Temporary Financial Assistance for Housing Expenditures and Mortality and Suicide Outcomes Among US Veterans.

INTRODUCTION: It is unclear whether interventions designed to increase housing stability can also lead to improved health outcomes such as reduced risk of death and suicide morbidity. The objective of this study was to estimate the potential impact of temporary financial assistance (TFA) for housing-related expenses from the US Department of Veterans Affairs (VA) on health outcomes including all-cause mortality, suicide attempt, and suicidal ideation. METHODS: We conducted a retrospective national cohort study of Veterans who entered the VA Supportive Services for Veteran Families (SSVF) program between 10/2015 and 9/2018. We assessed the association between TFA and health outcomes using a multivariable Cox proportional hazards regression approach with inverse probability of treatment weighting. We conducted these analyses on our overall cohort as well as separately for those in the rapid re-housing (RRH) and homelessness prevention (HP) components of SSVF. Outcomes were all-cause mortality, suicide attempt, and suicidal ideation at 365 and 730 days following enrollment in SSVF. RESULTS: Our analysis cohort consisted of 41,969 unique Veterans with a mean (SD) duration of 87.6 (57.4) days in the SSVF program. At 365 days following SSVF enrollment, TFA was associated with a decrease in the risk of all-cause mortality (HR: 0.696, p < 0.001) and suicidal ideation (HR: 0.788, p < 0.001). We found similar results at 730 days (HR: 0.811, p = 0.007 for all-cause mortality and HR: 0.881, p = 0.037 for suicidal ideation). These results were driven primarily by individuals enrolled in the RRH component of SSVF. We found no association between TFA and suicide attempts. CONCLUSION: We find that providing housing-related financial assistance to individuals facing housing instability is associated with improvements in important health outcomes such as all-cause mortality and suicidal ideation. If causal, these results suggest that programs to provide housing assistance have positive spillover effects into other important aspects of individuals' lives.

The Association Between Chronic Pain, Substance use, and Primary Care Experience Among Veterans with Ongoing or Recent Homelessness.

BACKGROUND: Chronic pain and problematic substance use are prevalent among Veterans with homeless experience (VHE) and may contribute to a challenging primary care experience. OBJECTIVE: To examine the association of chronic pain and problematic substance use with unfavorable primary care experiences among VHE and to explore the association of pain treatment utilization and unfavorable care experiences in VHE with chronic pain. METHODS: We surveyed VHE (n = 3039) engaged in homeless-tailored primary care at 29 Veterans Affairs Medical Centers (VAMCs). We assessed unfavorable primary care experiences with four validated Primary Care Quality-Homeless (PCQ-H) scales: multivariable logistic regressions explored associations between unfavorable care experiences for VHE with chronic pain and problematic substance use, chronic pain alone, problematic substance use alone, or neither. We then examined the association between receipt of pain treatments and unfavorable experiences among VHE with chronic pain. Last, we identified PCQ-H items that had the greatest difference in unfavorable response rates between VHE with and without chronic pain. RESULTS: The prevalence of unfavorable primary care experience was higher on all four scales for patients reporting chronic pain (with or without problematic substance use) (all p < 0.001), but not for problematic substance use alone, compared to VHE with neither pain nor problematic substance use. In analyses limited to VHE with chronic pain, those on long-term opioids were less likely to report an unfavorable experience (OR = 0.49, 95%CI 0.34-0.69). Receipt of occupational therapy was associated with lower odds of reporting an unfavorable experience (OR = 0.83, 95%CI 0707-0.98). PCQ-H items related to trust, relationships, and provider communication had the greatest differences in dissatisfaction ratings (all p < 0.001). CONCLUSIONS: Chronic pain is associated with unfavorable primary care experiences among VHE, potentially contributing to poor care outcomes. Strategies are needed to enhance patient-provider trust and communication and increase VHE's access to effective pain treatments.

Predictors of recurrent stroke and subsequent mortality among patients experiencing housing instability.

BACKGROUND: The experience of homelessness has been linked with developing poor health outcomes. Little is known about the risk of recurrent stroke among these individuals. This study investigated the correlates of developing recurrent stroke and subsequent mortality among Veterans with housing instability. METHODS: Using a national sample of Veterans from the U.S. Department of Veterans Affairs who had an indicator of housing instability between 2014-2018 (n=659,987), we identified 15,566 Veterans who experienced incident stroke. We compared characteristics of Veterans who experienced incident stroke and did and did not experience recurrent stroke and conducted logistic regressions using a discrete-time survival framework to assess two outcomes: recurrent stroke and all-cause mortality. RESULTS: Among our cohort, 91.3% did not experience recurrent stroke while 8.7% did during the observation period. The receipt of any level of primary care outpatient visits was associated with a reduction in the odds of recurrent stroke. Several medical diagnoses were also associated with increased odds of recurrent stroke, including hypertension (aOR 1.35, 95% CI 1.15-1.59), diabetes (aOR 1.21, 95% CI 1.07-1.36), and renal disease (aOR 1.17, 95% CI 1.02, 1.35). Veterans who used any level of VA Homeless Programs had reduced odds of all-cause mortality (high level: aOR 0.65, 95% CI 0.60-0.71; low level: aOR 0.66, 95% CI 0.60-0.73). CONCLUSION: Our study found several predictors of developing recurrent stroke and subsequent death in a population of Veterans experiencing housing instability. Implications include the need to monitor closely high-risk patients who have experienced incident stroke and have other co-occurring needs.

Change in Homeless and Health Services Use Following Migration Among Veterans with Experience of Homelessness.

BACKGROUND: Homelessness is associated with poor health outcomes, including lack of access to care. Homelessness experienced in rural areas is understudied but likely associated with difficulty accessing needed services. Prior studies have assessed the extent to which Veterans experiencing homelessness in rural areas "migrate" to urban areas, but have not focused on changes in services utilization following migration. OBJECTIVE: To determine whether Veterans with a history of homelessness experience changes in the use of homeless and health services following a migration from a rural to urban residence, and vice versa, and to assess the magnitude of those changes. DESIGN: Longitudinal retrospective analysis of services use among Veterans identified as experiencing homelessness and migrating at least 40 miles or from an urban to a rural area or vice versa. PARTICIPANTS: A total of 81,620 Veterans with incident homelessness who experienced a migration and for whom we could establish 2 quarters of both pre-migration and post-migration service utilization. MAIN MEASURES: In addition to sociodemographic and health-related factors, we assessed index location and destination using geographic descriptors both residential address and Veteran Affairs (VA) facility where Veterans were identified as experiencing homelessness. Outcomes included continuous measures of homeless services and outpatient care and dichotomous measures of emergency department use and inpatient admissions. KEY RESULTS: Regardless of a Veteran's index location, migration to or within a rural area was associated with a significant decrease in the number of homeless and outpatient services and reduced risk of emergency department use or inpatient admission relative to migration to or within an urban area. CONCLUSION: Controlling for sociodemographic and health-related factors, Veterans experiencing homelessness who had a residential migration to or within a rural area had a significant reduction in their use of VA health and homeless services compared to those who migrated to or within an urban area.

Frequent Episodic Utilizers of Veterans Health Administration Homeless Programs Use: Background Characteristics and Health Services Use.

OBJECTIVE: To assess sociodemographic, diagnostic, and services use factors associated with veterans' repeated, episodic use of Veterans Health Administration (VHA) Homeless Programs. DESIGN: This retrospective cohort study used stepwise multivariate logistic regression to assess the odds of veterans being frequent episodic utilizers of VHA Homeless Programs (ie, ≥4 services use episodes during the observation period). SETTING: The study used administrative data from veterans who accessed VHA services across the United States. PARTICIPANTS: The sample comprised 31 098 veterans who completed a VHA Homeless Program intake assessment in 2013 and accessed VHA Homeless Programs during 2013-2016. MAIN OUTCOME MEASURE: Frequent episodic use of VHA Homeless Programs (ie, ≥4 services use episodes during the observation period). RESULTS: Only 2.4% of the study sample had 4 or more episodes of VHA Homeless Program use during the observation period; risk factors included experience of military sexual trauma, history of incarceration, diagnosis of psychosis and substance use disorder, and use of acute care. CONCLUSIONS: Addressing veterans' needs related to poverty, income, and postincarceration reintegration may reduce the frequent episodic use of VHA Homeless Programs. Interventions embedded in emergency departments and inpatient units may also be considered.

Tenant-Based Housing Voucher Programs: A Community Guide Systematic Review.

CONTEXT: Unaffordable or insecure housing is associated with poor health in children and adults. Tenant-based housing voucher programs (voucher programs) limit rent to 30% or less of household income to help households with low income obtain safe and affordable housing. OBJECTIVE: To determine the effectiveness of voucher programs in improving housing, health, and other health-related outcomes for households with low income. DESIGN: Community Guide systematic review methods were used to assess intervention effectiveness and threats to validity. An updated systematic search based on a previous Community Guide review was conducted for literature published from 1999 to July 2019 using electronic databases. Reference lists of included studies were also searched. ELIGIBILITY CRITERIA: Studies were included if they assessed voucher programs in the United States, had concurrent comparison populations, assessed outcomes of interest, were written in English, and published in peer-reviewed journals or government reports. MAIN OUTCOME MEASURES: Housing quality and stability, neighborhood opportunity (safety and poverty), education, income, employment, physical and mental health, health care use, and risky health behavior. RESULTS: Seven studies met inclusion criteria. Compared with low-income households not offered vouchers, voucher-using households reported increased housing quality (7.9 percentage points [pct pts]), decreased housing insecurity or homelessness (-22.4 pct pts), and decreased neighborhood poverty (-5.2 pct pts).Adults in voucher-using households had improved health care access and physical and mental health. Female youth experienced better physical and mental health but not male youth. Children who entered the voucher programs under 13 years of age had improved educational attainment, employment, and income in their adulthood; children's gains in these outcomes were inversely related to their age at program entry. CONCLUSION: Voucher programs improved health and several health-related outcomes for voucher-using households, particularly young children. Research is still needed to better understand household's experiences and contextual factors that influence achievement of desired outcomes.

Perceptions of Care Coordination Among Homeless Veterans Receiving Medical Care in the Veterans Health Administration and Community Care Settings: Results From a National Survey.

BACKGROUND: Initiatives to expand Veterans' access to purchased health care outside Veterans Health Administration (VHA) facilities ("community care") present care coordination challenges for Veterans experiencing homelessness. OBJECTIVE: Among Veterans with homeless experiences, to evaluate community care use and satisfaction, and compare perceptions of care coordination among Veterans using VHA services and community care to those using VHA services without community care. RESEARCH DESIGN: Cross-sectional analysis of responses to a 2018 mailed survey. SUBJECTS: VHA outpatients with homeless experiences. MEASURES: Self-reported use of community care, Likert-style ratings of satisfaction with that care, and Access/Coordination experiences from the Primary Care Quality-Homeless (PCQ-H) survey. RESULTS: Of 4777 respondents, 1325 (26.7%) reported using community care; most of this subsample affirmed satisfaction with the community care they received (83%) and its timeliness (75%). After covariate adjustment, Veteran characteristics associated with greater community care use included female sex, being of retirement age and nonmarried, and having higher education, more financial hardship, ≥3 chronic conditions, psychological distress, depression, and posttraumatic stress disorder. Satisfaction with community care was lower among patients with travel barriers, psychological distress, and less social support. Compared with those using the VHA without community care, Veterans using VHA services and community care were more likely to report unfavorable access/coordination experiences [odds ratio (OR)=1.34, confidence interval (CI)=1.15-1.57]. This included hassles following referral (OR=1.37, CI=1.14-1.65) and perceived delays in receiving health care (OR=1.38, CI=1.19-1.61). CONCLUSIONS: Veterans with homeless experiences value community care options. Potential access benefits are balanced with risks of unfavorable coordination experiences for vulnerable Veterans with limited resources.

ReHouSED: A novel measurement of Veteran housing stability using natural language processing.

Housing stability is an important determinant of health. The US Department of Veterans Affairs (VA) administers several programs to assist Veterans experiencing unstable housing. Measuring long-term housing stability of Veterans who receive assistance from VA is difficult due to a lack of standardized structured documentation in the Electronic Health Record (EHR). However, the text of clinical notes often contains detailed information about Veterans' housing situations that may be extracted using natural language processing (NLP). We present a novel NLP-based measurement of Veteran housing stability: Relative Housing Stability in Electronic Documentation (ReHouSED). We first develop and evaluate a system for classifying documents containing information about Veterans' housing situations. Next, we aggregate information from multiple documents to derive a patient-level measurement of housing stability. Finally, we demonstrate this method's ability to differentiate between Veterans who are stably and unstably housed. Thus, ReHouSED provides an important methodological framework for the study of long-term housing stability among Veterans receiving housing assistance.

The Importance of Context: Linking Veteran Outpatients Screening Positive for Housing Instability with Responsive Interventions.

This study aims to explore the relationship between the context of screening for housing instability and Veterans' access to services, with the goal of ensuring effective processes to address housing instability among Veterans. This study used administrative data from 100,022 Veterans' electronic medical records and qualitative data collected during in-depth interviews with 22 health care providers and six Homeless Program staff. A mixed effects logistic regression assessed the relationship between Veterans' screening experiences and connection with services; qualitative data were analyzed using a grounded theory approach to present providers' reflections on administering screening for housing instability and responding to Veterans' positive screens with needed resources. We observed a significant relationship between providers' roles and location of screening with patients' timely linkage with services. Providing additional training related to how to conduct the screen and provide required resources, shifting screening responsibilities to providers with more flexibility to address these needs, and embedding supportive services in the care team may improve post-screening linkage with services.

Financial Strain and Suicide Attempts in a Nationally Representative Sample of US Adults.

Although research has identified many suicide risk factors, the relationship between financial strain and suicide has received less attention. Using data representative of the US adult population (n = 34,653) from wave 1 (2001-2002) and wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions, we investigated the association between financial strain-financial debt/crisis, unemployment, past homelessness, and lower income-and subsequent suicide attempts and suicidal ideation. Multivariable logistic regression controlling for demographic and clinical covariates showed that cumulative financial strain was predictive of suicide attempts between waves 1 and 2 (odds ratio (OR) = 1.53, 95% confidence interval (CI): 1.32, 1.77). Wave 1 financial debt/crisis (OR = 1.58, 95% CI: 1.06, 2.34), unemployment (OR = 1.52, 95% CI: 1.10, 2.10), past homelessness (OR = 1.50, 95% CI: 1.03, 2.17), and lower income (OR = 1.51, 95% CI: 1.01, 2.25) were each associated with subsequent suicide attempts. Respondents endorsing these 4 financial-strain variables had 20 times higher predicted probability of attempting suicide compared with respondents endorsing none of these variables. Analyses yielded similar results examining suicidal ideation. Financial strain accumulated from multiple sources (debt, housing instability, unemployment, and low income) should be considered for optimal assessment, management, and prevention of suicide.

Middle-aged Women's Experiences of Intimate Partner Violence Screening and Disclosure: "It's a private matter. It's an embarrassing situation".

BACKGROUND: National guidelines indicate that healthcare providers should routinely screen women of reproductive age for experience of intimate partner violence. We know little about intimate partner violence (IPV) screening and disclosure experience among women older than reproductive age. OBJECTIVE: To examine the perspectives of middle-aged women who had experienced past-year IPV regarding IPV screening and disclosure in the healthcare setting. DESIGN: Individual semi-structured qualitative interviews were conducted in-person as part of a larger study examining IPV screening and response services through the Veterans Health Administration. PARTICIPANTS: Twenty-seven women aged 45-64 (mean age 53) who experienced past-year IPV and received care at one of two Veterans Affairs Medical Centers. APPROACH: Interviews were digitally recorded and transcribed. Data were sorted and analyzed using templated notes and line-by-line coding, based on codes developed by the study team through an initial review of the data. Themes were derived from further analysis of the data coded for "screening" and "disclosure" for respondents aged 45 and older. KEY RESULTS: Barriers to disclosure of IPV to a healthcare provider included as follows: (a) feelings of shame, stigma, and/or embarrassment about experiencing IPV; (b) screening context not feeling comfortable or supportive, including lack of comfort with or trust in the provider and/or a perception that screening was conducted in a way that felt impersonal and uncaring; and (c) concerns about privacy and safety related to disclosure. Provider demonstrations of care, empathy, and support facilitated disclosure and feelings of empowerment following disclosure. CONCLUSIONS: Middle-aged women may benefit from routine IPV screening and response in the healthcare setting. Such interventions should be sensitive to concerns regarding stigma and privacy that may be prevalent among this population.

Social Determinants and Military Veterans' Suicide Ideation and Attempt: a Cross-sectional Analysis of Electronic Health Record Data.

BACKGROUND: Health care systems struggle to identify risk factors for suicide. Adverse social determinants of health (SDH) are strong predictors of suicide risk, but most electronic health records (EHR) do not include SDH data. OBJECTIVE: To determine the prevalence of SDH documentation in the EHR and how SDH are associated with suicide ideation and attempt. DESIGN: This cross-sectional analysis included EHR data spanning October 1, 2015-September 30, 2016, from the Veterans Integrated Service Network Region 4. PARTICIPANTS: The study included all patients with at least one inpatient or outpatient visit (n = 293,872). MAIN MEASUREMENTS: Adverse SDH, operationalized using Veterans Health Administration (VHA) coding for services and International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes, encompassed seven types (violence, housing instability, financial/employment problems, legal problems, familial/social problems, lack of access to care/transportation, and nonspecific psychosocial needs). We defined suicide morbidity by ICD-10 codes and data from the VHA's Suicide Prevention Applications Network. Logistic regression assessed associations of SDH with suicide morbidity, adjusting for socio-demographics and mental health diagnoses (e.g., major depression). Statistical significance was assessed with p < .01. KEY RESULTS: Overall, 16.4% of patients had at least one adverse SDH indicator. Adverse SDH exhibited dose-response-like associations with suicidal ideation and suicide attempt: each additional adverse SDH increased odds of suicidal ideation by 67% (AOR = 1.67, 99%CI = 1.60-1.75; p < .01) and suicide attempt by 49% (AOR = 1.49, 99%CI = 1.33-1.68; p < .01). Independently, each adverse SDH had strong effect sizes, ranging from 1.86 (99%CI = 1.58-2.19; p < .01) for legal issues to 3.10 (99%CI = 2.74-3.50; p < .01) for non-specific psychosocial needs in models assessing suicidal ideation and from 1.58 (99%CI = 1.10-2.27; p < .01) for employment/financial problems to 2.90 (99%CI = 2.30-4.16; p < .01) for violence in models assessing suicide attempt. CONCLUSIONS: SDH were strongly associated with suicidal ideation and suicide attempt even after adjusting for mental health diagnoses. Integration of SDH data in EHR could improve suicide prevention.

Adverse social factors and all-cause mortality among male and female patients receiving care in the Veterans Health Administration.

Social factors account more for health outcomes than medical care, yet health services research in this area is limited due to the lack of social factors data contained within electronic health records (EHR) systems. Few investigations have examined how cumulative burdens of co-occurring adverse social factors impact health outcomes. From 293,872 patients in one region of the Veterans Health Administration (VHA), we examined how increasing numbers of adverse social factors extracted from the EHR were associated with mortality across a one-year period for male and female patients. Adverse social factors were identified using four sources in the EHR: responses to universal VHA screens, International Classification of Disease (ICD) diagnostic codes that indicate social factors, receipt of VHA services related to social factors, and templated social work referrals. Seven types of adverse social factors were coded: violence, housing instability, employment or financial problems, legal issues, social or familial problems, lack of access to care or transportation, and nonspecific psychosocial needs. Overall, each increase in an adverse social factor was associated with 27% increased odds of mortality, after accounting for demographics, medical comorbidity, and military service-related disability. Non-specific psychosocial factors were most strongly associated with mortality, followed by social or familial problems. Although women were more likely than men to have multiple adverse social factors, social factors were not associated with mortality among women as they were among men. By incorporating social factors data, health care systems can better understand patient all-cause mortality and identify potential prevention efforts built around social determinants.

Social determinants and emergency department utilization: Findings from the Veterans Health Administration.

BACKGROUND: Social determinants of health (SDH) are strong predictors of morbidity and mortality but health care systems struggle to integrate documentation of SDH into health records in ways that can be used for health services research. Given the impact of social factors on health, it is important to examine the relationship with emergency department (ED) utilization. OBJECTIVE: To examine the association between seven indicators of SDH and ED utilization using electronic health record (EHR) data from the Veterans Health Administration (VHA). METHODS: This cross-sectional analysis included data from all patients who had at least one health care visit in the Veterans Integrated Service Network region 4 from October 1, 2015 through September 30, 2016 (n=293,872). Seven categories of adverse SDH included violence, housing instability, employment or financial problems, legal problems, social or family problems, lack of access to care or transportation, and non-specific psychosocial needs identified through structured coding in EHR. Negative binomial regression was used to examine the association of the count of adverse SDH (0-7) with the count of ED visits, adjusting for socio-demographic and health-related factors. RESULTS: Approximately 18% of patients visited the ED during the observation period. After adjusting for covariates, adverse SDH were positively associated with VHA ED utilization. Each of the SDH indicators, other than legal issues, was positively associated with increased ED utilization. CONCLUSION: Even after accounting for several demographic and health-related factors, adverse SDH demonstrated strong positive associations with VHA ED utilization.

Exploring Quality of Primary Care for Patients Who Experience Homelessness and the Clinicians Who Serve Them: What Are Their Aspirations?

To develop and evaluate an effective model of patient-centered, high-quality, homeless-focused primary care, our team explored key domains of primary care that may be important to patients. We anchored our conceptual framework in two reports from the Institute of Medicine (IOM) that defined components of primary care and quality of care. Using questions developed from this framework, we conducted semistructured interviews with 36 homeless-experienced individuals with past-year primary care engagement and 24 health care professionals (clinicians and researchers) who serve homeless-experienced patients in the primary care setting. Template analysis revealed factors important to this population. These included stigma, respect, and perspectives on patient control of medical decision-making in regard to both pain and addiction. For patients experiencing homelessness, the results suggest that quality primary care may have different meanings for patients and professionals, and that services should be tailored to meet homeless-specific needs.

Permanent Supportive Housing With Housing First to Reduce Homelessness and Promote Health Among Homeless Populations With Disability: A Community Guide Systematic Review.

CONTEXT: Poor physical and mental health and substance use disorder can be causes and consequences of homelessness. Approximately 2.1 million persons per year in the United States experience homelessness. People experiencing homelessness have high rates of emergency department use, hospitalization, substance use treatment, social services use, arrest, and incarceration. OBJECTIVES: A standard approach to treating homeless persons with a disability is called Treatment First, requiring clients be "housing ready"-that is, in psychiatric treatment and substance-free-before and while receiving permanent housing. A more recent approach, Housing First, provides permanent housing and health, mental health, and other supportive services without requiring clients to be housing ready. To determine the relative effectiveness of these approaches, this systematic review compared the effects of both approaches on housing stability, health outcomes, and health care utilization among persons with disabilities experiencing homelessness. DESIGN: A systematic search (database inception to February 2018) was conducted using 8 databases with terms such as "housing first," "treatment first," and "supportive housing." Reference lists of included studies were also searched. Study design and threats to validity were assessed using Community Guide methods. Medians were calculated when appropriate. ELIGIBILITY CRITERIA: Studies were included if they assessed Housing First programs in high-income nations, had concurrent comparison populations, assessed outcomes of interest, and were written in English and published in peer-reviewed journals or government reports. MAIN OUTCOME MEASURES: Housing stability, physical and mental health outcomes, and health care utilization. RESULTS: Twenty-six studies in the United States and Canada met inclusion criteria. Compared with Treatment First, Housing First programs decreased homelessness by 88% and improved housing stability by 41%. For clients living with HIV infection, Housing First programs reduced homelessness by 37%, viral load by 22%, depression by 13%, emergency departments use by 41%, hospitalization by 36%, and mortality by 37%. CONCLUSIONS: Housing First programs improved housing stability and reduced homelessness more effectively than Treatment First programs. In addition, Housing First programs showed health benefits and reduced health services use. Health care systems that serve homeless patients may promote their health and well-being by linking them with effective housing services.

Screening for Housing Instability: Providers' Reflections on Addressing a Social Determinant of Health.

BACKGROUND: The Veterans Health Administration (VHA) has a long history of addressing social determinants of health, including housing. In 2012, the VA integrated a two-question Homelessness Screening Clinical Reminder (HSCR) into the electronic medical record in outpatient clinics to identify Veterans experiencing housing instability and ensure referral to appropriate services. OBJECTIVE: This study explores perspectives of VA clinical providers regarding administration of the HSCR, their role in addressing housing status, and how a patient's housing status impacts clinical decision-making. DESIGN: We conducted a qualitative study using in-depth semi-structured interviewing. PARTICIPANTS: Twenty-two providers were interviewed (20 physicians and two nurse practitioners) between March and September 2016. APPROACH: Interviews were conducted with Veterans Health Administration (VHA) physician and non-physician practitioners who had administered the HSCR and documented at least five positive screens between 2013 and 2015. Our interview guide investigated provider experiences with administering the HSCR and addressing affirmative responses. The guide also elicited details about how patients' housing instability was identified (if at all) prior to implementation of the screening reminder, and how practices changed following implementation of the HSCR. Transcripts were analyzed using a modified grounded theory approach. KEY RESULTS: Providers reported that the HSCR prompted them to incorporate patient housing status into routine assessment, which they typically did not do prior to its implementation. Providers discussed adverse impacts of housing instability on patients' overall health and described how they factored patients' housing instability into clinical decision-making. Although providers viewed the health system as having an important role in addressing housing concerns, there were mixed opinions on whether it was the role of providers to directly administer the screening. CONCLUSIONS: Integration of a screener for housing instability into the electronic medical record increased provider attention to housing instability into the social history, and positive responses commonly impacted plans of care.

Barriers and facilitators to housing access and maintenance in HUD-VASH: Participant and staff perspectives.

Though the U.S. Departments of Housing and Urban Development (HUD) and Veterans Affairs (VA) supportive housing (HUD-VASH) program endeavors to address barriers to Veterans accessing and maintaining housing, participants report challenges that lead to program exits. This study aims to understand participants' views on the factors contributing to their exits from HUD-VASH, as well as how program staff may respond to challenges. This mixed methods study includes four sources of data: (1) surveys with Veterans, (2) semi-structured interviews with a subsample of surveyed Veterans, (3) Veterans' administrative data from VA electronic data systems, and (4) focus groups with staff from local public housing authorities and VA case management teams. Veterans reported barriers to housing access (e.g., difficult procedures, lack of communication, lack of affordable and adequate housing stock) and housing maintenance (e.g., program rules, mental health and substance use, access to resources), and staff described strategies devised, at the local level, in response to these issues (e.g., better engagement with property owners, funds for deposits and household goods, increased interagency collaboration through HUD-VASH Boot Camps). Findings can inform communities seeking to eliminate Veteran homelessness through HUD-VASH and other supported housing programs.

Persistent Super-Utilization of Acute Care Services Among Subgroups of Veterans Experiencing Homelessness.

BACKGROUND: Acute health care utilization often occurs among persons experiencing homelessness. However, knowing which individuals will be persistent super-utilizers of acute care is less well understood. OBJECTIVE: The objective of the study was to identify those more likely to be persistent super-utilizers of acute care services. RESEARCH DESIGN: We conducted a latent class analysis of secondary data from the Veterans Health Administration Corporate Data Warehouse, and Homeless Operations Management and Evaluation System. The study sample included 16,912 veterans who experienced homelessness and met super-utilizer criteria in any quarter between July 1, 2014 and December 31, 2015. The latent class analysis included veterans' diagnoses and acute care utilization. RESULTS: Medical, mental health, and substance use morbidity rates were high. More than half of the sample utilized Veterans Health Administration Homeless Programs concurrently with their super-utilization of acute care. There were 7 subgroups of super-utilizers, which varied considerably on the degree to which their super-utilization persisted over time. Approximately a third of the sample met super-utilizer criteria for ≥3 quarters; this group was older and disproportionately male, non-Hispanic white, and unmarried, with lower rates of post-9/11 service and higher rates of rural residence and service-connected disability. They were much more likely to be currently homeless with more medical, mental health, and substance use morbidity. CONCLUSION: Only a subset of homeless veterans were persistent super-utilizers, suggesting the need for more targeted interventions.

Comparing the Utilization and Cost of Health Services between Veterans Experiencing Brief and Ongoing Episodes of Housing Instability.

Housing instability is associated with costly patterns of health and behavioral health service use. However, little prior research has examined patterns of service use associated with higher costs among those experiencing ongoing housing instability. To address this gap, we compared inpatient and outpatient medical and behavioral health service utilization and costs between veterans experiencing brief and ongoing episodes of housing instability. We used data from a brief screening instrument for homelessness and housing instability that has been implemented throughout the US Department of Veterans Affairs (VA) health care system to identify a national sample of veterans experiencing housing instability. Veterans were classified as experiencing either brief or ongoing housing instability, based on two consecutive responses to the instrument, and we used a series of two-part regression models to conduct adjusted comparisons of costs between veterans experiencing brief and ongoing episodes of housing instability. Among 5794 veterans screening positive for housing instability, 4934 (85%) were experiencing brief and 860 (15%) ongoing instability. The average total annual incremental cost associated with ongoing versus brief episodes of housing instability was estimated at $7573, with the bulk of this difference found in inpatient services. Cost differences resulted more from a higher probability of service use among those experiencing ongoing episodes of housing instability than from higher costs among service users. Our findings suggest that VA programmatic efforts aimed at preventing extended episodes of housing instability could potentially result in substantial cost offsets for the VA health care system.