Obesity in U.S. low-income veterans:Prevalence, clinical characteristics, and homelessness.

OBJECTIVE: Obesity is associated with lower socioeconomic status. To date, however, scarce research has examined the prevalence, comorbidity, and incremental burden of obesity in relation to medical, psychiatric, functional, and homelessness measures among low-income veterans. METHODS: A nationally representative sample of 1004 low-income U.S. veterans was examined. Bivariate and multivariable analyses were conducted to assess relationships between obesity and medical and psychiatric comorbidities, functioning, and homelessness measures. RESULTS: The prevalence estimate of obesity among low-income U.S. veterans was 38.2% (confidence interval (CI): 34.2; 42.2), which is higher than previously reported for the general U.S. veteran population. It was particularly high among young, females with children. Obesity was associated with co-occurring medical (chronic pain, diabetes, sleep disorders, high blood pressure, heart disease) and psychiatric (trauma- and anxiety-related) conditions, poor functioning, and current psychiatric medication use. Veterans with obesity were less likely to have current savings and more likely to have current debt. They also were more likely to have experienced evictions and foreclosures and less likely to use active coping or positive reframing as a means of dealing with stressful situations. CONCLUSION: The prevalence of obesity among U.S. veterans is high. Specific demographic groups particularly vulnerable to developing obesity warrant targeted interventions. Modifying weight management programs, understanding coping styles, and assessing, monitoring, and treating obesity in low-income veterans may help improve overall health and quality of life in multiple domains.

Functional significance of posttraumatic growth in U.S. military veterans.

BACKGROUND: Although many studies indicate that individuals who have experienced a traumatic event can experience posttraumatic growth (PTG), some researchers have questioned the significance of PTG in associations with functioning. The role of PTG in functioning following trauma may be better elucidated by accounting for its joint effects with posttraumatic stress disorder (PTSD) symptoms. METHODS: Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 3847 trauma-exposed U.S. veterans. Participants completed assessments of potentially traumatic events, PTSD symptoms, and PTG, as well as a broad range of sociodemographic, military, trauma, health, personality, and psychosocial characteristics. RESULTS: PTG was independently and moderately associated with higher mental, cognitive, and psychosocial functioning, but not physical functioning. Results showed a similar pattern of findings when examining relations between subdomains of PTG and these aspects of functioning. Additionally, among veterans who screened positive for PTSD, those who endorsed PTG reported higher levels of mental, cognitive, and/or psychosocial functioning than those who did not endorse PTG. LIMITATIONS: Findings may be limited by the use of a cross-sectional design, retrospective self-reports of PTG, and a predominantly older white male veteran sample. CONCLUSION: Results provide support for the functional significance of PTG and highlight the importance of considering PTSD symptoms to better understand the role of PTG in functioning. Clinical interventions to foster PTG may help promote post-trauma functioning.

Suicide risk screening and evaluation among patients accessing VHA services and identified as being newly homeless.

OBJECTIVE: To evaluate universal suicide risk screening and evaluation processes among newly homeless Veterans. STUDY SETTING: Not applicable. STUDY DESIGN: Examination of Veterans Health Administration (VHA) using newly homeless patients' health record data in Calendar Year 2021. DATA COLLECTION: Not applicable. DATA SOURCE: Health record data. PRINCIPAL FINDINGS: Most patients received suicide risk screening and/or evaluation in the year prior to and/or following homeless identification (n = 49,505; 87.4%). Smaller percentages of patients were screened and/or evaluated in close proximity to identification (n = 7358; 16.0%), 1-30 days prior to identification (n = 12,840; 39.6%), or 1-30 days following identification (n = 14,263; 34.3%). Common settings for screening included primary care, emergency and urgent care, and mental health services. Of positive screens (i.e., potentially elevated risk for suicide), 72.6% had a Comprehensive Suicide Risk Evaluation (CSRE) completed in a timely manner (i.e., same day or within 24 h). Age, race, and sex were largely unrelated to screening and/or evaluation. CONCLUSIONS: Although many newly identified homeless patients were screened and/or evaluated for suicide risk, approximately 13% were not screened; and 27% of positive screens did not receive a timely CSRE. Continued efforts are warranted to facilitate suicide risk identification to ensure homeless patients have access to evidence-based interventions.

Legal Services for Veterans (LSV): Protocol for evaluating the grant-based LSV initiative supporting community organizations' delivery of legal services to veterans.

BACKGROUND: 1.8 million Veterans are estimated to need legal services, such as for housing eviction prevention, discharge upgrades, and state and federal Veterans benefits. While having one's legal needs met is known to improve one's health and its social determinants, many Veterans' legal needs remain unmet. Public Law 116-315 enacted in 2021 authorizes VA to fund legal services for Veterans (LSV) by awarding grants to legal service providers including nonprofit organizations and law schools' legal assistance programs. This congressionally mandated LSV initiative will award grants to about 75 competitively selected entities providing legal services. This paper describes the protocol for evaluating the initiative. The evaluation will fulfill congressional reporting requirements, and inform continued implementation and sustainment of LSV over time. METHODS: Our protocol calls for a prospective, mixed-methods observational study with a repeated measures design, aligning to the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) and Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) frameworks. In 2023, competitively selected legal services-providing organizations will be awarded grants to implement LSV. The primary outcome will be the number of Veterans served by LSV in the 12 months after the awarding of the grant. The evaluation has three Aims. Aim 1 will focus on measuring primary and secondary LSV implementation outcomes aligned to RE-AIM. Aim 2 will apply the mixed quantitative-qualitative Matrixed Multiple Case Study method to identify patterns in implementation barriers, enablers, and other i-PARIHS-aligned factors that relate to observed outcomes. Aim 3 involves a mixed-methods economic evaluation to understand the costs and benefits of LSV implementation. DISCUSSION: The LSV initiative is a new program that VA is implementing to help Veterans who need legal assistance. To optimize ongoing and future implementation of this program, it is important to rigorously evaluate LSV's outcomes, barriers and enablers, and costs and benefits. We have outlined the protocol for such an evaluation, which will lead to recommending strategies and resource allocation for VA's LSV implementation.

Increased Medicare payments for homeless patients provide new opportunities for care.

A final rule has been issued that increases Medicare fee-for-service payment rates for individuals experiencing homelessness. This rule provides new, incentivized opportunities to better screen for and document homelessness among patients in acute inpatient settings. With greater identification of homeless patients, there may be increased needs to develop comprehensive discharge plans that involve coordination with housing providers and social service agencies to prevent the high repeated use of acute care found among many homeless patients.

Evaluation of a collaborative model between managed care and affordable housing on acute care costs.

OBJECTIVES: This study evaluated a collaborative service model between the largest Medicaid managed care organization (MCO) in Texas, Superior HealthPlan, and the affordable housing provider Prospera Housing Community Services. STUDY DESIGN: Using a quasi-experimental 2-groups research design, we compared health care outcomes and costs between a sample of 104 participants served by the Prospera+Superior collaborative model and a group of 104 participants who had health care coverage through the Superior HealthPlan Medicaid MCO but did not live at Prospera properties (ie, Superior-only group). METHODS: Data from medical claims were analyzed to examine change in outcomes 12 months before and after implementation of the Prospera+Superior collaborative model in 2019. RESULTS: The Prospera+Superior group had a 56% lower rate of emergency department/urgent care visits and spent $2061 less in prescription costs than the Superior-only group after implementation. CONCLUSIONS: These findings provide needed evidence of the clinical and economic value of forming multisector collaborative models between MCOs and other community providers.

Links of Previous Incarceration with Geriatric Syndromes and Chronic Health Conditions Among Older Adults in the United States.

BACKGROUND: This study investigated the association between previous incarceration and various geriatric and chronic health conditions among adults 50 and older in the United States. METHODS: Data came from the National Longitudinal Study of Adolescent to Adult Health - Parent Study (AHPS) collected in 2015-2017, including 2,007 individuals who participated in the parent study (Parent Sample) and 976 individuals who participated in the spouse/partner study (Spouse/Partner Sample). Multiple logistic regression was used to investigate the relationship between previous incarceration and geriatric syndromes (dementia, difficulty walking, difficulty seeing, difficulty with activities of daily living) and chronic health conditions (self-reported poor/fair health, diagnosis of cancer, hypertension, diabetes, heart disease, stroke, chronic lung disease, depression, and alcohol use [4 or more drinks per week]). RESULTS: In adjusted analyses, respondents with previous incarceration in the AHPS had significantly higher odds of reporting difficulty walking, activities of daily living difficulty, cancer diagnosis, depression diagnosis, and chronic lung disease (aORs= 2.21-2.95). Respondents in the AHPS spouse/partner study reported higher odds of difficulty seeing, cancer, depression, chronic lung disease, and heavy alcohol use (aORs= 1.02-2.15). CONCLUSIONS: Previous incarceration may have an adverse impact on healthy aging. Findings highlight the importance of addressing the enduring health impacts of incarceration, particularly as individuals transition into older adulthood.

Prior Incarceration and Performance on Immediate and Delayed Verbal Recall Tests: Results from National Longitudinal Study of Adolescent to Adult Health - Parent Study.

OBJECTIVE: This study aimed to investigate the cognitive functioning of formerly incarcerated older adults compared to their never-incarcerated counterparts, focusing on immediate and delayed verbal recall. METHODS: Data are from 2,003 respondents who participated in the National Longitudinal Study of Adolescent to Adult Health - Parent Study (AHPS) (ages 47-82; mean age 62). AHPS participants were administered word recall memory exercises to the parent respondent from the Rey Auditory-Verbal administered Learning Test, including (a) 90-second (immediate or short-term verbal memory), (b) 60-second recall tests (delayed or long-term verbal memory), and (c) combined word recall on the 90- and 60-second tests. RESULTS: Adjusting for control variables, respondents who reported prior incarceration had a lower rate of verbal recall on the combined word recall (Incidence risk ratio [IRR] = .915, 95% Confidence Interval [CI] = .840, .997) and immediate word recall (IRR = .902, 95% CI = .817, .996). When restricting the sample to respondents over age 60, prior incarceration was associated with lower combined word recall (IRR = .847, 95% CI = .752, .954), immediate word recall (IRR = .857, 95% CI = .762, .963), and delayed word recall (IRR = .834, 95% CI = .713, .974). DISCUSSION: This study underscores the adverse impact of prior incarceration on cognitive functioning in the older adult population, emphasizing the need for targeted interventions and support for formerly incarcerated older adults. The results reinforce the importance of addressing the long-term consequences of incarceration, especially as individuals enter older adulthood.

Patterns of Psychiatric Medication Prescriptions for Veterans in Treatment Courts and Other Specialty Courts.

Psychiatric medications can serve as important tools for addressing behavioral health issues among criminal justice-involved (CJI) veterans. This study used national data on 12,790 CJI veterans in the U.S. Department of Veterans Affairs (VA) Veterans Justice Outreach program from 2019 to 2020 to compare patterns of psychiatric medication prescriptions among veterans who entered a veterans treatment court (n = 6975), another specialty court (SC; n = 414), or no-SC (n = 5401). Different classes of medications were examined, including antidepressants, stimulants, antipsychotics, benzodiazepines, and medications for substance use disorders. The results showed that 60.2% of the total sample was prescribed a psychiatric medication within 1 year of entering the Veterans Justice Outreach program. There was no significant difference in overall psychiatric prescribing among veterans treatment court, other SC, and no-SC groups, but there were a few differences in certain classes of psychiatric medications. Moreover, about 7.8% of veterans who were in the no-SC group and were prescribed psychiatric medications did not have a psychiatric diagnosis. Veterans who were younger, non-Hispanic white, married, with a VA service-connected disability rating, had a diagnosis of mental and/or substance use disorder, and used more VA health care services were more likely to have been prescribed psychiatric medication. Together, these findings illustrate the essential role of psychiatric medications in courts and programs that serve CJI veterans, as well as the important link between VA service engagement and psychiatric prescriptions.

The Use of Mobile Medical Units for Populations Experiencing Homelessness in the United States: A Scoping Review.

With annual point-in-time counts indicating a rise in unsheltered homelessness in the United States, much attention has been paid to how to best provide care to this population. Mobile medical units (MMUs) have been utilized by many programs. However, little is known regarding the evidence behind their effectiveness. A scoping review is conducted of research on MMU provision of medical services for populations experiencing homelessness in the USA to examine the extent and nature of research activity, summarize available evidence, and identify research gaps in the existing literature. Following guidelines for scoping reviews, PubMed and Google Scholar were used to identify an initial 294 papers published from January 1, 1980, to May 1, 2023, using selected keywords, which were distilled to a final set of 50 studies that met eligibility criteria. Eligible articles were defined as those that pertain to the provision of healthcare (inclusive of dental, vision, and specialty services) to populations experiencing homelessness through a MMU in the United States and have been published after peer review. Of the 50 studies in the review, the majority utilized descriptive (40%) or observational methods (36%), with 4 review and 8 controlled studies and no completed randomized controlled trials. Outcome measures utilized by studies include MMU services provided (58%), patient demographics (34%), health outcomes (16%), patient-centered measures (14%), healthcare utilization (10%) and cost analysis (6%). The studies that exist suggest MMUs can facilitate effective treatment of substance use disorders, provision of primary care, and services for severe mental illness among people experiencing homelessness. MMUs have potential to provide community-based healthcare services in settings where homeless populations reside, but the paucity of randomized controlled trials indicates further research is needed to understand if MMUs are more effective than other care delivery models tailored to populations experiencing homelessness.

Temporary Financial Assistance Reduced The Probability Of Unstable Housing Among Veterans For More Than 1 Year.

The Department of Veterans Affairs (VA) aims to reduce homelessness among veterans through programs such as Supportive Services for Veteran Families (SSVF). An important component of SSVF is temporary financial assistance. Previous research has demonstrated the effectiveness of temporary financial assistance in reducing short-term housing instability, but studies have not examined its long-term effect on housing outcomes. Using data from the VA's electronic health record system, we analyzed the effect of temporary financial assistance on veterans' housing instability for three years after entry into SSVF. We extracted housing outcomes from clinical notes, using natural language processing, and compared the probability of unstable housing among veterans who did and did not receive temporary financial assistance. We found that temporary financial assistance rapidly reduced the probability of unstable housing, but the effect attenuated after forty-five days. Our findings suggest that to maintain long-term housing stability for veterans who have exited SSVF, additional interventions may be needed.

Systematic Review of Financial Interventions for Adults Experiencing Behavioral Health Conditions.

OBJECTIVE: The authors reviewed the literature on finance-based interventions used to improve clinical and psychosocial outcomes among adults experiencing mental disorders, substance use disorders, or both. METHODS: A systematic review of the peer-reviewed literature, published from 1900 to 2022, was conducted. Only studies with participants with a mental disorder or a substance use disorder, a structured finance-based intervention or program, a quantitative dependent variable in a behavioral health outcomes domain, and a defined research design were included. Studies were rated with a quality assessment tool, and overall evidence (levels I-VII) for the outcomes was rated. RESULTS: In total, 544 articles were identified, screened for eligibility, and reduced to 55 articles. These articles were rated by two independent raters, and 18 articles were ultimately included. Of these 18 articles, four reported findings of randomized controlled trials (RCTs), one conducted a secondary analysis of an RCT, and the remaining articles were observational studies. The most studied intervention was representative payeeship, which reduced substance use and enhanced money management, showing the strongest evidence for improving outcomes among adults with behavioral health conditions. Weaker evidence suggested that financial education and assistance interventions could improve health care utilization and other psychosocial outcomes among individuals with mental or substance use disorders. CONCLUSIONS: Level II-V evidence indicates that finance-based interventions can improve outcomes among adults experiencing behavioral health conditions. Further research is needed to assess the impact of interventions beyond representative payee programs on objectively measured outcomes.

Growing Concern About Unsheltered Homelessness Among Veterans: Clinical Characteristics and Engagement in Health Care Services.

OBJECTIVES: Veteran homelessness has declined in the past decade, but the proportion of unsheltered homeless veterans has increased. We identified characteristics of unsheltered homelessness in a large contemporary veteran cohort and examined outpatient and inpatient encounters before and after intake to US Department of Veterans Affairs (VA) homeless programs. METHODS: National data from the Homeless Operations Management Evaluation System (HOMES) database and the Corporate Data Warehouse were analyzed on 191 204 veterans experiencing housing instability from January 2018 through December 2021. We used hierarchical multivariate logistic regressions to model associations between sheltered status and veteran correlates. Repeated-measures analysis of variance assessed changes in care utilization after intake in homeless programs. RESULTS: Age <50 years (odds ratio [OR] = 1.3; 95% CI, 1.2-1.4), Hispanic ethnicity (OR = 1.2; 95% CI, 1.1-1.3), some college education (OR = 1.1; 95% CI, 1.0-1.1), and a bachelor's degree (OR = 1.2; 95% CI, 1.1-1.2) were associated with veteran unsheltered homelessness. Unsheltered veterans were more likely to have a VA service-connected disability (OR = 1.4; 95% CI, 1.4-1.5), military sexual trauma (OR = 1.1; 95% CI, 1.0-1.1), and/or combat exposure (OR = 1.1; 95% CI, 1.0-1.1). Unsheltered and sheltered homeless veterans had an increase in outpatient encounters and a decrease in inpatient care after intake to the VA homeless program. CONCLUSIONS: Contemporary unsheltered homeless veterans are younger and Hispanic with some college education. Innovative public health approaches that better engage and reduce barriers to entry need to be tested for a diverse unsheltered homeless population.

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.

Family member incarceration and loneliness among low-income U.S. veterans.

Exposure to incarceration can have significant ramifications for one's social relationships. However, the study of how the incarceration of a family member influences loneliness, including among specific segments of the population that experience elevated levels of loneliness, such as U.S. military veterans, has gone understudied. This study aimed to examine the relationship between family member incarceration and perceptions of loneliness among a sample of low-income U.S. military veterans. Data are from the National Veteran Homeless and Other Poverty Experiences Study-a national survey of low-income U.S. veterans collected in December 2022 and January 2023. Multiple Poisson is used to assess the relationship between family member incarceration and a loneliness index, and multinomial logistic regression was used to estimate the relationship with specific constructs in the loneliness index. The results indicate that respondents who ever experienced the incarceration of a family member reported significantly more loneliness (incidence risk ratio = 1.189, 95% CI [1.035, 1.366]). Further, analyses of the specific items in the loneliness index revealed that family member incarceration was related to an increased risk of reporting feelings of often lacking companionship (relative risk ratio = 1.598, 95% CI [1.077, 2.370]) and often feeling isolated from others (1.711, 95% CI [1.014, 2.886]). Given the potential adverse consequences of loneliness and family member incarceration for well-being, the results from this study emphasize the need for increased attention and coordinated approaches in addressing feelings of loneliness, developing efforts to mitigate the harms of family member incarceration within the U.S. veteran community. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Use and Interest in Virtual Reality for Mental and Physical Health in a U.S. Population-Based Sample of Low-Income Veterans.

Virtual reality (VR) represents a new way to deliver health interventions, but research is needed on experience and interest in using VR for health among important subgroups in the United States. This descriptive study examined these issues among low-income veterans in the United States. Data were analyzed from a nationally representative sample of 1,028 low-income veterans surveyed in late 2022-early 2023. The results showed that while only 10 percent of the sample had ever used a VR headset, 35 percent of veterans reported they would be "somewhat/very willing" to use VR for mental health or substance use problems. Veterans with higher levels of education (adjusted odds ratio [aOR] = 1.25, 95% confidence interval [CI] = 1.07-1.47), lower mental health functioning (aOR = 0.96, 95% CI = 0.94-0.98), and previous VR experience (aOR = 5.30, 95% CI = 2.96-9.48) were significantly more willing to use VR to treat their mental health or substance use problems. These findings suggest many veterans are willing to use VR to improve their mental health, and they could benefit from greater exposure and education about VR-based interventions.

Sustained mental health and functional responses to the COVID-19 pandemic in Black and White Veterans with psychosis or recent homelessness.

The COVID-19 pandemic disproportionately impacted marginalized populations including Black Americans, people with serious mental illness, and individuals experiencing homelessness. Although the double disadvantage hypothesis would suggest that individuals with multiple minoritized statuses would experience worse psychosocial impacts from the pandemic, this may not be the case for vulnerable Black Veterans. The present study investigated the sustained mental health and functional responses to the pandemic in Black and White Veterans with psychosis or recent homelessness and in a control group of Veterans enrolled in the Department of Veterans Affairs healthcare services. Clinical interviews and questionnaires were administered remotely by telephone at five time points from May 2020 through July 2021, including a retrospective time point for March 2020 (i.e., before the pandemic started). Overall, there was a striking absence of systematic differences by race in the trajectories of psychiatric symptoms and functioning among Veterans during the study period. These findings are consistent with a report on initial responses to the pandemic that revealed only a few select differences by race among Veteran groups. The lack of racial disparities is inconsistent with the double disadvantage hypothesis. Although further investigation is needed, one possible interpretation is that the wrap-around services offered by the Veterans Health Administration may have mitigated expected differences by race among Veterans with psychosis or homelessness. Future research should continue to examine whether VA services mitigate disparities in mental health and psychosocial outcomes.