Connecting unstably housed veterans living in rural areas to health care: Perspectives from Health Care Navigators.

OBJECTIVE: To understand existing care practices and policies, and potential enhancements, to improve the effectiveness of the US Department of Veterans Affairs (VA) Supportive Services for Veteran Families (SSVF) Health Care Navigators (HCN) in linking Veterans experiencing housing instability in rural areas with health care services. DATA SOURCES AND STUDY SETTING: We used primary data collected during semistructured interviews with HCNs (n = 21) serving rural areas across the United States during Spring 2022. STUDY DESIGN: We applied the Consolidated Framework for Implementation Research (CFIR) 2009 and the Social Ecological Model (SEM) to the collection and analysis of qualitative data to understand how HCNs administer services within SSVF and the larger community. DATA COLLECTION/EXTRACTION METHODS: We used rapid qualitative methods to summarize and analyze data. Templated matrix summaries identified facilitators and barriers to linking Veterans with health care services and policy and practice implications. PRINCIPAL FINDINGS: Using CFIR 2009, we identified contextual factors affecting successful implementation of HCN services within SSVF; we offer a crosswalk between CFIR 2009 and the version updated in 2022. Framing facilitators and barriers within the SEM provided insight into whether implementation strategies should be addressed at a community, interpersonal, or intrapersonal level within the SEM. Facilitators included sufficient knowledge, training, and mentorship opportunities for HCNs and their capacity to collaborate within their organization and with other community-based organizations. Barriers included lack of local technology and housing resources, inadequate understanding of Veterans' service eligibilities and pathways to access those services, and deficient collaboration with the VA. CONCLUSIONS: Understanding facilitators and barriers experienced by HCN when linking unstably housed Veterans in rural areas with health care services can inform future strategies, including policy changes such as increased training to support HCNs' understanding of eligibility, benefits, and entitlements as well as improving communication and collaboration between VA and community partners.

Examining the Intersection of Housing Instability and Violence Among LGBTQ Adults.

To assess the relationship between LGBTQ status and (1) current, recent, and lifetime experiences of housing instability, (2) risk of housing instability due to fears of interpersonal violence, and (3) perceived housing challenges, this study examined online survey data from individuals with a household income <$35,000 (N = 1,270). Analyses compared LGBTQ and cisgender heterosexual respondents using chi-square tests and logistic regression. Over their lifetime, LGBTQ respondents had increased odds of sleeping outdoors (adjusted odds ratios [AOR] = 1.580) or in a car (AOR = 1.465) because they had nowhere else to stay. They also had increased odds of reporting housing challenges related to violence from family/friends (AOR = 3.278), substance abuse (AOR = 3.063), and mental health (AOR = 2.048). Interventions serving LGBTQ adults should prioritize safety concerns and consider providing services to both individuals and families. In addition, providers should increase sensitivity toward issues of sexual orientation and gender identity and the unique needs of LGBTQ adults.

Providers' reflections on infrastructure and improvements to promote access to care for Veterans experiencing housing instability in rural areas of the United States: A qualitative study.

Veterans in rural areas of the United States face barriers to accessing healthcare and other services, which are intensified for those experiencing housing instability. Recent legislative acts have the potential to address obstacles faced by rural patients in the U.S. This study explores how infrastructure-including features related to the physical and digital environment-impacts the ability of rural Veterans experiencing housing instability to access healthcare and related services from the perspective of homeless service providers within the Veterans Health Administration (VHA). We conducted semi-structured telephone interviews (n = 22) with providers in high/low performing and/or resourced communities across the U.S. in May and June 2021 and analysed transcripts using template analysis. Themes described by providers highlight how infrastructure limitations in rural areas can exacerbate health disparities for Veterans experiencing housing instability, the impact of COVID-19 on service access, and recommendations to enhance service delivery. Providers suggested that VHA reconfigure where and how staff work, identify additional resources for transportation and/or alternative transportation models, and increase Veterans' access to technology and broadband Internet. Federal infrastructure investments should address challenges faced by Veterans experiencing housing instability in rural areas and the concerns of providers connecting them with care.

Association Between Registered Sex Offender Status and Risk of Housing Instability and Homelessness among Veterans.

Research is limited about whether and to what extent registered sex offenders (RSOs) face an increased risk of housing instability. The intersection of RSO and housing instability is particularly salient for veterans as there are disproportionately higher rates of veterans among both RSOs and homeless populations. This study assessed the relationship between RSO status and risk of housing instability and homelessness among military veterans. We matched a list of 373,774 RSOs obtained from publicly available sex offender registries in 19 states with a cohort of 5.9 million veterans who responded to a brief screening for housing instability administered throughout the Veterans Health Administration between 2012 and 2016. Logistic regression estimated adjusted odds of any housing instability and homelessness among veterans identified as RSOs. Veterans identified as RSOs had 1.81 (95% confidence interval [CI] 1.46-2.25) and 2.97 (95% CI 1.67-5.17) times greater odds of reporting any housing instability and homelessness, respectively, than non-RSOs. Findings represent some of the strongest evidence to date for the high risk of housing instability and homelessness among RSOs, suggesting a clear gap in policy and programmatic responses to their unique housing needs. Evidence-based alternative approaches to residence restriction laws may reduce recidivism and protect public safety.

Individual, social, and environmental factors associated with active transportation commuting during the COVID-19 pandemic.

OBJECTIVE: Physical inactivity is a major public health concern. Though active transportation through bicycling and walking can increase physical activity and thereby positively affect health, factors that influence people's decisions to commute using active transportation modes remain underexplored and often fail to capture equity-related barriers. Increases in active transportation during the COVID-19 pandemic call for a better understanding of these influences. This study examines the commute mode choices of essential workers in Philadelphia, Pennsylvania, USA to explore the extent to which active transportation to work is explained by individual, social, and environmental factors and whether active transportation choices reflect inequalities. METHODS: Drawing on the theory of planned behavior and the social-ecological model, this study utilizes data from an online survey (N = 213) completed between June and August 2020. Bivariate analyses compare respondents who commuted using active transportation modes to those who did not using chi-square and ANOVA tests. A series of logistic regression models using forward stepwise selection, controlling for demographic characteristics and commute distance, identify salient individual, social, and environmental factors associated with active transportation. RESULTS: Nearly half of respondents changed their commute mode during the pandemic, most often to limit exposure to COVID-19. The full model, accounting for 54% of variation in active transportation commuting, indicated significantly lower odds of active transportation use among non-white (Odds Ratio [OR]: 0.155) respondents and those who reported time constraints (OR: 0.450), concerns about safety from traffic (OR: 0.482), and greater satisfaction with community support for bicycling and pedestrian issues (OR: 0.551) and significantly higher odds among those who reported safety concerns around germs (OR: 1.580). CONCLUSIONS: Structural and social investments that make bicycling and walking safer commuting alternatives during COVID-19 could protect essential works and contribute to sustained behavior change. Community engagement is essential for implementation efforts.

At the Intersection of Homeless Encampments and Heroin Addiction: Service Use Barriers, Facilitators, and Recommendations from the City of Philadelphia's Encampment Resolution Pilot.

We provide an overview of the pilot and evaluation measures used for an independent evaluation of the Encampment Resolution Pilot (ERP) wherein the City of Philadelphia closed two homeless encampments in May 2018 and sought to assist those displaced by the closures with housing and treatment services. The evaluation used the Rapid Assessment, Response, and Evaluation method to collect qualitative findings on service use barriers and facilitators from open-ended interviews with people staying in the encampments (N = 27) and service providers (N = 10). We assessed how the ERP allowed providers to "push the system" by removing access barriers, and providing amenable, effective, and accessible housing and drug treatment services that led to more widely adopted best practices. However, there was a clear need for additional supportive services and aftercare for those exiting treatment. Providers also cited a need for more integrated medical and mental health services.

Mental health care in the context of intimate partner violence: Survivor perspectives.

Experience of violence or abuse from an intimate partner (intimate partner violence, IPV) can result in a variety of psychological and mental health impacts for which survivors may seek psychotherapy or other mental health services. Individuals experiencing IPV may have specific needs and preferences related to mental health care, yet the question of how to best provide client-centered mental health care in the context of IPV has received little attention in the literature. In this article, we report on findings from qualitative interviews with 50 women reporting past-year IPV who received care through the Veterans Health Administration regarding experiences with and recommendations for mental health services. Participants described client-centered mental health care in the context of recent or ongoing IPV as being characterized by flexibility and responsiveness around discussion of IPV; respect for the complexity of clients' lives and support for self-determination; and promoting safety and access to internal and external resources for healthy coping. We discuss findings in terms of their implications for the mental health field, highlighting the need for flexibility in application of evidence-based treatments, improved coordination between therapeutic and advocacy services, and training to enhance competencies around understanding and responding to IPV. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.

Correlates of Transitions Into Housing Instability Among Veterans Accessing Veterans Health Administration Health Care.

BACKGROUND: Prior research has explored the patterns and dynamics of homelessness; such an understanding is necessary to improve policy and programmatic responses and prevent new episodes of housing instability. OBJECTIVES: The objectives of this study are to identify correlates of veterans' transitions into housing instability and inform initiatives aimed to address their needs, with a focus on how to prevent new episodes of housing instability. METHODS: The cohort for this study includes 4,633,069 veterans who responded to the Veterans Health Administration's universal screen for housing instability at least twice between October 1, 2012, and September 30, 2016; 1.2% reported recent housing instability and 98.8% reported ongoing housing stability. The χ or Fisher exact tests, as appropriate, compared veterans' characteristics by housing status. A multivariate logistic regression identified independent risk factors associated with recent housing instability, controlling for sociodemographic, military service, diagnostic, and health services use variables. RESULTS: Sociodemographic and health services use variables increased veterans' odds of transitioning into housing instability. The diagnoses with the greatest effect sizes were drug use disorder (adjusted odds ratio=1.50, 95% confidence interval: 1.45-1.55) and opioid use disorder, which was associated with a >2-fold increase in the odds of experiencing recent housing instability (adjusted odds ratio=2.22, 95% confidence interval: 2.04-2.41). CONCLUSIONS: The present study provides evidence to inform existing and future interventions to prevent new episodes of housing instability. Veterans with opioid use disorder were at greatest risk of becoming unstably housed; increasing access to medication-assisted treatment in homeless-focused services is needed.

Mitigating loss of health insurance and means tested benefits in an unconditional cash transfer experiment: Implementation lessons from Stockton's guaranteed income pilot.

•Cash transfers, universal basic income, and guaranteed income have re-emerged as potential solutions to income volatility.•Methods used in Stockton's guaranteed income experiment, are testing how GI can exist alongside existing safety net benefits.•A multi-tiered approach to mitigating potential means tested benefits loss is both effective and ethically sound.

The intersection of interpersonal violence and housing instability: Perspectives from women veterans.

Women veterans in the United States face a disproportionate risk of housing instability (HI) and interpersonal violence (IV), largely perpetrated by intimate partners or involving nonpartner sexual violence, compared to both male veterans and nonveteran women. To explore the ways in which IV and HI intersect in the experiences of women veterans, we analyzed transcripts of in-depth qualitative interviews with 20 women veterans who had screened positive for HI at a Veterans Affairs Medical Center. Three broad themes emerged related to the intersection of IV (specifically intimate partner violence or nonpartner sexual violence) and HI among women veterans: (1) HI can be precipitated by and increase vulnerability to IV, (2) experiences of IV impact women's definitions of housing safety and security, and (3) IV can pose a barrier to accessing housing services and other support systems. Findings indicate areas for improvement to screening processes and service provision to more effectively address the co-occurring and interacting safety and housing needs of women veterans. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Veterans' assignment to single-site versus scattered-site permanent supportive housing.

To address homelessness among Veterans, a growing proportion of permanent supportive housing units supported by the U.S. Departments of Housing and Urban Development and Veterans Affairs Supportive Housing (HUD-VASH) program are allocated to programs where multiple Veterans with a history of homelessness live in a particular building, referred to as single-site housing. This mixed-methods study-including administrative data from Veterans who moved into HUD-VASH housing and qualitative data from focus groups with services providers at 10 single-site programs-describes the characteristics and needs of Veterans who moved into single-site HUD-VASH programs, the rationale for developing single-site HUD-VASH programs, and the services provided in single-site programs that are responsive to Veterans' needs. Based on quantitative analyses, Veterans who were older and had chronic medical and mental health conditions and sought related care were at increased odds of receiving single-site housing. Qualitatively, we found that HUD-VASH programs developed single-site programs for two reasons: to ensure that the most vulnerable Veterans remained housed through the provision of supportive services and to increase housing options for hard-to-house Veterans, including those who require more support because of medical, mental health, or substance use disorders; physical disabilities; or lack of ability to live independently for other reasons. Due to the high needs of Veterans served by single-site programs, development of these programs should consider both space and staffing needs. Future research should assess the relationship between assignment to housing type and health and housing outcomes for participants as well as service enhancements to address Veterans' needs. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Making Connections: Understanding How Screening, Triage, and Referral Processes Can Promote Veteran Housing Stability.

To improve understanding of the screening, triage, and referral processes within social determinant of health-Electronic Medical Record (EMR) integration, we explored how Veterans connect with needed resources following screening for housing instability using three data sources: administrative Homelessness Screening Clinical Reminder (HSCR) data, administrative Supportive Services for Veterans Families (SSVF) data, and chart review data. The cohort included Veterans who had responded to the HSCR in the 90 days prior to presenting for SSVF services between October 2012 and 2015 (N = 134); chart reviews were abstracted for a sample (n = 53). Most Veterans who presented for SSVF services had screened negative for housing instability (68.7%) on the HSCR, yet chart abstractions demonstrated that more than half connected to triage assistance prior to seeking services irrespective of their screening outcome. Future screening efforts should consider the role of the person administering the screening instrument and critical areas for assessment.

Women's Participation in Research on Intimate Partner Violence: Findings on Recruitment, Retention, and Participants' Experiences.

BACKGROUND: Research on intimate partner violence (IPV) faces unique challenges to recruitment and retention. Little is known about successful strategies for recruiting and retaining in research women who have experienced IPV, and their experiences of research participation. PURPOSE: This article presents findings on recruitment, retention, and research participation experiences from a longitudinal observational study of IPV among women receiving care through the Veterans Health Administration. METHODS: Administrative tracking data were analyzed to identify strengths, challenges, and outcomes of multiple recruitment strategies for an observational study of women patients who had experienced past-year IPV. Qualitative interviews with a purposively selected subset of the larger sample were used to identify motivations for and experiences of study participation. RESULTS: Of the total sample (N = 169), 92.3% were recruited via direct outreach by the research team (63.3% via letter, 29.0% in person), compared with provider or patient self-referral (3.6% and 4.1%, respectively); 88% returned for a follow-up assessment. In qualitative interviews (n = 50), participants expressed a desire to help others as a primary motivation for study participation. Although some participants experienced emotional strain during or after study visits, they also expressed perceiving value in sharing their experiences, and several participants found the experience personally beneficial. Participants expressed that disclosure was facilitated by interviewers' empathic and neutral stance, as well as the relative anonymity and time-limited nature of the research relationship. CONCLUSIONS: Direct outreach to women Veterans Health Administration patients to participate in research interviews about IPV experience was feasible and effective, and proved more fruitful for recruitment than reliance on provider or patient self-referral. Women who have experienced IPV may welcome opportunities to contribute to improvements in care through participation in interviews.

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.

Recent Intimate Partner Violence and Housing Instability Among Women Veterans.

INTRODUCTION: Women Veterans are at increased risk of both housing instability and intimate partner violence compared with their non-Veteran counterparts. The objectives of the present study were (1) to assess the relationship between women Veterans' experience of intimate partner violence and various indicators of housing instability, and (2) to assess what correlates help to explain experiences of housing instability among women Veterans who experienced past-year intimate partner violence. METHODS: Data were collected from U.S. Department of Veterans Affairs electronic medical records for 8,427 women Veterans who were screened for past-year intimate partner violence between April 2014 and April 2016 at 13 Veterans Affairs' facilities. Logistic regressions performed during 2017 assessed the relationship between past-year intimate partner violence and housing instability. RESULTS: A total of 8.4% of the sample screened positive for intimate partner violence and 11.3% for housing instability. Controlling for age and race, a positive intimate partner violence screen increased odds of housing instability by a factor of 3. Women Veterans with past-year intimate partner violence were more likely to have an indicator of housing instability if they identified as African American, had screened positive for military sexual trauma, or had a substance use disorder; receiving compensation for a disability incurred during military service and being married were protective. CONCLUSIONS: For women Veterans, intimate partner violence interventions should assess for both physical and psychological housing needs, and housing interventions should coordinate with intimate partner violence programs to address common barriers to resources.

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.

Supporting veterans' transitions from permanent supportive housing.

OBJECTIVES: Little research has assessed the nature of veterans' departures from permanent supportive housing (PSH), which may be of positive valence (e.g., moving into more independent housing). This study aimed to identify participants appropriate for "graduation" from PSH and how to support their transitions. METHOD: This mixed methods study used qualitative data from PSH program staff, 445 PSH participants' responses to a survey assessing their experiences and administrative records, and qualitative data from a subsample of 10 participants who graduated from the program. Participants were classified as "stayers" (retained in PSH for at least 600 days); "graduates" (exited with improvement in community integration); or "involuntary leavers" (exited for reasons of negative valence). Template analysis of qualitative data from PSH staff described graduation processes; qualitative data from participants were analyzed using a thematic analysis approach. The study compared veterans' characteristics using chi-square and analysis of variance (ANOVA) tests; a multinomial logistic regression assessed correlates of graduates' and involuntary leavers' exits from PSH. RESULTS: Approximately one half of participants who exited the program were graduates. Processes used by program staff to identify potential graduates varied. Participants' self-report of substance use and mental health problems was associated with involuntary leaver status. Frequency of case management, a trusting relationship between participant and case manager, and participants' receipt of compensation related to disability incurred during military service were associated with graduation. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: To support successful transitions from PSH, programs should focus on providing high-quality case management that may respond flexibly to participants' varying recovery needs. (PsycINFO Database Record

Pathways into homelessness among post-9/11-era veterans.

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

Examining the bidirectional association between veteran homelessness and incarceration within the context of permanent supportive housing.

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