriers to health care, there are other significant barriers to the use of mental health services for people who live in poverty. A better understanding of these factors will help in meeting the service needs of impoverished mentally ill people.     

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.