Generalizing the Value of Ongoing Assessments of Suicidal Ideation or Behavior for Estimating the Risk of Subsequent Suicide Attempts.

In analyses conducted for program planning, the Veterans Health Administration evaluated associations between self-reports of suicidal ideation and behavior using the Columbia Scale obtained on two occasions separated by three months and clinical or administrative records of suicide attempts over the subsequent three months., Combining information from the two assessments improved prediction of suicidal behavior and found that risk was greater when ideation was reported on both assessments, than when it was first reported at follow-up. The absence of reported ideation at the second assessment was not associated with a clinically relevant reduction in risk. These findings confirm recent reports from the Mental Health Research Network (MHRN).

Using patient-reported outcome measures for program evaluation: Design and findings on intention-to-treat outcomes from the Veterans Outcome Assessment survey.

The Veterans Outcomes Assessment (VOA) program surveys Veteran Health Administration (VHA) patients when they begin mental health treatment and at follow-up at three months to obtain patient-reported outcomes measures (PROM). It complements VA's evolving program in measurement-based care by providing additional data that can be useful for program evaluation including assessments of patients who have not been seen for ongoing mental health care. In principle, it provides data on intention-to-treat outcomes for program evaluation to complement the outcomes for patients who are receiving ongoing treatment that can be derived from measurement-based care. VOA findings confirm differences in outcomes between patients who have continued to be seen for treatment and those who have not. Patients in general mental health clinics with no encounters between the baseline and follow-up assessments who reported discontinuing care because they did not want or need treatment improved more, and those who discontinued due to problems improved less than those who remained in treatment. Experience with VOA has identified a number of issues that must be addressed before it is possible to use intention-to-treat outcomes for program evaluation.

Use of the Columbia-Suicide Severity Rating Scale (C-SSRS) in a large sample of Veterans receiving mental health services in the Veterans Health Administration.

OBJECTIVE: To evaluate the associations of self-reports of suicidal ideation and behavior using the Columbia-Suicide Severity Rating Scale (C-SSRS) in a survey of patients receiving mental health services in the Veterans Health Administration (VHA) with reports of attempts documented in medical records and administrative data. METHOD: The C-SSRS was administered to 15,373 Veterans in the Veterans Outcome Assessment (VOA) survey. Concurrent validity was evaluated by comparing self-reports from the past 3 months with VHA records. Predictive validity was evaluated by logistic regression models using attempts over the subsequent 3 months as the outcome. RESULTS: Tests of concurrent validity found strong associations between self-reports and attempts documented in VHA records, but there were substantial numbers of discordant responses. In tests of predictive validity, area under the ROC curve for predicting future attempts was >0.8. There were differences in the distribution of responses and of psychometric properties across VHA mental health programs. CONCLUSIONS: Findings support the value of screening and the validity of the self-reports based on the C-SSRS, but limitations in concordance with medical records and variability across programs suggest the need for clinical judgment in interpreting responses.

A National Study of Veterans Treatment Court Participants: Who Benefits and Who Recidivates.

Although there are now over 400 veterans treatment courts (VTCs) in the country, there have been few studies on participant outcomes in functional domains. Using national data on 7931 veterans in the Veterans Affairs (VA) Veterans Justice Outreach program across 115 VA sites who entered a VTC from 2011 to 2015, we examined the housing, employment, income, and criminal justice outcomes of VTC participants; and identified veteran characteristics predictive of outcomes. VTC participants spent an average of nearly a year in the program and 14% experienced a new incarceration. From program admission to exit, 10% more participants were in their own housing, 12% more were receiving VA benefits, but only 1% more were employed. Controlling for background characteristics, a history of incarceration predicted poor criminal justice, housing, and employment outcomes. Participants with property offenses or probation/parole violations and those with substance use disorders were more likely to experience a new incarceration. Participants with more mental health problems were more likely to be receiving VA benefits and less likely to be employed at program exit. Together, these findings highlight the importance of proper substance abuse treatment as well as employment services for VTC participants so that they can benefit from the diversion process.

Diversion of Veterans With Criminal Justice Involvement to Treatment Courts: Participant Characteristics and Outcomes.

OBJECTIVE: This study compared characteristics and outcomes between veterans who participated in veterans treatment courts (VTCs) and veterans involved in criminal justice who participated in other treatment courts (TCs) or who participated in neither VTCs or TCs. METHODS: Data from 22,708 veterans (N=8,083 VTC participants, 680 participants in other TCs [other-TC participants], and 13,945 participants in neither VTCs nor TCs [non-TC participants]) in the Veterans Justice Outreach (VJO) program were analyzed by using multilevel regression models. RESULTS: VTC participants were more likely than other VJO participants to have served in Iraq or Afghanistan, but there were no sociodemographic disparities in access to VTCs. VTC participants were more likely than non-TC participants to have drug or public-order offenses, and they were more likely than other-TC participants to have DUI offenses. VTC participants had better independent housing outcomes than other VJO participants, and they had better employment outcomes than non-TC participants. However, VTC and other-TC participants were also more likely to have jail sanctions and new incarcerations compared with non-TC participants. CONCLUSIONS: VTCs are a growing service model that serves a broad group of veterans with a range of criminal offenses. Although VTCs show moderate benefits in housing and employment, specialized services are needed to reduce recidivism and maximize these benefits.

Impact of Supported Housing on Social Relationships Among Homeless Veterans.

OBJECTIVE: This study examined social network structure and function among a sample of 460 homeless veterans who participated in an experimental trial of the Housing and Urban Development-Veterans Affairs Supported Housing (HUD-VASH) program. METHODS: Participants were randomly assigned to HUD-VASH (housing subsidies and case management), case management only, or standard care. Mixed-model longitudinal analysis was used to compare treatment groups on social network outcomes over 18 months. RESULTS: Veterans in HUD-VASH reported significantly greater increases in social support than veterans in the two other groups, as well as greater frequency of contacts, availability of tangible and emotional support, and satisfaction with nonkin relationships over time. These gains largely involved relationships with providers and other veterans encountered in treatment. CONCLUSIONS: Supported housing may play a pivotal role in fostering constructive new relationships with persons associated with service programs but may have a more limited impact on natural support networks.

A 20-Site Comparison of Transition-in-Place Versus Traditional Transitional Housing Programs.

Transition-in-Place (TIP) is a housing model being piloted in the veterans affairs transitional housing program, Grant & Per Diem (GPD). This observational 20-site study compares characteristics and outcomes of 488 clients in TIP and 10,388 clients in traditional GPD programs. TIP participants were younger, better educated, healthier, and reported higher employment income than traditional GPD participants. Adjusting for these differences, TIP participants were more likely to have their own housing and reported higher employment and public support income at program exit, although the differences were small. These results inform use of the TIP model as a public health intervention.

Homeless Veterans Eligible for Medicaid Under the Affordable Care Act.

OBJECTIVE: Among homeless veterans and those at risk of homelessness currently enrolled in Veterans Affairs (VA) health care, this study examined the proportion likely to become eligible for Medicaid in 2014 and their health needs. METHODS: A total of 114,497 homeless and at-risk veterans were categorized into three groups: currently covered by Medicaid, likely to become eligible for Medicaid, and not likely. RESULTS: Seventy-eight percent of the sample was determined to be likely to become eligible for Medicaid in states that expand Medicaid. Compared with veterans not likely to become eligible for Medicaid, those likely to become eligible were less likely to have general medical and psychiatric conditions and to have a VA service-connected disability but more likely to have substance use disorders. CONCLUSIONS: Programs serving homeless and at-risk veterans should anticipate the potential interplay between VA health care and the expansion of Medicaid in states that implement the expansion.

Characteristics and Use of Services Among Literally Homeless and Unstably Housed U.S. Veterans With Custody of Minor Children.

OBJECTIVE: The study examined the number of homeless veterans with minor children in their custody ("children in custody"), compared sociodemographic and clinical characteristics among homeless veterans with and without children in custody, and observed differences in referral and admission patterns among veterans with and without children in custody for a variety of U.S. Department of Veterans Affairs (VA) programs for homeless veterans. METHODS: Data were obtained from the VA Homeless Operations Management and Evaluation System for 89,142 literally homeless and unstably housed veterans. Sociodemographic, housing, health, and psychosocial characteristics of veterans were analyzed. RESULTS: Among literally homeless veterans, 9% of men and 30% of women had children in custody; among unstably housed veterans, 18% of men and 45% of women had children in custody. Both male and female veterans with children in custody were younger and less likely to have chronic general medical conditions and psychiatric disorders compared with other veterans, but, notably, 11% of homeless veterans with children in custody had psychotic disorders. Veterans with children in custody were more likely than other veterans to be referred and admitted to the VA's permanent supported housing program, and women were more likely than men to be admitted to the program. CONCLUSIONS: A substantial proportion of homeless veterans served by the VA have severe mental illness and children in custody, which raises concerns about the parenting environment for their children. Particular focus should be directed at VA's supported-housing program, and the practical and ethical implications of serving homeless parents and their children need to be considered.

Street outreach and other forms of engagement with literally homeless veterans.

Street outreach is one of the most direct methods of engaging homeless individuals, but the characteristics of those most likely to be engaged this way is not well-understood. Data from the Department of Veterans Affairs (VA) Homeless Operations Management and Evaluation System showed that of the 70,778 literally homeless veterans engaged in VA homeless services in 2011-2012, 12% were through street outreach while the majority was through provider referrals (41%) and self-referrals (28%). Veterans engaged through street outreach had more extensive histories of recent homelessness, were more likely to be chronically homeless, and were more likely to be referred and admitted to the VA's supported housing program than other veterans. These findings suggest street outreach is an especially important approach to engaging chronic street homeless veterans in services and linking them to permanent supported housing.

National comparison of literally homeless male and female VA service users: entry characteristics, clinical needs, and service patterns.

BACKGROUND: Although there are growing numbers of homeless female U.S. veterans, the U.S. Department of Veterans Affairs (VA) has traditionally served a predominantly male population; thus, it is important to examine differences between homeless female and male veterans in their service needs and the current provision of VA homeless services. METHODS: A national registry of 119,947 users of VA homeless services from 2011 to 2012 was used to 1) estimate the proportion of female veterans among VA homeless service users, 2) examine the proportion of VA homeless service users who are literally homeless by gender, and 3) report differences between female and male VA homeless service users who are literally homeless on sociodemographic and clinical characteristics, as well as on outreach, referral, and admission patterns for an array of specialized VA services. FINDINGS: Of VA homeless service users, 8% were female compared with 7% among all homeless veterans, 6% among all VA service users, and 7% among all veterans. Of female VA homeless service users, 54% were literally homeless, slightly fewer than the 59% of male VA homeless service users. Comparing literally homeless VA service users, females were younger, 21% more had dependent children, 8% more were diagnosed with non-military-related posttraumatic stress disorder, and 19% to 20% more were referred and admitted to VA's supported housing program than males. CONCLUSIONS: Female veterans use VA homeless services at a rate similar to their use of general VA services and they have unique needs, especially for child care, which may require additional specialized resources.

Alcohol and drug use disorders among homeless veterans: prevalence and association with supported housing outcomes.

This study examines the prevalence of alcohol and drug disorders among homeless veterans entering the Housing and Urban Development-Veterans Affairs Supported Housing (HUD-VASH) program and its association with both housing and clinical outcomes. A total of 29,143 homeless veterans were categorized as either having: no substance use disorder, only an alcohol use disorder, only a drug use disorder, or both alcohol and drug use disorders. Veterans were compared on housing and clinical status prior to admission to HUD-VASH and a smaller sample of 14,086 HUD-VASH clients were compared on their outcomes 6 months after program entry. Prior to HUD-VASH, 60% of program entrants had a substance use disorder and 54% of those with a substance use disorder had both alcohol and drug use disorders. Homeless veterans with both alcohol and drug use disorders had more extensive homeless histories than others, and those with any substance use disorder stayed more nights in transitional housing or residential treatment in the previous month. After six months in HUD-VASH, clients with substance use disorders continued to report more problems with substance use, even after adjusting for baseline differences, but there were no differences in housing outcomes. These findings suggest that despite strong associations between substance use disorders and homelessness, the HUD-VASH program is able to successfully house homeless veterans with substance use disorders although additional services may be needed to address their substance abuse after they become housed.

Homelessness in a national sample of incarcerated veterans in state and federal prisons.

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

Latent homeless risk profiles of a national sample of homeless veterans and their relation to program referral and admission patterns.

OBJECTIVES: We identified risk and need profiles of homeless veterans and examined the relation between profiles and referrals and admissions to Department of Veterans Affairs (VA) homeless service programs. METHODS: We examined data from the VA's new Homeless Operations Management and Evaluation System on 120,852 veterans from 142 sites nationally in 2011 and 2012 using latent class analyses based on 9 homeless risk factors. The final 4-class solution compared both referral and admission to VA homeless services. RESULTS: We identified 4 latent classes: relatively few problems, dual diagnosis, poverty-substance abuse-incarceration, and disabling medical problems. Homeless veterans in the first group were more likely to be admitted to the VA's permanent supportive housing program, whereas those in the second group were more likely to be admitted to more restrictive VA residential treatment. Homeless veterans in the third group were more likely to be admitted to the VA's prisoner re-entry program, and those in the fourth group were more likely to be directed to VA medical services. CONCLUSIONS: The heterogeneous risk and need profiles of homeless veterans supported the diversity of VA homeless services and encouraged the development of specialized services to meet their diverse needs.

The impact of current alcohol and drug use on outcomes among homeless veterans entering supported housing.

Permanent supported housing has increasingly been identified as a central approach to helping homeless individuals with disabilities exit from homelessness. Given that one third or more of homeless individuals actively use substances, it is important to determine the extent to which individuals who report using alcohol and/or drugs at the time of housing benefit from such programs. The current study examines data from the evaluation of the United States Department of Housing and Urban Development-Veterans Affairs (HUD-VA) Supported Housing (HUD-VASH) program to determine differences in housing and clinical outcomes among participants with two different levels of active alcohol or drug use at time of housing entry. Whereas veterans with 1-15 days of active use and 15-30 days of active use had significantly more days homeless than abstainers, albeit with small effect sizes (.06 and .19, respectively), there were no significant differences in days housed or days in institutions. Interaction analysis suggests that the highest frequency substance users who spent time in residential treatment prior to housing had the poorest housing outcomes, while those who were not in residential treatment had outcomes comparable to abstainers. Although active substance users clearly benefit from supportive housing with small differences in outcomes from abstainers, high frequency substance users who were admitted to residential treatment before housing placement, may be an especially vulnerable population.

Risk of incarceration and clinical characteristics of incarcerated veterans by race/ethnicity.

PURPOSE: Unprecedented growth in the US prison population has highlighted the overrepresentation of racial/ethnic minorities in prisons. This study examined the hypothesis that veteran status is protective against incarceration for veterans of different racial/ethnic minorities and compared the clinical characteristics of incarcerated veterans by race/ethnicity. METHODS: Using national data from a prisoner re-entry program and data from the 2010 National Survey of Veterans, this study examined the risk of incarceration among veterans who were racial/ethnic minorities and compared sociodemographic and clinical characteristics to White incarcerated veterans. RESULTS: Of a sample of 30,834 incarcerated veterans, 52 % were White, 39 % African American, 7 % Hispanic, and 2 % were categorized as "Other." African American veterans were 5.6 times and Hispanic veterans 4.3 times more likely to be incarcerated than White veterans across age groups. However, the published odds of being incarcerated as an African American in the general population compared to Whites (6.7 times) is higher, suggesting that veteran status may be somewhat protective against incarceration for African Americans, particularly among certain age groups. Among incarcerated veterans, multivariate analyses found that African American veterans were significantly more likely to have a drug/abuse dependency diagnosis and be currently incarcerated for a drug offense than Whites. Hispanic veterans were significantly more likely to be chronically homeless and also more likely to be incarcerated for a drug offense. CONCLUSIONS: Racial/ethnic differences in incarceration persist among veterans, although are slightly attenuated. Efforts to connect incarcerated veterans with mental health services post-release should be supported, especially in connecting veterans to substance abuse treatment.

Differential impact of supported housing on selected subgroups of homeless veterans with substance abuse histories.

OBJECTIVE: Studies have demonstrated that supported housing is an effective intervention for individuals who are homeless and have a mental illness or substance use disorder. This study examined data from an experimental trial of the U.S. Department of Housing and Urban Development-Veterans Affairs Supported Housing (HUD-VASH) program to identify differences in the program's impact on subgroups defined by sociodemographic or clinical characteristics. METHODS: Data were analyzed from 259 male homeless veterans with substance abuse problems who were randomly assigned to HUD-VASH (intensive case management [ICM] plus rent subsidy vouchers), ICM only, or treatment as usual between June 1992 and December 1995. Four subgroups were defined: African American versus Caucasian, younger versus older than 42.3 years, co-occurring diagnoses of mental illness versus diagnosis of a substance use disorder only, and active versus less active substance use upon program entry. Mixed models were used to identify significant interactions between HUD-VASH assignment and each subgroup. RESULTS: Compared with ICM alone, HUD-VASH was associated with more positive housing outcomes for Caucasians, veterans with co-occurring mental disorders, and veterans who were active substance users. HUD-VASH was associated with more positive socioclinical outcomes for African Americans. No differences were observed in housing or socioclinical outcomes as a function of age. CONCLUSIONS: Among homeless veterans with a substance use disorder, Caucasians and those with active substance use showed greater housing benefits than other veterans from HUD-VASH than from ICM alone. African Americans showed greater socioclinical benefit than Caucasians from HUD-VASH versus ICM. Interaction analysis deserves further study.

Sobriety as an admission criterion for transitional housing: a multi-site comparison of programs with a sobriety requirement to programs with no sobriety requirement.

BACKGROUND: This study examined whether homeless clients enrolled in transitional housing programs that required sobriety (SR) as an admission criterion have outcomes comparable to clients enrolled in programs that did not require sobriety (NSR) as an admission criterion. METHODS: A total of 1062 military veterans in 40 transitional housing programs funded by the United States Department of Veterans Affairs were grouped based on whether they were in SR or NSR programs and followed over a one-year period after program discharge. Participants in SR and NSR programs were compared on their ratings of the social climate of the program, and housing and psychosocial outcomes. RESULTS: Participants in SR programs reported more days housed and better psychosocial outcomes than participants in NSR programs, although the differences were small and there were no differences in ratings of their social climate. Both participants in SR and NSR programs showed improvements on most outcomes after discharge from transitional housing. There were no significant differences in outcomes between participants actively abusing substances at program entry compared to those who were not. CONCLUSIONS: Requiring sobriety as an admission criterion in transitional housing made only a small difference in housing outcomes post-discharge. Further study is needed to determine whether requiring sobriety at admission in transitional housing is necessary for successful client outcomes.

Do faith-based residential care services affect the religious faith and clinical outcomes of homeless veterans?

Data on 1,271 clients in three residential care services funded by the Department of Veterans Affairs was used to examine: (1) how religious-oriented programs differ in their social environment from secular programs, (2) how religious-oriented programs affect the religiosity of clients, and (3) how client religiosity is associated with outcomes. Programs were categorized as: secular, secular now but religious in the past, and currently religiously oriented. Results showed (1) participants in programs that were currently religious reported the greatest program clarity, but secular services reported the most supportive environments; (2) participants in programs that were currently religious did not report increases in religious faith or religious participation over time; nevertheless (3) greater religious participation was associated with greater improvement in housing, mental health, substance abuse, and quality of life. These findings suggest religious-oriented programs have little influence on clients' religious faith, but more religiously oriented clients have somewhat superior outcomes.

Factors related to rapidity of housing placement in Housing and Urban Development-Department of Veterans Affairs Supportive Housing program of 1990s.

The Housing and Urban Development-Department of Veterans Affairs Supportive Housing (HUD-VASH) program is the largest supported housing program in the country for homeless veterans who are seeking rapid entry into permanent independent housing. This study examined factors related to how rapidly clients were housed in the early years of the program and how long they stayed in the program. Mental health, substance abuse, work/income, criminal history, and site were examined as predictors of process times. Regression analyses based on 627 HUD-VASH clients who entered the program between 1992 and 2003 showed that client characteristics were not rate-limiting factors for obtaining HUD-VASH housing; i.e., clients who had greater substance abuse problems or more extensive criminal histories did not take longer to obtain housing. The large differences associated with site of entry partly reflected a curvilinear relationship between the duration of operation of the HUD-VASH program and process times; i.e., at relatively younger and older programs, clients entered housing slightly faster than at programs in the middle range. Lastly, HUD-VASH clients whose case managers reported good therapeutic alliances stayed in the program longer. These findings have implications for the continued expansion of the HUD-VASH program.