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The National Center on Homelessness Among Veterans

….to promote recovery oriented care for Veterans who are homeless or at-risk for homelessness.

The primary goal of the Center is to develop, promote, and enhance policy, clinical care research, and education to improve homeless

services so that Veterans may live as independently and self-sufficiently as possible in a community of their choosing.

• The Center was awarded in May 2009• Co-located at Philadelphia VAMC and Tampa VAMC• Academic Partners:

• University of Pennsylvania • University of South Florida

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Policy Analysis

Model Development

Education

Research

Center Structure

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Center Personnel

• Vince Kane, MSW - Center Director• Roger Casey, PhD - Deputy Director• Dennis Culhane, PhD - Director of Research• Steve Metraux, PhD - Associate Director of

Research, Philadelphia• Robert Rosenheck, MD - Associate Director• Roger Peters, PhD - Investigator • John Kuhn, MSW, MPH - Investigator• Colleen Clark, PhD - Associate Director of

Research, Tampa

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New Directions (Role of the Center)

• Focus on the what works – When?– With Who?

• How do we get to Zero homelessness among Veterans and keep it there?

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Focus of Research to Date

• Last 20+ years • Why are there homeless Veterans

(epidemiology)?• How effective are the programs?

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Percentage of veterans among homeless and domiciled US males in 1996: by age group

15%

60%

47%

34%

46%

63%

49%

38%

14%

8%

0%

20%

40%

60%

20-34 PostVN ('82 - )

35-44 PostVN ('73-'81)

45-54 (VN) 55-64 (Korea-VN)

>64 (WWII +Korea)

Perc

enta

ge o

f Vet

eran

s

HomelessDomiciled

From NSHAPC, 2000 and CPS, 1996

O.R =2.0 O.R =3.2 O.R 1.4 O.R =.89 O.R =.88

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Percentage of veterans among homeless1 and domiciled US women in 1996

3.12%

1.27%

0%

1%

2%

3%

4%

5%

6%

All US Women

Perc

enta

ge o

f Vet

eran

s

HomelessDomiciled

1. Community sample from NSHAPC; CPS, 1996

Odds Ratio = 3.6

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Percentage of OIF/OEF veterans among all homeless1

and domiciled veterans (2007)

1.30%

4.00%

0.00%

2.50%

5.00%

OIF/OEF VeteransPere

cent

age

of O

IF/O

EF V

eter

ans

HomelessDomiciled

Odds Ratio = 0.39

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Do veterans think their homelessness is associated with military service?

• On average, homeless Veterans became homeless 12.5 years AFTER discharge from the military.

• When asked “Did military service increase your risk of homelessness?”– No 59%– Somewhat 25%– Very much 16%

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Clinical Outcomes

• VA has evaluated outcomes of over 4,500 homeless Veterans in nine different program initiatives.

• Follow-up durations of 8 months to 5 years

• Typically, 70% - 80% are housed 1 year after program entry or discharge.

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Outcomes in the HUD-VA Supported Housing Program:Percentage of Days Housed in Past 60 days

0

20

40

60

80

100

Baseline 6 mos. 1 year 18 mos. 2 years 3 years

% D

ays

Hou

sed

in P

ast 6

0 D

ays

VASH exp. : N=182Case mgt. N=88Std. care: N=187

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Outcomes in the HUD-VA Supported Housing Program:Percentage of Days Homeless in Past 60 days

0

10

20

30

40

50

Baseline 6 mos. 1 year 18 mos. 2 years 3 years

% D

ays

Hom

eles

s in

Pas

t 60

Day

s

VASH exp. : N=182Case mgt. N=88Std. care: N=187

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Outcomes in the HUD-VA Supported Housing Program:Days of Alcohol Use in past 30 days

0

2.5

5

7.5

10

Baseline 6 mos. 1 year 18 mos. 2 years 3 years

Day

s of

Alo

coho

l Use

in P

ast 3

0 D

ays

VASH exp. : N=182Controls

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Days Competitive Employment in Supported Employment (IPS) [Adjusted Means (Rosenheck and Mares 2008)]

0

2

4

6

8

10

12

bl 3-mo 6-mo 9-mo 12-mo 15-mo 18-mo 21-mo 24-mo

IPSControl#

Day

s

16

4 45 5

1011 11

13

4

6 6 67

87 7

0

5

10

15

Year - 4 Year - 3 Year - 2 Year - 1 Year + 1 Year + 2 Year + 3 Year + 4

Year Before (-) or After (+) Program Initiation

Perc

ent R

ecei

ved

Ben

efits

Joint Outreach Sites Comparison Sites

SSA-VA Joint Outreach: Rates of Award Among All Outreach Veterans (N=34,431)

Intervention

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New Directions (short list)

• Update and Expand Epidemiologic Studies• Improve Clinical Outcomes: Evaluate

Smoking Cessation (80% currently smoke)• Test Computerized Psychotherapy for

Substance Abuse• Evaluate Traumatic Brain Injury Among

Homeless Veterans• Justice Outreach/Jail Diversion• Test New Case Management Models

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Goals of Initial Research Projects in the Center

• Fine-tune program targeting by geographic regions and demographic groups

• Improve effectiveness of VA homeless programs

• Improve coordination between VA and non-VA homeless services

• Develop prevention-oriented system for returning Veterans

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Multi-Site Prevalence Study

• Based on Homeless management Information System (HMIS) and VA data from 10 jurisdictions across US

• Compares prevalence of homelessness among Veteran and general populations

• Identifies demographic groups (gender, age, race, poverty) among Veterans that are at highest risk for homelessness in multiple jurisdictions

• Supports targeting decisions

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AHAR Supplement

• Annual Homeless Assessment Report • AHAR Supplement:

– Same format as AHAR– Focus is exclusively on Veterans– Can provide estimates of Veterans who use

mainstream homeless services– Data available for two-thirds of the CoC’s in the US;

first national data since 1996– Due out: October/November 2010

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Services Utilization Research

• Based on matching data on homeless Veterans and records of other services

• Data matches may include:– Homeless services (VA & Non-VA)– Health & Mental Health Services (VA & Non-VA)– Criminal Justice

• Addresses questions related to:– Mainstream services use by homeless Veterans– Overlaps between VA and non-VA services– Costs and cost offsets

• Goal: Improved Coordination between VA and Non-VA services

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Veterans Affairs Supportive Housing (VASH)

• Use VASH to build an evidence base for effective supportive housing models

• Evaluate different housing & case management configurations

• Case management (CM) dynamics:– Intensity & duration of case management regimens– Start points and tapering schedules– Types of services provided in conjunction with CM– Peer support– Substance Abuse– Fidelity

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Homelessness Among Returning OEF/OIF Veterans: Risk Resiliency Study

• Follows a cohort of returning OEF (Afghanistan) and OIF (Iraq) veterans to determine factors contributing to risk of homelessness

• Detailed data from induction & discharge interviews (DoD) and homeless data (VA)

• Builds on VA homelessness research from previous eras

• Rich data on circumstances of Veterans to link with subsequent homelessness

• Data will inform the design of prevention efforts

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Evaluating Housing Programs for Homeless Veterans

In order to determine the best match of Veterans housing and housing services, this study will:

• Evaluate community-based housing services• Define key features of the housing and

associated services• Determine criteria that measure these features• Conduct assessments to describe the housing

options

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Evaluation of Housing and Housing Services Study

Program Characteristics

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

5.00

Obtaining

Housing

Housing-related

Services

Linkages forServices &Resources

Organizational

Clim

ate

Staff -Consum

erInteraction

Host Agency

Characteristics

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TBI in the Homeless Veteran Population

Demographic Data of Homeless Veterans with TBI:• 22% of casualties of returning Veterans

(Institute of Medicine, 2008) • 59% of admissions to Walter Reed between January ‘03 –

February ‘05 (Institute of Medicine, 2008)• 33% of subjects diagnosed with substance use disorders

had indications of TBI (Walker et al, 2008)• 77% of homeless Veterans seen in VA Homeless Programs

had a primary or secondary diagnosis of Substance Use Disorder (NEPEC, 2008)

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TBI in the Homeless Veteran Population

• Examine national prevalence

• Formulate education and training for VA and community-partner staff

• Develop and implement models of case management, housing support services and residential treatment

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TBI in the Homeless Veteran Population

The study is integral to the Center’s goal of examining the homeless Veteran population to:

• Further understand the population and needs• Develop evidence-based training and programs that

will enhance current services• Work toward ending homelessness among Veterans

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Homeless Veterans in the Criminal Justice System

• 15-16% of jail inmates are homeless, including significant numbers of Veterans• 30-39% of homeless inmates have a mental health disorder• 78% of this group have substance use disorders• More likely to have violent charges, held in jail longer, rapid cycling, high utilizers of services

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Homeless Veterans in the Criminal Justice System

Implications-Interventions-Research:(1) Early identification/screening in justice settings(2) Training (law enforcement, courts, jail, probation)(3) Triage and diversion (4) Coordination and linkage with VA services

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Veteran’s Justice System Involvement

• First phase: comprehensive survey of the structure and function of the Veterans Justice Outreach Specialists (VJO Specialists) at all 153 VA Medical Centers.

• Second phase: utilize this information for a study where various elements of the VJO specialist positions will be studied in relation to a variety of outcomes.

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