Invited Commentary: Data Sources for Estimating Numbers of People Experiencing Homelessness in the United States-Strengths and Limitations.

In the accompanying article, Mosites et al. (Am J Epidemiol. 2021;190(11):2432-2436) evaluate data sources that enumerate people experiencing homelessness in the United States with respect to their strengths and limitations for conducting epidemiologic research in homeless populations. We largely agree with their key arguments, yet offer additional points that provide important context about these data for researchers and other stakeholders. Overall, we believe that it is possible to address many of the noted shortcomings of these data, and once addressed, the data could be more effectively leveraged to improve the health, housing stability, and quality of life of people experiencing homelessness.

Rates and Predictors of Returns to Homelessness Among Veterans, 2018-2022.

INTRODUCTION: The progress made by the U.S. Department of Veterans Affairs toward ending veteran homelessness requires that attention be paid to preventing returns to homelessness. METHODS: Using national Veterans Affairs data on 293,820 exits from a Veterans Affairs homeless program to a permanent housing destination between January 2018 and December 2022, rates and predictors of returns to homelessness among veterans were examined. Analyses were conducted in June-August 2023. A return to homelessness was operationally defined as a return encounter with a Veterans Affairs homeless program. RESULTS: A total of 5.8% of successful exits to permanent housing resulted in a return to homelessness within 6 months, 10.2% resulted in a return within 12 months, and 16.7% resulted in a return within 24 months. In the total sample, veterans who were male (hazard ratio=1.47), were widowed (hazard ratio=1.29), had diagnoses of drug use disorder (hazard ratio=1.40) or psychotic disorder (hazard ratio=1.20), and had used more inpatient or urgent care services in the previous year (hazard ratio=1.05-1.15) were at significantly greater risk of returning to homelessness. Many of these predictors remained significant in subgroup analyses of female veterans, veterans aged ≥65 years, and veterans in the Housing and Urban Development-Veterans Affairs Supportive Housing program. CONCLUSIONS: Most homeless veterans served by Veterans Affairs who exit to permanent housing do not return to homelessness within two years. The most critical period seems to be the first year, when 1 in 10 veterans return to homelessness. Knowledge of these risk factors may be important in planning secondary and tertiary prevention efforts for 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.

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.

Capturing the Dynamics of Homelessness Through Ethnography and Mobile Technology: Protocol for the Development and Testing of a Smartphone Technology-Supported Intervention.

BACKGROUND: US military veterans who have experienced homelessness often have high rates of housing transition. Disruptions caused by these transitions likely exacerbate this population's health problems and interfere with access to care and treatment engagement. Individuals experiencing homelessness increasingly use smartphones, contributing to improved access to medical and social services. Few studies have used smartphones as a data collection tool to systematically collect information about the daily life events that precede and contribute to housing transitions, in-the-moment emotions, behaviors, geographic movements, and perceived social support. OBJECTIVE: The study aims to develop and test a smartphone app to collect longitudinal data from veterans experiencing homelessness (VEH) and to evaluate the feasibility and acceptability of using the app in a population that is unstably housed or homeless. METHODS: This study's design had 3 phases. Phase 1 used ethnographic methods to capture detailed data on day-to-day lived experiences of up to 30 VEH on topics such as housing stability, health, and health behaviors. Phase 2 involved focus groups and usability testing to develop and refine mobile phone data collection methods. Phase 3 piloted the smartphone mobile data collection with 30 VEH. We included mobile ethnography, real-time surveys through an app, and the collection of GPS data in phase 3. RESULTS: The project was launched in June 2020, and at this point, some data collection and analysis for phases 1 and 2 are complete. This project is currently in progress. CONCLUSIONS: This multiphase study will provide rich data on the context and immediate events leading to housing transitions among VEH. This study will ensure the development of a smartphone app that will match the actual needs of VEH by involving them in the design process from the beginning. Finally, this study will offer important insights into how best to develop a smartphone app that can help intervene among VEH to reduce housing transitions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/53022.

Universal screening for homelessness and risk for homelessness in the Veterans Health Administration.

We examined data for all veterans who completed the Veterans Health Administration's national homelessness screening instrument between October 1, 2012, and January 10, 2013. Among veterans who were not engaged with the US Department of Veterans Affairs homeless system and presented for primary care services, the prevalence of recent housing instability or homelessness was 0.9% and homelessness risk was 1.2%. Future research will refine outreach strategies, targeting of prevention resources, and development of novel interventions.

Community-level characteristics associated with variation in rates of homelessness among families and single adults.

OBJECTIVES: We modeled rates of family and single-adult homelessness in the United States in metropolitan and nonmetropolitan regions and as a function of community-level demographic, behavioral, health, economic, and safety net characteristics. METHODS: We entered community-level characteristics and US Department of Housing and Urban Development point-in-time counts for a single night in January 2009 into separate mixed-effects statistical analyses that modeled homelessness rates for 4 subpopulations: families and single adults in metropolitan and nonmetropolitan regions. RESULTS: Community-level factors accounted for 25% to 50% of the variance in homelessness rates across models. In metropolitan regions, alcohol consumption, social support, and several economic indicators were uniquely associated with family homelessness, and drug use and homicide were uniquely associated with single-adult homelessness. In nonmetropolitan regions, life expectancy, religious adherence, unemployment, and rent burden were uniquely associated with family homelessness, and health care access, crime, several economic indicators, and receipt of Supplemental Security Income were uniquely associated with single-adult homelessness. CONCLUSIONS: Considering homeless families and single adults separately enabled more precise modeling of associations between homelessness rates and community-level characteristics, indicating targets for interventions to reduce homelessness among these subpopulations.

Temporary Financial Assistance Decreased Health Care Costs For Veterans Experiencing Housing Instability.

Compared with housed people, those experiencing homelessness have longer and more expensive inpatient stays as well as more frequent emergency department visits. Efforts to provide stable housing situations for people experiencing homelessness could reduce health care costs. Through the Supportive Services for Veteran Families program, the Department of Veterans Affairs partners with community organizations to provide temporary financial assistance to veterans who are currently homeless or at imminent risk of becoming homeless. We examined the impact of temporary financial assistance on health care costs for veterans in the Supportive Services for Veteran Families program and found that, on average, people receiving the assistance incurred $352 lower health care costs per quarter than those who did not receive the assistance. These results can inform national policy debates regarding the proper solution to housing instability.

Association of Temporary Financial Assistance With Housing Stability Among US Veterans in the Supportive Services for Veteran Families Program.

Importance: Temporary financial assistance (TFA) for housing-related expenses is a key component of interventions to prevent homelessness or to quickly house those who have become homeless. Through the US Department of Veterans Affairs (VA) Supportive Services for Veteran Families (SSVF) program, the department provides TFA to veterans in need of housing assistance. Objective: To assess the association between TFA and housing stability among US veterans enrolled in the SSVF program. Design, Setting, and Participants: This retrospective cohort study analyzed data on veterans who were enrolled in the SSVF program at 1 of 203 partner organizations in 49 US states and territories. Some veterans had repeat SSVF episodes, but only the first episodes were included in this analysis. An episode was defined as the period between entry into and exit from the program occurring between October 1, 2015, and September 30, 2018. Exposures: Receipt of TFA. Main Outcomes and Measures: The main outcome was stable housing, defined as permanent, independent residence with payment by the program client or housing subsidy after exit from the SSVF program. Covariates included demographic characteristics, monthly income and source, public benefits, health insurance, use of other VA programs for homelessness, comorbidities, and geographic location. Multivariable mixed-effects logistic regression, inverse probability of treatment weighting, and instrumental variable approaches were used. Results: The overall cohort consisted of 41 969 veterans enrolled in the SSVF program, of whom 29 184 (mean [SD] age, 50.4 [12.9] years; 25 396 men [87.0%]) received TFA and 12 785 (mean [SD] age, 50.0 [13.3] years; 11 229 men [87.8%]) did not receive TFA. The mean (SD) duration of SSVF episodes was 90.5 (57.7) days. A total of 69.5% of SSVF episodes involved receipt of TFA, and the mean (SD) amount of TFA was $6070 ($7272). Stable housing was obtained in 81.4% of the episodes. Compared with those who did not receive TFA, veterans who received TFA were significantly more likely to have stable housing outcomes (risk difference, 0.253; 95% CI, 0.240-0.265). An association between the amount of TFA received and stable housing was also found, with risk differences ranging from 0.168 (95% CI, 0.149-0.188) for those who received $0 to $2000 in TFA to 0.226 (95% CI, 0.203-0.249) for those who received more than $2000 to $4000 in TFA. Conclusions and Relevance: This study found that receipt of TFA through the SSVF program was associated with increased rates of stable housing. These results may inform national policy debates regarding the optimal solutions to prevent and reduce housing instability.

National Utilization Patterns of Veterans Affairs Homelessness Programs in the Era of Housing First.

OBJECTIVE: Although Housing First is the primary service model for housing chronically homeless adults, the Department of Veterans Affairs (VA) serves a heterogeneous population of homeless veterans and operates a continuum of models. This study examined longitudinally how various VA homelessness programs are used by type, timing, and sequence to identify utilization patterns and associated client characteristics. METHODS: Nationally linked administrative data from seven VA homelessness programs for 15,260 veterans who newly entered any VA homelessness program in 2015 and were followed for 2 years were analyzed with an innovative sequence and cluster analytic approach. RESULTS: The analysis found five main profiles: brief program use (59% of total sample), permanent supported housing plus (21%), heavy multiple program use (3%), transitional housing use (6%), and rapid rehousing program use (10%). The transitional housing use profile had the lowest proportion of women, and the brief use profile had the highest proportion of white veterans. Veterans in the supported housing plus profile used the most VA general medical and mental health services and were most likely to be in permanent housing by the end of the study period, although, notably, over 40% of veterans in the other profiles, except for the heavy multiple-use profile, were also in permanent housing by the end of the study. CONCLUSIONS: Findings suggest that the VA's continuum of housing models is providing veterans who have diverse needs with an array of pathways for recovery. However, additional attention and research are needed for veterans in the heavy multiple program use profile.

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

Cost of health care utilization among homeless frequent emergency department users.

Research demonstrates that homelessness is associated with frequent use of emergency department (ED) services, yet prior studies have not adequately examined the relationship between frequent ED use and utilization of non-ED health care services among those experiencing homelessness. There has also been little effort to assess heterogeneity among homeless individuals who make frequent use of ED services. To address these gaps, the present study used Medicaid claims data from 2010 to estimate the association between the number of ED visits and non-ED health care costs for a cohort of 6,338 Boston Health Care for the Homeless Program patients, and to identify distinct subgroups of persons in this cohort who made frequent use of ED services based on their clinical and demographic characteristics. A series of gamma regression models found more frequent ED use to be associated with higher non-ED costs, even after adjusting for demographic and clinical characteristics. Latent class analysis was used to examine heterogeneity among frequent ED users, and the results identified 6 characteristically distinct subgroups among these persons. The subgroup of persons with trimorbid illness had non-ED costs that far exceeded members of all 5 other subgroups. Study findings reinforce the connection between frequent ED use and high health care costs among homeless individuals and suggest that different groups of homeless frequent ED users may benefit from interventions that vary in terms of their composition and intensity. (PsycINFO Database Record

Characteristics and Likelihood of Ongoing Homelessness Among Unsheltered Veterans.

INTRODUCTION: Unsheltered homelessness is an important phenomenon yet difficult to study due to lack of data. The Veterans Health Administration administers a universal homelessness screener, which identifies housing status for Veterans screening positive for homelessness. METHODS: This study compared unsheltered and sheltered Veterans, assessed differences in rates of ongoing homelessness, and estimated a mixed-effect logistic regression model to examine the relationship between housing status and ongoing homelessness. RESULTS: Eleven percent of Veterans who screened positive for homelessness were unsheltered; 40% of those who rescreened were homeless six months later, compared with less than 20% of sheltered Veterans. Unsheltered Veterans were 2.7 times as likely to experience ongoing homelessness. DISCUSSION: Unsheltered Veterans differ from their sheltered counterparts-they are older, more likely to be male, less likely to have income-and may be good candidates for an intensive housing intervention. Future research will assess clinical characteristics and services utilization among this population.

Services utilization among recently homeless veterans: a gender-based comparison.

OBJECTIVE: As women emerge as a significant segment of the Veteran population, there is a need to understand how they enter the homeless system, the impact of homelessness on healthcare, and how this varies by gender. METHODS: This study provides a gender-based comparison of Veterans' utilization of U.S. Department of Veterans Affairs (VA) health and behavioral health services following the onset of a homeless episode and assesses the relationship between services utilization and Veterans' entry into the homeless system. RESULTS: Male and female veterans were equally as likely to use mainstream and VA homeless services. There were few differences between genders in inpatient services use following a homeless episode. Men used more substance abuse outpatient treatment and emergency services whereas women used outpatient medical treatment. Veterans who sought non-VA homeless services were less likely to use outpatient services but more likely to access emergency services. CONCLUSION: Veterans experiencing homelessness who do not use VA homeless assistance services are less engaged with preventative VA health and behavioral healthcare. Veterans who are homeless but not identified as such by VA, particularly women, need additional engagement. Ongoing study of gender-based differences in services utilization among homeless and at-risk Veterans is needed.