Thomas Byrne

Examining mortality among formerly homeless adults enrolled in Housing First: An observational study

BackgroundAdults who experience prolonged homelessness have mortality rates 3 to 4 times that of the general population. Housing First (HF) is an evidence-based practice that effectively ends chronic homelessness, yet there has been virtually no research on premature mortality among HF enrollees. In the United States, this gap in the literature exists despite research that has suggested chronically homeless adults constitute an aging cohort, with nearly half aged 50xa0years old or older.MethodsThis observational study examined mortality among formerly homeless adults in an HF program. We examined death rates and causes of death among HF participants and assessed the timing and predictors of death among HF participants following entry into housing. We also compared mortality rates between HF participants and (a) members of the general population and (b) individuals experiencing homelessness. We supplemented these analyses with a comparison of the causes of death and characteristics of decedents in the HF program with a sample of adults identified as homeless in the same city at the time of death through a formal review process.ResultsThe majority of decedents in both groups were between the ages of 45 and 64 at their time of death; the average age at death for HF participants was 57, compared to 53 for individuals in the homeless sample. Among those in the HF group, 72xa0% died from natural causes, compared to 49xa0% from the homeless group. This included 21xa0% of HF participants and 7xa0% from the homeless group who died from cancer. Among homeless adults, 40xa0% died from an accident, which was significantly more than the 14xa0% of HF participants who died from an accident. HIV or other infectious diseases contributed to 13xa0% of homeless deaths compared to only 2xa0% of HF participants. Hypothermia contributed to 6xa0% of homeless deaths, which was not a cause of death for HF participants.ConclusionsResults suggest HF participants face excess mortality in comparison to members of the general population and that mortality rates among HF participants are higher than among those reported among members of the general homeless population in prior studies. However, findings also suggest that causes of death may differ between HF participants and their homeless counterparts. Specifically, chronic diseases appear to be more prominent causes of death among HF participants, indicating the potential need for integrating medical support and end-of-life care in HF.

Predictors of Homelessness Among Families and Single Adults After Exit From Homelessness Prevention and Rapid Re-Housing Programs: Evidence From the Department of Veterans Affairs Supportive Services for Veteran Families Program

This article assesses the extent and predictors of homelessness among veterans (both veterans in families with children and single adults veterans) exiting the Supportive Services for Veteran Families (SSVF) program, which is a nationwide homelessness prevention and rapid re-housing program geared primarily toward those experiencing crisis homelessness. Among rapid re-housing participants, 16% and 26% of single adult veterans experienced an episode of homelessness at 1 and 2 years post-SSVF exit; the comparable figures at those follow-up times for veterans in families were 9.4% and 15.5%, respectively. Relatively fewer single adult veterans and veterans in families receiving homelessness prevention services experienced an episode of homelessness at 1 and 2 years post-SSVF exit. veteran-level characteristics, including age, gender, prior history of homelessness, and recent engagement with U.S. Department of Veterans Affairs (VA) health care, were generally more salient predictors of homelessness following SSVF exit than variables measuring SSVF program factors or community-level housing market conditions.

Unsheltered homelessness among veterans: correlates and profiles

AbstractnWe identified correlates of unsheltered status among Veterans experiencing homelessness and described distinct subgroups within the unsheltered homeless Veteran population using data from a screening instrument for homelessness that is administered to all Veterans accessing outpatient care at a Veterans Health Administration (VHA) facility. Correlates of unsheltered homelessness included male gender, white race, older age, lower levels of VHA eligibility, substance use disorders, frequent use of VHA inpatient and infrequent use of VHA outpatient services, and residing in the West. We identified six distinct subgroups of unsheltered Veterans; the tri-morbid frequent users represented the highest need group, but the largest group was comprised of Veterans who made highly infrequent use of VHA healthcare services. Differences between sheltered and unsheltered Veterans and heterogeneity within the unsheltered Veteran population should be considered in targeting housing and other interventions.

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.

Screening for Homelessness in the Veterans Health Administration: Monitoring Housing Stability through Repeat Screening

Objective. This study examined veterans responses to the Veterans Health Administrations (VHAs) universal screen for homelessness and risk of homelessness during the first 12 months of implementation. Methods. We calculated the baseline annual frequency of homelessness and risk of homelessness among all veterans who completed an initial screen during the study period. We measured changes in housing status among veterans who initially screened positive and then completed a follow-up screen, assessed factors associated with such changes, and identified distinct risk profiles of veterans who completed a follow-up screen. Results. More than 4 million veterans completed an initial screen; 1.8% (n=77,621) screened positive for homelessness or risk of homelessness. Of those who initially screened positive for either homelessness or risk of homelessness and who completed a second screen during the study period, 85.0% (n = 15,060) resolved their housing instability prior to their second screen. Age, sex, race, VHA eligibility, and screening location were all associated with changes in housing stability. We identified four distinct risk profiles for veterans with ongoing housing instability. Conclusion. To address homelessness among veterans, efforts should include increased and targeted engagement of veterans experiencing persistent housing instability.

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.

Using Getting To Outcomes to facilitate the use of an evidence-based practice in VA homeless programs: a cluster-randomized trial of an implementation support strategy

BackgroundIncorporating evidence-based integrated treatment for dual disorders into typical care settings has been challenging, especially among those serving Veterans who are homeless. This paper presents an evaluation of an effort to incorporate an evidence-based, dual disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking—Veterans Edition (MISSION-Vet) into case management teams serving Veterans who are homeless, using an implementation strategy called Getting To Outcomes (GTO).MethodsThis Hybrid Type III, cluster-randomized controlled trial assessed the impact of GTO over and above MISSION-Vet Implementation as Usual (IU). Both conditions received standard MISSION-Vet training and manuals. The GTO group received an implementation manual, training, technical assistance, and data feedback. The study occurred in teams at three large VA Medical Centers over 2xa0years. Within each team, existing sub-teams (case managers and Veterans they serve) were the clusters randomly assigned. The trial assessed MISSION-Vet services delivered and collected via administrative data and implementation barriers and facilitators, via semi-structured interview.ResultsNo case managers in the IU group initiated MISSION-Vet while 68% in the GTO group did. Seven percent of Veterans with case managers in the GTO group received at least one MISSION-Vet session. Most case managers appreciated the MISSION-Vet materials and felt the GTO planning meetings supported using MISSION-Vet. Case manager interviews also showed that MISSION-Vet could be confusing; there was little involvement from leadership after their initial agreement to participate; the data feedback system had a number of difficulties; and case managers did not have the resources to implement all aspects of MISSION-Vet.ConclusionsThis project shows that GTO-like support can help launch new practices but that multiple implementation facilitators are needed for successful execution of a complex evidence-based program like MISSION-Vet.Trial registrationClinicalTrials.gov NCT01430741

Testing Alternative Definitions of Chronic Homelessness

OBJECTIVEnThis study examined the potential impact of a proposed change to the official federal definition of chronic homelessness.nnnMETHODSnUsing administrative data from the emergency shelters in a large U.S. city, this study estimated the number of persons identified as chronically homeless under the current definition of chronic homelessness, a proposed new federal definition, and two alternative definitions and examined shelter utilization for each group.nnnRESULTSnFewer than half as many people were considered chronically homeless under the proposed new federal definition compared with the current definition. Persons considered chronically homeless by the proposed new definition and, to a lesser extent, by the two alternative definitions, made heavier use of shelter compared with persons who met the current definition.nnnCONCLUSIONSnA proposed new and two alternative definitions of chronic homelessness are better suited than the existing federal definition for identifying persons with the most protracted experiences of homelessness.

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.

Comparing the Utilization and Cost of Health Services between Veterans Experiencing Brief and Ongoing Episodes of Housing Instability

Housing instability is associated with costly patterns of health and behavioral health service use. However, little prior research has examined patterns of service use associated with higher costs among those experiencing ongoing housing instability. To address this gap, we compared inpatient and outpatient medical and behavioral health service utilization and costs between veterans experiencing brief and ongoing episodes of housing instability. We used data from a brief screening instrument for homelessness and housing instability that has been implemented throughout the US Department of Veterans Affairs (VA) health care system to identify a national sample of veterans experiencing housing instability. Veterans were classified as experiencing either brief or ongoing housing instability, based on two consecutive responses to the instrument, and we used a series of two-part regression models to conduct adjusted comparisons of costs between veterans experiencing brief and ongoing episodes of housing instability. Among 5794 veterans screening positive for housing instability, 4934 (85%) were experiencing brief and 860 (15%) ongoing instability. The average total annual incremental cost associated with ongoing versus brief episodes of housing instability was estimated at