Clinical Review

Predictors of VA and Non-VA Health Care Service Use by Homeless Veterans Residing in a Low-Demand Emergency Shelter

When given a choice between VA and non-VA outpatient services, significantly more veterans chose to use VA medical and psychiatric services, but outpatient substance abuse-related services were used equally.

Fed Pract. 2016 March;33(3):42-48

Author(s):

James C. Petrovich, PhD

David E. Pollio, PhD

Carol S. North, MD, MPE

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References

1. U.S. Department of Veterans Affairs. Homeless veterans: VA is working to end homelessness among veterans. U.S. Department of Veterans Affairs Website. www.va.gov/homeless/about_the_initiative.asp#one. Updated January 26, 2016. Accessed February 16, 2016.

2. Henry M, Cortes A, Morris S, Abt Associates; U. S. Department of Housing and Urban Development Office of Community Planning and Development. The 2013 Annual Homeless Assessment Report (AHAR) to Congress: Part 1 Point-in-Time Estimates of Homelessness. HUD Exchange Website. https://www.hudexchange.info/resources/documents/ahar-2013-part1.pdf. Published October 2014. Accessed February 16, 2016.

3. U.S. Department of Veterans Affairs. Homeless Veterans: Housing Assistance. U.S. Department of Veterans Affairs Web site. http://www.va.gov/homeless/housing.asp. Updated November 5, 2015. Accessed February 16, 2016.

4. Austin EL, Pollio DE, Holmes S, et al. VA's expansion of supportive housing: successes and challenges on the path to Housing First. Psychiatr Serv. 2014;65(5):641-647.

5. Tsai J, Kasprow WJ, Rosenheck RA. Alcohol and drug use disorders among homeless veterans: prevalence and association with supported housing outcomes. Addict Behav. 2014;39(2):455-460.

6. Wenzel SL, Bakhtiar L, Caskey NH, et al. Homeless veterans utilization of medical, psychiatric, and substance abuse services. Med Care. 1995;33(11):1132-1144.

7. McQuire J, Gelberg L, Blue-Howells J, Rosenheck RA. Access to primary care for homeless veterans with serious mental health illness or substance abuse: a follow-up evaluation of co-located primary care and homeless social services. Adm Policy Ment Health. 2009;36(4):255-264.

8. Tsai J, Mares AS, Rosenheck RA. Do homeless veterans have the same needs and outcomes as non-veterans? Mil Med. 2012;177(1):27-31.

9. Andersen RM. A behavioral model of families use of health services: Research Series No. 25. Chicago, IL: University of Chicago Center for Health Administrative Studies; 1968.

10. Andersen RM. Revisiting the behavioral model and access to medical care: does it matter? J Health Soc Behav. 1995;36(1):1-10.

11. Pollio DE, North CS, Eyrich KM, Foster DA, Spitznagel E. Modeling service access in a homeless population. J Psychoactive Drugs. 2003;35(4):487-495.

12. Gelberg L, Andersen RM, Leake BD. The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people. Health Serv Res. 2000;34(6):1273-1302.

13. Padgett D, Struening EL, Andrews H. Factors affecting the use of medical, mental health, alcohol, and drug treatment services by homeless adults. Med Care. 1990;28(9):805-821.

14. Stein JA, Andersen RM, Koegel P, Gelberg L. Predicting health services utilization among homeless adults: a prospective analysis. J Health Care Poor Underserved. 2000;11(2):212-230.

15. Gamache G, Rosenheck RA, Tessler R. Factors predicting choice of provider among homeless veterans with mental illness. Psychiatr Serv. 2000;51(8):1024-1028.

16. Wenzel SL, Audrey Burnam, M, Koegel P, et al. Access to inpatient or residential substance abuse treatment among homeless adults with alcohol or other drug use disorders. Med Care. 2001;39(11):1158-1169.

17. Pollio DE, North CS, Eyrich KM, Foster DA, Spitznagel E. Modeling service access in a homeless population. J Psychoactive Drugs. 2003;35(4):487-495.

18. Solorio MR, Milburn NG, Andersen RM, Trifskin S, Rodríguez MA. Emotional distress and mental health service use among urban homeless adolescents. J Behav Health Serv Res. 2006;33(4):381-393.

19. Stein JA, Andersen RM, Robertson M, Gelberg L. Impact of hepatitis B and C infection on health services utilization in homeless adults: a test of the Gelberg-Anderson Behavioral Model for Vulnerable Populations. Health Psychol. 2012;31(1):20-30.

20. Linton KF, Shafer MS. Factors associated with the health service use of unsheltered, chronically homeless adults. Soc Work Public Health. 2013;29(1):73-80.

21. Petrovich JC, Pollio DE, North CS. Characteristics and service use of homeless veterans and nonveterans residing in a low-demand emergency shelter. Psych Serv. 2014;65(6):751-757.

22. U.S. Census Bureau. State & County Quick Facts: Fort Worth (city), Texas. U.S. Census Bureau Website. http://quickfacts.census.gov/qfd/states/48/4827000.html. Revised December 2, 2015. Accessed February 17, 2016.

23. Tarrant County Homeless Coalition. 2014 point in time count results. Tarrant County Homeless Coalition Website. http://www.ahomewithhope.org/staff/local-data-research/2014-homeless-count/. Accessed February 16, 2016.

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25. Iqbal SU, Rogers W, Selim A, et al. The Veterans RAND 12 Item Health Survey (VR-12): What it is and how it is Used. Washington, DC: Veterans Health Administration; 2009.

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28. Blue-Howells J, McQuire J, Nakashima J. Co-location of health care services for homeless veterans: a case study of innovation in program implementation. Soc Work Health Care. 2008;47(3):219-231.

29. Piette JD, Holtz B, Beard AJ, et al; Ann Arbor PACT Steering Committee. Improving chronic illness care for veterans within the framework of the Patient-Centered Medical Home: experiences from the Ann Arbor Patient-Aligned Care Team Laboratory. Transl Behav Med. 2011;1(4):615-623.

In 2009, the VA announced a goal of ending veteran homelessness by 2015.¹The primary focus of this new policy has been housing veterans experiencing chronic homelessness, many of whom languish outside the VA housing system. Since that time, progress has been made with point-in-time enumerations indicating that veteran homelessness has decreased nationally. Despite this progress, however, more than 55,000 veterans are still estimated to experience homelessness each night.²

Historically, the VA has offered an array of services specifically meant to alleviate veteran homelessness (grant, per diem, and other transitional housing programs; vocational rehabilitation, etc).³ The majority of these programs require some period of veteran abstinence as a condition for providing housing services. The recent move toward permanent “housing first” programs with few conditions for enrollment and participation provides new opportunities for housing veterans experiencing chronic homelessness, who are the specific target of the goal of ending veteran homelessness.⁴

Because veterans experiencing chronic homelessness have additional, substantial need for medical, psychiatric, and substance-abuse services, the VA also offers these services to this population.^5-7 Veterans experiencing homelessness also may access parallel non-VA services.⁸ Information about veterans outside of traditional VA housing services, specifically those housed in low-demand shelters, is needed to develop services for this population and will be critical to success in ending veteran homelessness.

The Behavioral Model of Health Services Use^9-11 and its later refinement, the Behavioral Model for Vulnerable Persons,¹² have been used to conceptualize health care service use (Figure). In these models, health service use is predicted by 3 types of factors: predisposing factors (eg, age, race, gender, residential history), enabling factors (eg, availability, accessibility, affordability, acceptability), and service need factors (eg, substance-use disorders, mental health problems, physical health problems).

Studies applying these models of health care service use to both general homeless populations and, specifically to populations of veterans experiencing homelessness have found that service use is most influenced by need-based factors (eg, drug abuse, poor health, mental health problems).^6,12-20 These same studies indicate that predisposing factors (eg, age, race, and gender) and enabling factors (eg, insurance, use of other services, and usual place of care) are also associated with service use, though less consistently.

Studies focused on veterans experiencing homelessness, however, included only treatment-seeking populations, which are not necessarily representative of the broader population of veterans experiencing homelessness. Additionally, none of these prior studies focused on the unique subset of veterans residing in low-demand shelters (characterized by unlimited duration of stay, no government ID or fee required for entry, and no requirement for service participation). This is a population that seems to be less engaged in services but nevertheless is challenged.²¹ This study, therefore, is focused on nontreatment seeking veterans residing in a low-demand shelter. The study applied the Behavioral Model of Health Services Use and the Behavioral Model for Vulnerable Persons to examine use of VA and non-VA services.

Study Parameters

This study was conducted in Fort Worth, Texas, the 17th largest city in the U.S. with more than 810,000 residents.²² In 2013, a biennial point-in-time count identified about 2,300 individuals who were homeless in Fort Worth. Most were found in emergency shelters (n = 1,126, 50%) or transitional housing (n = 965, 40%). Slightly more than 10% (n = 281) were found to be unsheltered: sleeping on the streets or in encampments, automobiles, or abandoned buildings.²³ Although national estimates identify 12% of all adults who are homeless as veterans,² only 8% (n = 189) of people experiencing homelessness in Fort Worth reported military service.²³

Access to the full array of VA emergency department (ED), inpatient, and outpatient medical, psychiatric, and substance-abuse services are available to veterans experiencing homelessness at the Dallas VA Medical Center (DVAMC), located 35 miles away. Only VA outpatient medical, psychiatric, and substance-related services are available in Fort Worth through the VA Outpatient Clinic and Health Care for the Homeless Veterans (HCHV) program. If veterans experiencing homelessness seek care outside of the VA system, a comprehensive network of emergency, inpatient and outpatient medical, psychiatric, and substance-related services is available in Fort Worth.

Sample

The study sample included 110 adult male veterans randomly recruited as they awaited admission to a private, low-demand emergency shelter. The study excluded veterans with a dishonorable discharge to ensure participants were eligible for VA services. Institutional review board approvals were obtained prior to the study from the University of Texas at Arlington and DVAMC. All participants provided informed consent and were given a $5 gift for their involvement.