Differential Risk for Homelessness among US Male and Female Veterans with a Positive Screen for Military Sexual Trauma

IMPORTANCE:

Military sexual trauma (MST) is associated with adverse physical and mental health outcomes following military separation. Recent research suggests that MST may be a determinant in several factors associated with post deployment homelessness.

OBJECTIVE:

To evaluate MST as an independent risk factor for homelessness and to determine whether risk varies by sex.

DESIGN, SETTING, AND PARTICIPANTS:

A retrospective cohort study of US veterans who used Veterans Health Administration (VHA) services between fiscal years 2004 and 2013 was conducted using administrative data from the Department of Defense and VHA. Included in the study were 601 892 US veterans deployed in Iraq or Afghanistan who separated from the military between fiscal years 2001 and 2011 and subsequently used VHA services.

EXPOSURE:

Positive response to screen for MST administered in VHA facilities.

MAIN OUTCOMES AND MEASURES:

Administrative evidence of homelessness within 30 days, 1 year, and 5 years following the first VHA encounter after last deployment.

RESULTS:

The mean (SD) age of the 601 892 participants was 38.9 (9.4) years, 527 874 (87.7%) were male, 310 854 (51.6%) were white, and 382 361 (63.5%) were enlisted in the Army. Among veterans with a positive screen for MST, rates of homelessness were 1.6% within 30 days, 4.4% within 1 year, and 9.6% within 5 years, more than double the rates of veterans with a negative MST screen (0.7%, 1.8%, and 4.3%, respectively). A positive screen for MST was significantly and independently associated with postdeployment homelessness. In regression models adjusted for demographic and military service characteristics, odds of experiencing homelessness were higher among those who screened positive for MST compared with those who screened negative (30-day: adjusted odds ratio [AOR], 1.89; 95% CI, 1.58-2.24; 1-year: AOR, 2.27; 95% CI, 2.04-2.53; and 5-year: AOR, 2.63; 95% CI, 2.36-2.93). Military sexual trauma screen status remained independently associated with homelessness after adjusting for co-occurring mental health and substance abuse diagnoses in follow-up regression models (30-day: AOR, 1.62; 95% CI, 1.36-1.93; 1-year: AOR, 1.49; 95% CI, 1.33-1.66; and 5-year: AOR, 1.39; 95% CI, 1.24-1.55). In the fully adjusted models, the interaction between MST status and sex was significant in the 30-day and 1-year cohorts (30-day: AOR, 1.54; 95% CI, 1.18-2.02; and 1-year: AOR, 1.46; 95% CI, 1.23-1.74), denoting higher risk for homelessness among males with a positive screen for MST.

CONCLUSIONS AND RELEVANCE:

A positive screen for MST was independently associated with postdeployment homelessness, with male veterans at greater risk than female veterans. These results underscore the importance of the MST screen as a clinically important marker of reintegration outcomes among veterans. These findings demonstrate significant long-term negative effects and inform our understanding of the public health implications of sexual abuse and harassment.

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By:  Brignone E1, Gundlapalli AV2, Blais RK1, Carter ME2, Suo Y2, Samore MH2, Kimerling R3, Fargo JD1.

• 1Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah 2Department of Psychology, Utah State University, Logan.
• 2Informatics, Decision Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah3Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City4Department of Biomedical Informatics, Univer.
• 3National Center for PTSD, VA Palo Alto Health Care System, Palo Alto, California6Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, California.
• JAMA Psychiatry. 2016 Apr 20. doi: 10.1001/jamapsychiatry.2016.0101. 

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Tailoring Care to Vulnerable Populations by Incorporating Social Determinants of Health: The Veterans Health Administration's "Homeless Patient Aligned Care Team" Program

INTRODUCTION:

Although the clinical consequences of homelessness are well described, less is known about the role for health care systems in improving clinical and social outcomes for the homeless. We described the national implementation of a "homeless medical home" initiative in the Veterans Health Administration (VHA) and correlated patient health outcomes with characteristics of high-performing sites.

METHODS:

We conducted an observational study of 33 VHA facilities with homeless medical homes and patient- aligned care teams that served more than 14,000 patients. We correlated site-specific health care performance data for the 3,543 homeless veterans enrolled in the program from October 2013 through March 2014, including those receiving ambulatory or acute health care services during the 6 months prior to enrollment in our study and 6 months post-enrollment with corresponding survey data on the Homeless Patient Aligned Care Team (H-PACT) program implementation. We defined high performance as high rates of ambulatory care and reduced use of acute care services.

RESULTS:

More than 96% of VHA patients enrolled in these programs were concurrently receiving VHA homeless services. Of the 33 sites studied, 82% provided hygiene care (on-site showers, hygiene kits, and laundry), 76% provided transportation, and 55% had an on-site clothes pantry; 42% had a food pantry and provided on-site meals or other food assistance. Six-month patterns of acute-care use pre-enrollment and post-enrollment for 3,543 consecutively enrolled patients showed a 19.0% reduction in emergency department use and a 34.7% reduction in hospitalizations. Three features were significantly associated with high performance: 1) higher staffing ratios than other sites, 1) integration of social supports and social services into clinical care, and 3) outreach to and integration with community agencies.

CONCLUSION:

Integrating social determinants of health into clinical care can be effective for high-risk homeless veterans.

Below:  Homeless-patient aligned care team model for treatment engagement

Full article at:   http://goo.gl/0S9gb5

By:  O'Toole TP1, Johnson EE2, Aiello R2, Kane V3, Pape L2.

• 1National Center on Homelessness Among Veterans, Providence VA Medical Center, 830 Chalkstone Ave, Providence, RI 02909. Email: Thomas.OToole@va.gov.
• 2The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island.
• 3The National Center on Homelessness Among Veterans, Office of Homeless Programs, US Department of Veterans Affairs, Providence, Rhode Island and Lebanon VA Medical Center, Lebanon, Pennsylvania. 
• Prev Chronic Dis. 2016 Mar 31;13:E44. doi: 10.5888/pcd13.150567.

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The Epidemiology of Substance Use Disorders in US Veterans: A Systematic Review & Analysis of Assessment Methods

BACKGROUND:

Substance use disorders (SUDs), which encompass alcohol and drug use disorders (AUDs, DUDs), constitute a major public health challenge among US veterans. SUDs are among the most common and costly of all health conditions among veterans.

OBJECTIVES:

This study sought to examine the epidemiology of SUDs among US veterans, compare the prevalence of SUDs in studies using diagnostic and administrative criteria assessment methods, and summarize trends in the prevalence of SUDs reported in studies sampling USveterans over time.

METHODS:

Comprehensive electronic database searches were conducted. A total of 3,490 studies were identified. We analyzed studies samplingUS veterans and reporting prevalence, distribution, and examining AUDs and DUDs.

RESULTS:

Of the studies identified, 72 met inclusion criteria. The studies were published between 1995 and 2013. Studies using diagnostic criteria reported higher prevalence of AUDs (32% vs. 10%) and DUDs (20% vs. 5%) than administrative criteria, respectively. Regardless of assessmentmethod, both the lifetime and past year prevalence of AUDs in studies sampling US veterans has declined gradually over time.

CONCLUSION:

The prevalence of SUDs reported in studies sampling US veterans are affected by assessment method. Given the significant public health problems of SUDs among US veterans, improved guidelines for clinical screening using validated diagnostic criteria to assess AUDs and DUDs in US veteran populations are needed.

SCIENTIFIC SIGNIFICANCE:

These findings may inform VA and other healthcare systems in prevention, diagnosis, and intervention for SUDs among US veterans.

Below:  Prevalence of lifetime alcohol use disorders (AUDs) among US veterans reported by studies using diagnostic (ie, DSM) criteria (Panel A) and administrative (ie, ICD-9) criteria (Panel B), by publication year. Note: black solid lines represent trend lines, calculated using weighted least squares regression. Note: Some of the data points overlap with each other since they had the same or very similar data point. DSM, Diagnostic and Statistical Manual of Mental Disorders; DUD, drug use disorder; ICD-9, international classification of diseases.

Below:  Prevalence of past year alcohol use disorders (AUDs) among US veterans reported by studies using diagnostic (ie, DSM) criteria (Panel A) and administrative (ie, ICD-9) criteria (Panel B), by publication year. Note: black solid lines represent trend lines, calculated using weighted least squares regression. Note: Some of the data points overlap with each other since they had the same or very similar data point. AUD, alcohol use disorder; DSM, Diagnostic and Statistical Manual of Mental Disorders; ICD-9, international classification of diseases.

Below:  Prevalence of lifetime drug use disorders (DUDs) among US veterans reported by studies using diagnostic (ie, DSM) criteria (Panel A) and administrative (ie, ICD-9) criteria (Panel B), by publication year. Note: black solid lines represent trend lines, calculated using weighted least squares regression. Note: Some of the data points overlap with each other since they had the same or very similar data point. AUD, alcohol use disorder; DSM, Diagnostic and Statistical Manual of Mental Disorders; ICD-9, international classification of diseases.

Full article at:   http://goo.gl/H6dSHm

By:  Lan CW1, Fiellin DA2, Barry DT3,4, Bryant KJ5, Gordon AJ6,7,8, Edelman EJ2, Gaither JR9, Maisto SA10, Marshall BD11.

• 1Department of Community Health Sciences, University of California, Los Angeles, Fielding School of Public Health, Los Angeles, California.
• 2Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut.
• 3Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut.
• 4Pain Treatment Services, APT Foundation, Inc., New Haven, Connecticut.
• 5National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland.
• 6Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
• 7Mental Health Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
• 8Center for Research on Health Care, University of Pittsburgh, Pittsburgh, Pennsylvania.
• 9Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut.
• 10Department of Psychology, Syracuse University, Syracuse, New York.
• 11Department of Epidemiology, Brown University, School of Public Health, Providence, Rhode Island. 

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Patient Perspectives on an Opioid Overdose Education and Naloxone Distribution Program in the US Department of Veterans Affairs

BACKGROUND:

In an effort to prevent opioid overdose mortality among Veterans, Department of Veterans Affairs (VA) facilities began implementing Opioid Overdose Education and Naloxone Distribution (OEND) in 2013 and a national program began in 2014. VA is the first national health care system to implement OEND. The goal of this study is to examine patient perceptions of OEND training and naloxone kits.

METHODS:

Four focus groups were conducted between December 2014 and February 2015 with 21 patients trained in OEND. Participants were recruited from a VA residential facility in California with a substance use disorder treatment program (mandatory OEND training) and a homeless program (optional OEND training). Data were analyzed using matrices and open and closed coding approaches to identify what participants liked and did not like, group discussion disagreements, and suggestions for improvement.

RESULTS:

Veterans thought OEND training was interesting, novel, and empowering, and that naloxone kits will save lives. Some veterans expressed concern about using syringes in the kits. A few patients who never used opioids were not interested in receiving kits. Veterans had differing opinions about legal and liability issues, whether naloxone kits might contribute to relapse, and whether and how to involve family in training. Some veterans expressed uncertainty about the effects of naloxone. Suggested improvements included active learning approaches, enhanced training materials, and increased advertisement.

CONCLUSIONS:

OEND training was generally well-received among study participants, including those with no indication for a naloxone kit. Patients described a need for OEND and believed it could save lives. Patient feedback on OEND training benefits, concerns, opinions, and suggestions provides important insights to inform future OEND training programs both within VA and in other health care settings. Training is critical to maximizing the potential for OEND to save lives and this study includes specific suggestions for improving the effectiveness and acceptability of training.

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By:  Oliva EM1, Nevedal A1, Lewis ET1,2, McCaa MD1, Cochran MF1,3, Konicki PE4,5, Davis CS6, Wilder C7,8.

• 1 VA Palo Alto Health Care System - Center for Innovation to Implementation , Menlo Park , CA , USA.
• 2 VA Office of Mental Health Operations - Program Evaluation and Resource Center , Menlo Park , CA , USA.
• 3 Stanford University School of Medicine - Department of Psychiatry and Behavioral Sciences , Stanford , CA , USA.
• 4 Louis Stokes Cleveland VA Medical Center , Cleveland , OH , USA.
• 5 Case Western Reserve University School of Medicine - Department of Psychiatry , Cleveland , OH , USA.
• 6National Health Law Program , Los Angeles , CA , USA.
• 7 Cincinnati VA Medical Center , Cincinnati , OH , USA.
• 8 University of Cincinnati College of Medicine - Department of Psychiatry and Behavioral Neuroscience , Cincinnati , OH , USA.
• Subst Abus. 2015 Dec 16:0. 

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Homeless Veterans Eligible for Medicaid Under the Affordable Care Act

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.

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.

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.

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.

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By: Tsai J1, Kasprow WJ1, Culhane D1, Rosenheck RA1.

• 1Dr. Tsai and Dr. Rosenheck are with the Veterans Affairs (VA) New England Mental Illness Research, Education and Clinical Center, West Haven, Connecticut. They are also with the Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, where Dr. Kasprow is affiliated (e-mail: jack.tsai@yale.edu ). Dr. Kasprow is also with the VA Northeast Program Evaluation Center, West Haven, Connecticut. Dr. Culhane is with the School of Social Policy and Practice, University of Pennsylvania, Philadelphia.  

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Identifying Homelessness among Veterans Using VA Administrative Data: Opportunities to Expand Detection Criteria

Researchers at the U.S. Department of Veterans Affairs (VA) have used administrative criteria to identify homelessness among U.S. Veterans. Our objective was to explore the use of these codes in VA health care facilities. We examined VA health records (2002-2012) of Veterans recently separated from the military and identified as homeless using VA conventional identification criteria (ICD-9-CM code V60.0, VA specific codes for homeless services), plus closely allied V60 codes indicating housing instability. Logistic regression analyses examined differences between Veterans who received these codes. 

Health care services and co-morbidities were analyzed in the 90 days post-identification of homelessness. VA conventional criteria identified 21,021 homeless Veterans from Operations Enduring Freedom, Iraqi Freedom, and New Dawn (rate 2.5%). Adding allied V60 codes increased that to 31,260 (rate 3.3%). While certain demographic differences were noted, Veterans identified as homeless using conventional or allied codes were similar with regards to utilization of homeless, mental health, and substance abuse services, as well as co-morbidities. 

Differences were noted in the pattern of usage of homelessness-related diagnostic codes in VA facilities nation-wide. Creating an official VA case definition for homelessness, which would include additional ICD-9-CM and other administrative codes for VA homeless services, would likely allow improved identification of homeless and at-risk Veterans. This also presents an opportunity for encouraging uniformity in applying these codes in VA facilities nationwide as well as in other large health care organizations.

Below: Map of usage of various administrative indicators for the recognition of homelessness in VA medical facilities across the country (V60.0, V60.1, V60.89. V60.9 and non-ICD codes: clinic stop codes and inpatient treatment codes as described in the text). The pie charts are derived from a normalized ratio: the frequency of the specific code given as a first indicator of homelessness (numerator) as a proportion of the total number of Veterans identified as homeless in the area (denominator). Two representative years are shown.

Below:  A stacked bar graph of the variability in usage of V60 and non-ICD codes to identify homelessness among Veterans across 4 VA regions in the US. Region 1 includes the East Coast, Region 4 the West Coast. The time period studied is 2002–2012.

Read more at: http://ht.ly/ScZij

By: Rachel Peterson,1,2 Adi V. Gundlapalli,1,3,* Stephen Metraux,4,5 Marjorie E. Carter,1,3 Miland Palmer,1,3 Andrew Redd,1,3 Matthew H. Samore,1,3 and Jamison D. Fargo1,2,4

²Department of Psychology, Utah State University, Logan, Utah, United States of America

³Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America

⁴National Center on Homelessness Among Veterans, Philadelphia, Pennsylvania, United States of America

⁵Health Policy and Public Education, University of the Sciences, Philadelphia, Pennsylvania, United States of America

1Salt Lake Informatics, Decision-enhancement and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System
2Department of Psychology, Utah State University, Logan, Utah, United States of America
3Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
4National Center on Homelessness Among Veterans, Philadelphia, Pennsylvania, United States of America

5Health Policy and Public Education, University of the Sciences, Philadelphia, Pennsylvania, United States of America

1Salt Lake Informatics, Decision-enhancement and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, United States of America

Comparison of Homeless Male Veterans in Metropolitan and Micropolitan Areas in Nebraska

151 homeless male veterans (112 metropolitan, 39 micropolitan) were recruited from Veterans Affairs facilities and area shelters in Omaha, Lincoln, Grand Island, and Hastings in Nebraska. 

Results showed that compared to homeless veterans in metropolitans, those in micropolitans were more likely to be White, unmarried, living in transitional settings, and were far more transient but reported greater social support and housing satisfaction. 

Veterans in micropolitans also reported more medical problems, diagnoses of anxiety and personality disorders, and unexpectedly, were more likely to report using various health services and less travel time for services. 

Together, these findings suggest access to homeless and health services for veterans in micropolitan areas may be facilitated through Veterans Affairs facilities and community providers that work in close proximity to one another. 

Many homeless veterans in these areas are transient, making them a difficult population to study and serve. Innovative ways to provide outreach to homeless veterans in micropolitan and more rural areas are needed.

Via:  http://ht.ly/SaUmk 

By: Tsai J1,2, Ramaswamy S3,4, Bhatia SC3,4, Rosenheck RA5,6,7.

• 1Veterans Affairs New England Mental Illness Research, Education, and Clinical Center, 950 Campbell Ave., 151D, West Haven, CT, 06516, USA
• 2Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA. Jack.Tsai@yale.edu.
• 3Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA.
• 4Department of Psychiatry, Creighton University, Omaha, NE, USA.
• 5Veterans Affairs New England Mental Illness Research, Education, and Clinical Center, 950 Campbell Ave., 151D, West Haven, CT, 06516, USA.
• 6Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
• 7Yale School of Public Health, Yale University, New Haven, CT, USA.

Risk Factors for Homelessness among US Veterans

Homelessness among US veterans has been a focus of research for over 3 decades. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, this is the first systematic review to summarize research on risk factors for homelessness among US veterans and to evaluate the evidence for these risk factors. Thirty-one studies published from 1987 to 2014 were divided into 3 categories: more rigorous studies, less rigorous studies, and studies comparing homeless veterans with homeless nonveterans. 

The strongest and most consistent risk factors were substance use disorders and mental illness, followed by low income and other income-related factors. There was some evidence that social isolation, adverse childhood experiences, and past incarceration were also important risk factors. 

Veterans, especially those who served since the advent of the all-volunteer force, were at greater risk for homelessness than other adults. Homeless veterans were generally older, better educated, and more likely to be male, married/have been married, and to have health insurance coverage than other homeless adults. 

More studies simultaneously addressing premilitary, military, and postmilitary risk factors for veteran homelessness are needed. This review identifies substance use disorders, mental illness, and low income as targets for policies and programs in efforts to end homelessness among veterans.

Read more at:  http://ht.ly/S9OU1 

By: Jack Tsai* and Robert A. Rosenheck
VA New England Mental Illness Research, Education, and Clinical Center, West Haven, Connecticut (Jack Tsai, Robert A. Rosenheck); Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Jack Tsai, Robert A. Rosenheck); and Department of Epidemiology and Public Health, Yale School of Public Health, New Haven, Connecticut (Robert A. Rosenheck)

Increased Risk for Substance Use and Health-Related Problems among Homeless Veterans

The first aim of this study was to compare self-reported causes of homelessness between veterans and nonveterans. A second aim examined whether homeless male veterans were more likely than homeless male nonveterans to experience current problems with addictions, mental health, and physical health. Additionally, a third aim was to compare frequency of emergency room visits and treatment needs between the two groups.

Veterans reported higher rates of substance use and mental health problems as a primary cause of homelessness when compared to nonveterans. Homeless veterans were more likely than nonveterans to report current problems with addictions, mental health problems, and physical problems. Finally, over half of homeless veterans (53.1%) reported an ER visit in the past year compared to only 40.9% of nonveterans.

Veterans may be more likely to become homeless due to addiction and mental health and over half of homeless veterans are presenting to hospital emergency rooms. Given the greater utilization among homeless veterans, emergency rooms may serve as a prime opportunity to provide brief treatment and referrals for needed services.

Via: http://ht.ly/S9Oxh 

By: Dunne EM1, Burrell LE 2nd1, Diggins AD1, Whitehead NE1, Latimer WW2.

• 1Department of Clinical and Health Psychology, University of Florida, Gainesville, Florida.
• 2Department of Health Sciences, Lehman College, City University of New York, Bronx, New York.