Predicting Homelessness Among Transitioning U.S. Army Soldiers.

INTRODUCTION: This study develops a practical method to triage Army transitioning service members (TSMs) at highest risk of homelessness to target a preventive intervention. METHODS: The sample included 4,790 soldiers from the Study to Assess Risk and Resilience in Servicemembers-Longitudinal Study (STARRS-LS) who participated in 1 of 3 Army STARRS 2011-2014 baseline surveys followed by the third wave of the STARRS-LS online panel surveys (2020-2022). Two machine learning models were trained: a Stage-1 model that used administrative predictors and geospatial data available for all TSMs at discharge to identify high-risk TSMs for initial outreach; and a Stage-2 model estimated in the high-risk subsample that used self-reported survey data to help determine highest risk based on additional information collected from high-risk TSMs once they are contacted. The outcome in both models was homelessness within 12 months after leaving active service. RESULTS: Twelve-month prevalence of post-transition homelessness was 5.0% (SE=0.5). The Stage-1 model identified 30% of high-risk TSMs who accounted for 52% of homelessness. The Stage-2 model identified 10% of all TSMs (i.e., 33% of high-risk TSMs) who accounted for 35% of all homelessness (i.e., 63% of the homeless among high-risk TSMs). CONCLUSIONS: Machine learning can help target outreach and assessment of TSMs for homeless prevention interventions.

Gender Differences in Connecting Veterans to Care Through the Veterans Crisis Line: A Mixed Methods Evaluation of Referrals to Suicide Prevention Coordinators.

BACKGROUND: Suicide is a major public health crisis within the US military veteran community, with distinct gender differences in suicide risk and behavior. The Veterans Crisis Line (VCL) is a component of the Veterans Health Administration (VHA) suicide prevention program; through VCL, veterans may be referred to a VHA Suicide Prevention Coordinator (SPC) to arrange follow-up care. Research shows that engagement with an SPC is a strong protective factor in reducing veteran suicide risk. METHODS: We evaluated SPC referral acceptance and assessed correlates of SPC referral decline using VCL administrative data for contacts: (1) made between January 1, 2018, through December 31, 2019; (2) by veterans contacting VCL on their own behalf; (3) with gender identified; and (4) current thoughts of suicide. Then, among a subsample of 200 veterans, evenly distributed by gender, we examined data from call synopsis notes to identify reasons given for veterans declining an SPC referral. RESULTS: We found it was generally callers rated as lower risk by responders, and callers with loneliness as a reason for contacting VCL, who more frequently declined the SPC referral. An analysis of reasons given for declining SPC referral found that concerns with/about Veterans Affairs care were a key concern, particularly among women veterans articulating specific negative care experiences. Other reasons for referral decline included managing the veteran's needs directly on the call or via alternative resources. CONCLUSION: The VCL as an intervention provides an important opportunity to re-engage vulnerable veterans into care, one that may be more challenging for women veterans.

Sensitivity of health records for self-reported nonfatal drug and alcohol overdose.

BACKGROUND AND OBJECTIVES: Public health surveillance for overdose sometimes depends on nonfatal drug overdoses recorded in health records. However, the proportion of total overdoses identified through health record systems is unclear. Comparison of overdoses from health records to those that are self-reported may provide insight on the proportion of nonfatal overdoses that are not identified. METHODS: We conducted a cohort study linking survey data on overdose from a national survey of Veterans to United States Department of Veterans Affairs (VA) health records, including community care paid for by VA. Self-reported overdose in the prior 3 years was compared to diagnostic codes for overdoses and substance use disorders in the same time period. RESULTS: The sensitivity of diagnostic codes for overdose, compared to self-report as a reference standard for this analysis, varied by substance: 28.1% for alcohol, 23.1% for sedatives, 12.0% for opioids, and 5.5% for cocaine. There was a notable concordance between substance use disorder diagnoses and self-reported overdose (sensitivity range 17.9%-90.6%). DISCUSSION AND CONCLUSIONS: Diagnostic codes in health records may not identify a substantial proportion of drug overdoses. A health record diagnosis of substance use disorder may offer a stronger inference regarding the size of the population at risk. Alternatively, screening for self-reported overdose in routine clinical care could enhance overdose surveillance and targeted intervention. SCIENTIFIC SIGNIFICANCE: This study suggests that diagnostic codes for overdose are insensitive. These findings support consideration of alternative approaches to overdose surveillance in public health.

Comparison of Patient Experience Between Primary Care Settings Tailored for Homeless Clientele and Mainstream Care Settings.

BACKGROUND: More than 1 million Americans receive primary care from federal homeless health care programs yearly. Vulnerabilities that can make care challenging include pain, addiction, psychological distress, and a lack of shelter. Research on the effectiveness of tailoring services for this population is limited. OBJECTIVE: The aim was to examine whether homeless-tailored primary care programs offer a superior patient experience compared with nontailored ("mainstream") programs overall, and for highly vulnerable patients. RESEARCH DESIGN: National patient survey comparing 26 US Department of Veterans Affairs (VA) Medical Centers' homeless-tailored primary care ("H-PACT"s) to mainstream primary care ("mainstream PACT"s) at the same locations. PARTICIPANTS: A total of 5766 homeless-experienced veterans. MEASURES: Primary care experience on 4 scales: Patient-Clinician Relationship, Cooperation, Accessibility/Coordination, and Homeless-Specific Needs. Mean scores (range: 1-4) were calculated and dichotomized as unfavorable versus not. We counted key vulnerabilities (chronic pain, unsheltered homelessness, severe psychological distress, and history of overdose, 0-4), and categorized homeless-experienced veterans as having fewer (≤1) and more (≥2) vulnerabilities. RESULTS: H-PACTs outscored mainstream PACTs on all scales (all P<0.001). Unfavorable care experiences were more common in mainstream PACTs compared with H-PACTs, with adjusted risk differences of 11.9% (95% CI=6.3-17.4), 12.6% (6.2-19.1), 11.7% (6.0-17.3), and 12.6% (6.2-19.1) for Relationship, Cooperation, Access/Coordination, and Homeless-Specific Needs, respectively. For the Relationship and Cooperation scales, H-PACTs were associated with a greater reduction in unfavorable experience for patients with ≥2 vulnerabilities versus ≤1 (interaction P<0.0001). CONCLUSIONS: Organizations that offer primary care for persons experiencing homelessness can improve the primary care experience by tailoring the design and delivery of services.

Gender Differences in the Predictors of Suicide-related Morbidity Among Veterans Reporting Current Housing Instability.

BACKGROUND: Veterans experiencing housing instability are at increased risk of suicide. Research is needed to identify gender differences in the predictors of both suicidal ideation and suicide attempt, particularly among Veterans who are unstably housed. OBJECTIVES: The objective of the present study was to explore whether correlates of suicide-related morbidity among unstably housed Veterans vary by gender and identify implications for improved care for these Veterans. METHODS: The study cohort included 86,325 Veterans who reported current housing instability between October 1, 2013, and September 30, 2016. This cross-sectional study assessed differences in demographic and outcome variables by gender using χ2 analyses and a series of multiple logistic regressions predicting suicidal ideation and suicide attempt, stratified by gender. RESULTS: Among unstably housed female Veterans, being younger than 40 years was associated with more than double the odds of having an indicator of suicidal ideation and >12 times the odds of having an indicator of a suicide attempt. The effect sizes associated with age were much less pronounced among unstably housed male Veterans. The presence of mental health and substance use conditions as well as a positive screen for military sexual trauma were associated with increased risk of suicide morbidity among both women and men. CONCLUSIONS: Intervention and prevention among unstably housed Veterans may be complicated by unpredictable living situations; further research should explore tailored interventions to address the complex needs of unstably housed Veterans and how suicide prevention can be woven throughout.

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.

Housing Instability Characteristics Among Transgender Veterans Cared for in the Veterans Health Administration, 2013-2016.

Objectives. To characterize housing instability among transgender veterans using Veterans Health Administration (VHA) health care in the United States.Methods. We used administrative data on veterans screened for housing instability from 2013 to 2016; participants included 5717 transgender veterans and 17 133 cisgender veterans. We defined housing instability by a positive screen or VHA Homeless Program use. We identified gender from medical records, reflecting either birth sex or gender identity. We identified transgender identity through transgender-related International Classification of Diseases, Ninth Revision and Tenth Revision codes. A multiple logistic regression assessed the association of transgender identity with housing instability.Results. Prevalence of housing instability was nearly 3 times higher among transgender veterans than among cisgender veterans (19.9% vs 6.7%; P < .001). The difference persisted when we adjusted for sociodemographics (adjusted odds ratio = 2.32; 95% confidence interval = 2.09, 2.57). Transgender veterans experiencing housing instability were more likely than cisgender veterans to be women, younger, unmarried, and White.Conclusions. Transgender veterans experience housing instability more frequently than do cisgender veterans. An increased focus on transgender identity is critical for reducing veteran homelessness.

Services Receipt Following Veteran Outpatients' Positive Screen for Homelessness.

INTRODUCTION: The Veterans Health Administration seeks to reduce homelessness among Veterans by identifying, and providing prevention and supportive services to, patients with housing concerns. The objectives of this study were to assess the proportion of Veterans Health Administration patients who received homeless or social work services within 6 months of a positive screen for homelessness or risk in the Veterans Health Administration and the demographic and clinical characteristics that predicted services utilization. METHODS: Data were from a cohort of 27,403 Veteran outpatients who screened positive for homelessness or risk between November 1, 2012 and January 31, 2013. During 2013, AORs were calculated using a mixed-effects logistic regression to estimate the likelihood of patients' receipt of VHA homeless or social work services based on demographic and clinical characteristics. RESULTS: The majority of patients received services within 6 months post-screening; predictors of services utilization varied by gender. Among women, diagnosis of drug abuse and psychosis predicted receipt of services, being unmarried increased the odds of using services among those screening positive for homelessness, and a diagnosis of post-traumatic stress disorder increased the odds of receiving services for at-risk women. Among men, being younger, unmarried, not service-connected/Medicaid-eligible, and having a medical or behavioral health condition predicted receipt of services. CONCLUSIONS: Receipt of housing support services among Veterans post-homelessness screening differs by patient demographic and clinical characteristics. Future research should investigate the role that primary and secondary prevention interventions play in Veterans' resolution of risk for homelessness and experience of homelessness.