Do Homeless Veterans Have the Same Needs and Outcomes as Non-Veterans?

MILITARY MEDICINE, 177, 1:27, 2012 Do Homeless Veterans Have the Same Needs and Outcomes as Non-Veterans? Jack Tsai, PhD * ; Alvin S. Mares, PhD ; Robert A. Rosenheck, MD * ABSTRACT Although veterans have been found to be at increased risk for homelessness as compared to non-veterans, it is not clear whether those who are homeless have more severe health problems or poorer outcomes in community-based supported housing. This observational study compared 162 chronically homeless veterans to 388 non-veterans enrolled in a national-supported housing initiative over a 1-year period. Results showed that veterans tended to be older, were more likely to be in the Vietnam era age group, to be male, and were more likely to have completed high school than other chronically homeless adults. There were no differences between veterans and non-veterans on housing or clinical status at baseline or at follow-up, but both groups showed significant improvement over time. These findings suggest that the greater risk of homelessness among veterans does not translate into more severe problems or treatment outcomes. Supported housing programs are similarly effective for veterans and non-veterans. INTRODUCTION Research has found veterans are at increased risk for homelessness compared to the general population, 1,2 particularly among veterans who have served in the all-volunteer force, which began effectively in 1975 following the Vietnam War. 3 5 In response, the U.S. Department of Veterans Affairs (VA) has implemented and developed a large array of health care initiatives to provide specialized services for these veterans. 6 Although VA has created its own homeless programs and has made a commitment to ending homeless among veterans in the coming years, 7 many veterans either do not have access to VA services or choose to use non-va community services. 3,8 10 There has been little study of veterans in non-va homeless programs 11 and few comparisons with non-veterans who are homeless. Past studies have generally found that homeless veterans are older, more likely to be white, better educated, and have greater substance abuse problems than other homeless men, 12,13 although a few studies have found that homeless veterans seeking residential treatment are a younger, more educated, and higher functioning subgroup than general veteran and non-veteran homeless groups. 14 However, it is not clear whether veterans remain at increased risk for homelessness compared to non-veterans once they are engaged in treatment in non-va community programs, even when they are encouraged to use VA services. The current observational study compared veterans and non-veterans in a national-supported housing initiative for * VA New England Mental Illness Research, Education, and Clinical Center, 950 Campbell Avenue, 151D, West Haven, CT 06516. Department of Psychiatry, Yale University, 300 George Street, New Haven, CT 06511. College of Social Work, The Ohio State University, 1947 College Road, Columbus, OH 43210. School of Epidemiology and Public Health, Yale University, 60 College Street, PO Box 208034, New Haven, CT 06520. The views presented here are those of the authors, alone, and do not represent the position of any federal agency or of the U.S. Government. chronically homeless adults initiated jointly by the U.S. Department of Housing and Urban Development, the Department of Health and Human Services, and the VA. Comparisons address individual characteristics at the time of program entry and whether veterans were at increased risk for homelessness and poor clinical outcomes during treatment, after accounting for baseline characteristics. METHODS Study Design Data were obtained from the Collaborative Initiative to Help End Chronic Homelessness (CICH). 15 CICH was implemented in 2004 by the U.S. Interagency Council on Homeless to provide adults who were chronically homeless with permanent housing and supportive primary health care and mental health services at 11 sites in the United States. The criterion for eligibility was chronic homelessness, defined as an unaccompanied homeless individual with a disabling condition who has either been continuously homeless for 1 year or more or has had at least four episodes of homelessness in the past 3 years. The 11 communities funded through CICH included Chattanooga, Tennessee; Chicago, Illinois; Columbus, Ohio; Denver, Colorado; Fort Lauderdale, Florida; Los Angeles, California; Martinez, California; New York, New York; Philadelphia, Pennsylvania; Portland, Oregon; and San Francisco, California. Each site developed a comprehensive plan, which included strategies for providing permanent housing, linking comprehensive supports with housing, increasing the use of mainstream services, integrating system and services, and ensuring its sustainability. Efforts were made when clinically appropriate to connect veterans with VA services and VA clinical staff worked within each program. A total of 756 participants gave informed consent to participate in the national evaluation of CICH. The mean number of participants at each site was 69, ranging from 52 to 98. Homeless adults were recruited by clinical and research staff at MILITARY MEDICINE, Vol. 177, January 2012 27

each site through a variety of methods, including community outreach and contacts with shelters, hospitals, and other mental health agencies. Among clients who consented to participate in the evaluation, 550 (72.75%) had data at all three time points: baseline, 6 months, and 12 months. The current study focused on these 550 (162 veterans and 388 non-veterans) participants during their first year of program participation. Measures Sociodemographic data were collected from participants by CICH staff through a structured interview. Veterans were categorized into war eras based on their age and the assumption that veterans were typically 19 years old when they enlisted, which is a technique effectively used before. 16,17 Mental health and substance abuse diagnoses were self-reported by participants and corroborated by assessing clinicians. Housing Participants reported the number of nights they spent in their own dwelling (apartment, room, or house), in an institution (halfway house, transitional housing, hospital, or jail), and homeless (shelters, outdoors, in vehicles, or abandoned buildings) in the previous 3 months. Clinical Status The Medical Outcomes Study Short Form-12 (SF-12), 18 consisting of 12 items and a mental health and physical health subscale, was used to assess the overall level of functioning in those respective domains. Scores range from 0 to 100 with a score of 50 representing the normal level of functioning in the general population and each 10-point interval representing one standard deviation. The SF-12 has been validated as an outcome measure in homeless populations. 19 Three subscales of the Brief Symptom Inventory (BSI) 20 were selected to measure the major domains of subjective distress: psychoticism, depression, and anxiety. Participants were asked to rate 16 items from 0 (never experience symptom) to 4 (very often experience symptom) items like nervousness or shakiness inside and the idea that someone else can control your thoughts. In this study, the BSI showed excellent internal consistency with alpha = 0.92, and the BSI score presented is the mean value for the three subscales. The Addiction Severity Index (ASI), 21 consisting of 6 items on an alcohol subscale and 13 items on a drug subscale, was used to document alcohol and drug use in the past month. Items are combined in a standard comparable score ranging from 0 to 1 for each subscale with higher scores reflecting more serious substance use. An observed psychotic behavior rating scale, 22 consisting of 10 types of behaviors (e.g., hallucinations, delusions, inappropriate behavior or speech), was used by evaluation staff who rated their observations during interviews. Each of these behaviors was coded 0 (not at all) to 3 (a lot) based on staff observations, and the total scale score was computed as the average score across these 10 items (à = 0.76). Health Service Use Participants reported the number of days they used outpatient and inpatient medical services in the past 3 months. They also reported the number of days they used outpatient and inpatient mental health services (including substance abuse services) in the past 3 months. VA Connection and VA Health Service Use Veteran participants were asked at each interview whether they had a VA service connected disability, a non-service connected VA pension, or both. Veterans were also asked whether they received medical/surgical or psychiatric/substance services in the last 3 months from a VA facility. Finally, veterans were asked whether they participated in any veteran-specific programs in the community in the past 3 months. Veteranspecific programs include the Vet Center, residential veteran programs, and non-residential veteran programs. Data Analysis First, differences in sociodemographics and baseline status between veterans and non-veterans were examined statistically (with t -tests and χ 2 tests). Then differences between veterans and non-veterans in their outcomes over time were examined, controlling for baseline differences (using mixed linear regression models). Subgroup analyses were conducted on only Vietnam era veterans and non-veterans, and only early all-volunteer force era veterans and non-veterans because previous studies suggest that veterans who served in these eras are of particular importance in homelessness research. Specific analyses were conducted on all veteran participants to examine whether the proportion of veterans who were connected to and received services at the VA increased over time (using Cochran s Q tests). It was reasoned that veterans enrolled in a supported housing program focused on providing links to other community services would become more engaged with VA services. Finally, all the analyses above were repeated on only male veterans and non-veterans to examine whether excluding females from the analyses would yield the same results and be applicable to the majority male veteran population. RESULTS There were several sociodemographic differences between veterans and non-veteran participants (Table I ). Veterans tended to be older, from the Vietnam era age group, were more likely male, and were more likely to have completed high school than non-veterans. However, there were no significant baseline differences between veterans and non-veterans on mental health diagnoses, housing, clinical status, or health service use. Table II shows the housing, clinical status, and health service use of veterans and non-veterans over 12 months. After controlling for differences in veteran sociodemographics and the program site, there were no group differences between veterans and non-veterans on outcomes, but both groups 28 MILITARY MEDICINE, Vol. 177, January 2012

TABLE I. Baseline Characteristics of Veterans and Non-veterans in Supported Housing Veterans ( n = 162; 29%) Non-veterans ( n = 388; 71%) Test of Difference ( df ) Sociodemographics Years of Age (SD) 48.57 (6.57) 44.37 (8.63) T (392.02) = 6.21 * War Era c 2 (1) = 39.04 * Vietnam (1966 1975) 104 (64%) 142 (37%) Early AVF a (1976 1985) 48 (30%) 169 (44%) Mid-AVF (1986 1995) 9 (6%) 59 (15%) Recent AVF (1996 2006) 1 (1%) 18 (5%) Gender-Male (%) 157 (97) 256 (66) c 2 (1) = 58.47 * Years of Education (SD) 12.65 (1.92) 11.43 (2.68) t (415.01) = 6.04 * Marital Status-Not Married (%) 161 (99) 387 (100) c 2 (1) = 0.41 Diagnoses Self-report Diagnoses Schizophrenia (%) 34 (21) 73 (19) c 2 (1) = 0.34 Bipolar Disorder (%) 28 (17) 77 (20) c 2 (1) = 0.49 Major Depressive (%) 42 (26) 115 (30) c 2 (1) = 0.77 Post-traumatic Stress Disorder (%) 13 (8) 19 (5) c 2 (1) = 2.04 Substance Abuse Alcohol Use Disorder (%) 92 (57) 198 (51) c 2 (1) = 1.52 Drug Use Disorder (%) 86 (53) 209 (54) c 2 (1) = 0.03 Dual Diagnosis b (%) 83 (51) 206 (53) c 2 (1) = 0.16 Developmental Disability (%) 11(7) 49 (13) c 2 (1) = 3.85 Any Physical Health Problem (%) 111 (69) 250 (64) c 2 (1) = 0.85 Housing Nights in Own Dwelling (SD) 4.95 (14.70) 6.62 (16.31) t (548) = 1.13 Nights in Institution (SD) 15.40 (29.37) 14.46 (27.08) t (548) = 0.36 Nights Homeless (SD) 57.43 (36.47) 56.11 (36.58) t (548) = 0.39 Clinical Status SF-12 Physical Component (SD) c 44.37 (9.48) 44.97 (10.15) t (548) = 0.65 SF-12 Mental Component (SD) 38.32 (7.96) 39.14 (7.88) t (548) = 1.11 BSI (SD) d 1.55 (0.90) 1.49 (0.90) t (548) = 0.66 Observed Psychotic Behavior Rating (SD) e 0.19 (0.23) 0.21 (0.29) t (548) = 1.01 ASI-Alcohol (SD) f 0.14 (0.21) 0.12 (0.19) t (548) = 1.02 ASI-Drug (SD) 0.05 (0.08) 0.06 (0.10) t (369.81) = 1.16 Health Service Use Days of Outpatient Medical Service Use (SD) 2.59 (6.21) 3.22 (7.80) t (548) = 0.91 Days of Outpatient Mental Health Service used (SD) 10.61 (19.52) 7.58 (16.88) t (266.34) = 1.73 Days of Inpatient Medical Service Use (SD) 0.14 (0.35) 0.17 (0.37) t (547) = 0.68 Days of Inpatient Mental Health Service Used (SD) 0.19 (0.45) 0.18 (0.41) t (546) = 0.26 * p < 0.001. a AVF = All Volunteer Force. b Dual diagnosis is a comorbid mental illness and substance use disorder. c SF-12 ranges from 0 to 100, with 50 representing a normal level of functioning. d BSI ranges from 0 to 4 with higher scores indicating more subjective distress. e Observed psychotic behavior rating ranges from 0 to 3 with higher scores indicating more observed psychosis. f ASI is a composite score ranging from 0 to 1 with higher scores reflecting more serious substance use. df, degrees of freedom with higher scores reflecting better health. showed significant improvements in housing (more nights in own dwelling and less nights in institution and homeless). There were no group differences in clinical outcomes, but both groups showed small improvements on the SF-12 Mental Health Summary scores, the BSI, the observed psychotic behavior rating, the ASI-Alcohol, and the ASI-Drug measures. On health service use, veterans reported greater use of outpatient mental health service than non-veterans, but there were no other group differences. Both groups showed small decreases in use of outpatient mental health services, inpatient medical services, and inpatient mental health services over the 12-month period following program entry. There were no significant interaction effects on any outcomes. To examine the effect of controlling for baseline differences before program entry, the analyses were repeated not controlling for these differences. Results remained the same with the only group difference found in veterans using more outpatient mental health services than non-veterans, F (1,580.34) = 5.34, p < 0.05. When subgroup analyses were conducted on Vietnam era participants, and then on early all-volunteer force era participants, there were no differences between veterans and nonveterans on any housing, clinical, or service use outcomes. Further analyses conducted on veteran participants found no significant increase in the proportion of veterans receiving VA service-connected disability payments over time ( Table III ). However, the proportion of veterans who received MILITARY MEDICINE, Vol. 177, January 2012 29

TABLE II. Differences in Housing, Clinical Status, and Health Service Use Among Veterans and Non-veterans Group Baseline 6 Month 12 Month Main Group Effect Main Time Effect Nights in Own Dwelling (SD) Veteran ( n = 162) 5 (2) a 79 (2) 82 (2) F (1,658) = 0 F (2,1139) = 2,105 * Non-veteran ( n = 388) 7 (1) 79 (1) 79 (1) Nights in Institution (SD) Veteran 14 (2) 5 (2) 3 (2) F (1,542) = 0 F (2,1026) = 41 * Non-veteran 14 (1) 4 (1) 5 (1) Nights Homeless (SD) Veteran 57 (2) 1 (2) 1 (2) F (1,515) = 1 F (2,990) = 887 * Non-veteran 57 (1) 4 (1) 3 (1) SF-12 Physical Component (SD) Veteran 44 (1) 45 (1) 44 (1) F (1,577) = 0 F (2,1082) = 0 Non-veteran 45 (0) 45 (0) 45 (0) SF-12 Mental Component (SD) Veteran 38 (1) 40 (1) 40 (1) F (1,590) = 0 F (2,1081) = 8 * Non-veteran 39 (0) 40 (0) 41 (0) BSI (SD) Veteran 2 (0) 1 (0) 1 (0) F (1,562) = 1 F (2,1081) = 25 * Non-veteran 1 (0) 1 (0) 1 (0) Observed Psychotic Behavior Veteran 0 (0) 0 (0) 0 (0) F (1,579) = 0 F (2,1074) = 3 ** b Rating (SD) ASI-Alcohol (SD) Veteran 0 (0) 0 (0) 0 (0) F (1,543) = 2 F (2,1053) = 5 *** ASI-Drug (SD) Veteran 0 (0) 0 (0) 0 (0) F (1,545) = 0 F (1,1055) = 4 ** Days of Outpatient Medical Service Veteran 2 (1) 2 (1) 2 (1) F (1,568) = 2 F (2,1058) = 1 Use (SD) Non-veteran 3 (0) 3 (0) 2 (0) Days of Outpatient Mental Health Veteran 11 (1) 11 (1) 8 (1) F (1,574) = 9 *** F (2,1067) = 3 ** Service Used (SD) Non-veteran 7 (1) 7 (1) 6 (1) Days of Inpatient Medical Service Veteran 0 (0) 0 (0) 0 (0) F (1,626) = 0 F (2,1108) = 6 *** Use (SD) Days of Inpatient Mental Health Veteran 0 (0) 0 (0) 0 (0) F (1,603) = 2 F (2,1082) = 12 * Service Used (SD) * p < 0.001, **p < 0.05, ***p < 0.01. a Values shown are least square means (SEs). b Both veterans and non-veterans showed small improvements on the observed psychotic behavior rating, the ASI- Alcohol, and ASI-Drug scores, although this is not obvious because values shown were rounded to whole numbers. Similarly, both veterans and non-veterans also showed small reductions in outpatient and inpatient mental health service use and inpatient medical service use. TABLE III. Veteran Participants Connection to the VA Healthcare System ( n = 159 162) Baseline 6 Month 12 Month Test of Difference Over Time VA Service Connected Disability ( n = 162) 21 (12.96%) 22 (13.58%) 22 (13.58%) Q (2) = 0.13 Non-service Connected VA Pension ( n = 159 162) 27 (16.67%) 31 (19.50%) 39 (24.07%) Q (2) = 10.38** VA Health Service Use ( n = 160 162) Medical/Surgical 80 (49.38%) 83 (51.88%) 82 (50.93%) Q (2) = 0.22 Psychiatric/Substance Abuse 32 (19.75%) 25 (15.63%) 20 (12.35%) Q (2) = 6.41* Attended a Veteran-specific Program ( n = 160 162) 43 (26.71%) 22 (13.75%) 24 (14.81%) Q (2) = 12.77** * p < 0.05, ** p < 0.01 non-service VA pensions significantly increased, the proportion of veterans who used VA psychiatric/substance abuse services significantly decreased, and the proportion of veterans who attended a veteran-specific program (i.e., VA or non-va) also decreased. When the main analyses were repeated on only male participants, results were similar except male veterans reported using significantly more outpatient mental health services at baseline than male non-veterans, t (262.02) = 2.50, p <0.05, and there was no significant difference over time in outpatient mental health service use. DISCUSSION Despite population-based findings that post-vietnam era veterans, and to a lesser extent, Vietnam era veterans are at increased risk for homelessness, mental illness, and substance abuse, 3 5 this study found that homeless veterans were not at increased risk for adverse outcomes once they were admitted to an interagency-supported housing program. When veteran participants in the CICH program were compared to non-veterans, they did not appear to be worse off clinically at the time of program entry or to have poorer outcomes as measured by days of homelessness or symptom severity. Once veterans were engaged in treatment, they seemed to benefit and function as well as other homeless adults. Both veteran and non-veterans gradually reduced their use of health services over time after they obtained housing, especially inpatient services. This suggests the effectiveness of supported housing programs in reducing clinical needs among chronically homeless adults, regardless of their level of risk, which is consistent with previous studies. 23,24 There were a few differences between veterans 30 MILITARY MEDICINE, Vol. 177, January 2012

and non-veterans. Veterans tended to be older, male, and with a higher level of education than non-veterans, consistent with findings in previous studies. 12,13 The majority of homeless veterans in this sample were from the Vietnam era age group, but studies have shown that the post-vietnam era age group (i.e., era of the early all-volunteer force) has the greatest relative risk of homelessness compared to non-veterans. 13,25 We found this was not the case once veterans were engaged in supported housing. Veterans tended to use more outpatient health services than non-veterans, which may have been due to the availability of services through the VA health care system. However, only half of the veterans in this sample reported that they use VA for medical services and less than one-fifth reported the use of VA psychiatric or substance abuse services. This finding highlights the fact that veterans often use services provided by community providers, as demonstrated previously, 11 and encourages VA to coordinate its efforts with community providers in serving homeless veterans. Several limitations require comment. Because this study was based on secondary analyses, we did not have data on the proportion of VA services used by veterans out of their total health service use. Veterans in this study were enrolled in a national-supported housing initiative that was not specifically focused on VA services and thus they may not be representative of all homeless veterans. Also, all measures used in this study relied on participant self-report which may have been biased in ways that were not measured. Future studies should employ more objective measures. Further research is needed on how often homeless veterans use non-va services only, or both VA and non-va services, and why. This study suggests that non-va services for homeless veterans are effective and any inherent epidemiological risk veterans may have, as compared to non-veterans, seem to be equalized once they are enrolled in supported housing. ACKNOWLEDGMENTS None of the authors had any conflicts of interest. The CICH Funder s Group representing U.S. Department of Housing and Urban Development, Department of Health and Human Services, and VA provided essential support and guidance to this evaluation. The CICH evaluation has been completed and the Federal Government is no longer involved. REFERENCES 1. U.S. Department of Housing and Urban Development, U.S. Department of Veterans Affairs : Veteran Homelessness: A Supplemental Report to the 2009 Annual Homeless Assessment Report to Congress. Washington, DC, U.S. Department of Housing and Urban Development, Office of Community Planning and Development; U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, 2009. 2. 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