Factors contributing to eviction from permanent supportive housing: Lessons from HUD-VASH

Characteristics and Healthcare Utilization Among Aging Veterans in Supported Housing: A Comparison With Independently Housed Age-Matched Veterans

BACKGROUND AND OBJECTIVES

There is a large and growing population of older, formerly homeless adults living in permanent supportive housing, and there are concerns about how to address their healthcare needs. This study compared veterans aged 55 years and older residing in the Department of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program to an age-matched group of independently housed veterans receiving care through the U.S. Department of Veterans Affairs (VA) healthcare system on health and healthcare service use characteristics.

RESEARCH DESIGN AND METHODS

Cross-sectional analyses were performed on 1,436,537 (66,072 HUD-VASH vs 1,370,465 housed) eligible veterans with index encounter dates between October 1, 2021, and July 31, 2022, using linked data from the VA's Homeless Operations Management and Evaluation System and the Corporate Data Warehouse. Propensity-score-adjusted logistic regression models were constructed to compare aging HUD-VASH versus housed veterans on outpatient and inpatient healthcare utilization.

RESULTS

HUD-VASH veterans were more likely to have physical and mental health morbidities, including substance use disorder than their independently housed counterparts. HUD-VASH veterans were less likely to utilize outpatient medical services, and more likely to use emergency and inpatient care services than independently housed veterans.

DISCUSSION AND IMPLICATIONS

Older veterans in the HUD-VASH program have greater healthcare needs and different patterns of healthcare utilization than their independently housed counterparts. Targeted interventions that better engage and reduce barriers to care among aging populations in supported housing are needed.

Addressing racial and ethnic disparities in premature exits from permanent supportive housing among residents with substance use disorders

BACKGROUND

Permanent supportive housing (PSH) is an evidence-based practice for reducing homelessness that subsidizes permanent, independent housing and provides case management-including linkages to health services. Substance use disorders (SUDs) are common contributing factors towards premature, unwanted ("negative") PSH exits; little is known about racial/ethnic differences in negative PSH exits among residents with SUDs. Within the nation's largest PSH program at the Department of Veterans Affairs (VA), we examined relationships among SUDs and negative PSH exits (for up to five years post-PSH move-in) across racial/ethnic subgroups.

METHODS

We used VA administrative data to identify a cohort of homeless-experienced Veterans (HEVs) (n = 2,712) who were housed through VA Greater Los Angeles' PSH program from 2016-2019. We analyzed negative PSH exits by HEVs with and without SUDs across racial/ethnic subgroups (i.e., African American/Black, Non-Hispanic White, Hispanic/Latino, and Other/Mixed [Asian, American Indian or Alaskan Native, and Native Hawaiian or Other Pacific Islander, and mixed race/ethnicity]) in controlled models and accounting for competing risk of death.

RESULTS

In competing risk models, HEVs with at least one SUD had 1.3 times the hazard of negative PSH exits compared to those without SUDs (95% CI: 1.00, 1.61). When stratifying by race/ethnicity, Other/Mixed race residents with at least one SUD had 6.4 times the hazard of negative PSH exits compared to their peers without SUDs (95% CI: 1.61-25.50). Hispanic/Latino residents with at least one SUD had 1.9 times the hazard compared to those without SUDs; however, this association was not statistically significant (95% CI: 0.85-4.37). African American/Black residents with at least one SUD had 1.2 times the hazard compared to those without SUDs (95% CI: 0.85-1.64), indicating no evidence of an association with negative PSH exits. Non-Hispanic White residents with at least one SUD had 1.1 times the hazard compared to those without SUDs (95% CI: 0.75-1.66), similarly indicating no evidence to suggest an association with negative PSH exits.

CONCLUSIONS

These findings suggest relationships between SUDs and negative PSH exits differ between racial/ethnic groups and suggest there may be value in culturally specific tailoring and implementation of SUD services for these subgroups.

The devastating dance between opioid and housing crises: Evidence from OxyContin reformulation

Housing instability and drug misuse are two of the United States' most pressing challenges, each bearing profound health and societal consequences. A crucial yet largely underexplored question is the extent to which the opioid crisis has intensified housing instability. Our study ventures into this relatively uncharted nexus, investigating how the OxyContin reformulation, a pivotal moment in the U.S. opioid epidemic, impacted eviction rates. Employing a dose-response Difference-in-Differences model and analyzing eviction data from 2004 to 2016, we demonstrate that the OxyContin reformulation precipitated a significant increase in evictions, especially in areas with weak eviction protections or limited access to psychiatric treatment resources. Channel analyses reveal increased marijuana initiation and heightened mental and physical health issues following the reformulation. Moreover, the OxyContin reformulation leads to greater reliance on the Supplemental Nutrition Assistance Program, signaling an escalated financial strain on governmental resources. Finally, we find evidence of increased marital disruption post-reformulation. Our findings underscore the urgent need for collaborative efforts between public health and housing authorities to address both the opioid and housing crises.

Multicomponent Co-Occurring Disorders Treatment and Wraparound Services for Individuals Experiencing Chronic Homelessness

Individuals experiencing chronic homelessness have high rates of persistent co-occurring mental health and substance use disorders (COD), and they often have difficulty with service engagement and retention, resulting in symptom exacerbation and housing loss. This study pilot tested Maintaining Independence and Sobriety Through Systems Integration, Outreach and Networking (MISSION), a multicomponent wraparound treatment approach to improve COD symptoms and housing stability among individuals experiencing chronic homelessness and persistent COD. This open pilot study enrolled and assessed 109 individuals with a COD experiencing chronic homelessness and offered one year of MISSION. Statistically significant improvements were observed in behavioral health symptoms and functioning, days of illicit drug use, and housing stability. By treatment completion, 85% of participants were referred to social and behavioral supports. This pilot study demonstrates that MISSION helped to successfully engage participants in treatment, reduce substance use and mental health symptoms, and improve housing outcomes.

Addressing racial and ethnic disparities in premature exits from permanent supportive housing among residents with substance use disorders

Background

Permanent supportive housing (PSH) is an evidence-based practice for reducing homelessness that subsidizes permanent, independent housing and provides case management-including linkages to health services. Substance use disorders (SUDs) are common contributing factors towards premature, unwanted ("negative") PSH exits; little is known about racial/ethnic differences in negative PSH exits among residents with SUDs. Within the nation's largest PSH program at the Department of Veterans Affairs (VA), we examined relationships among SUDs and negative PSH exits (for up to five years post-PSH move-in) across racial/ethnic subgroups.

Methods

We used VA administrative data to identify a cohort of homeless-experienced Veterans (HEVs) (n = 2,712) who were housed through VA Greater Los Angeles' PSH program from 2016-2019. We analyzed negative PSH exits by HEVs with and without SUDs across racial/ethnic subgroups (i.e., African American/Black, Non-Hispanic White, Hispanic/Latino, and Other/Mixed [Asian, American Indian or Alaskan Native, and Native Hawaiian or Other Pacific Islander, and multi-race]) in controlled models and accounting for competing risk of death.

Results

In competing risk models, HEVs with at least one SUD had 1.3 times the hazard of negative PSH exits compared to those without SUDs (95% CI: 1.00, 1.61). When stratifying by race/ethnicity, Other/Mixed race residents with at least one SUD had 6.4 times the hazard of negative PSH exits compared to their peers without SUDs (95% CI: 1.61-25.50). Hispanic/Latino residents with at least one SUD had 1.9 times the hazard compared to those without SUDs, also indicating a strong relationship with negative PSH exits; however, this association was not statistically significant (95% CI: 0.85-4.37). Black residents with at least one SUD had 1.2 times the hazard compared to those without SUDs (95% CI: 0.85-1.64), indicating no evidence of an association with negative PSH exits. Similarly, Non-Hispanic White residents with at least one SUD had 1.1 times the hazard compared to those without SUDs (95% CI: 0.75-1.66).

Conclusions

These findings suggest relationships between SUDs and negative PSH exits differ between race/ethnic groups and suggest there may be value in culturally specific tailoring and implementation of SUD services for these subgroups.

Neuropsychological functioning, neurobehavioral symptoms, and community reintegration in unstably housed veterans with mental health conditions

Objective: Returning Veterans often have conditions (e.g. posttraumatic stress disorder [PTSD], depression, and history of traumatic brain injury [TBI]) associated with cognitive dysfunction and problems with work, school, housing, and relationships. Rehabilitative efforts in Veterans aim to promote community reintegration, or successful adjustment in one's home, community, and desired social roles. We examined associations between neuropsychological performance, neurobehavioral symptoms, and community reintegration in Veterans. Method: 89 Iraq/Afghanistan Veterans at risk for homelessness and receiving residential mental healthcare completed a neuropsychological assessment and the Community Reintegration for Service Members-Computer Adaptive Test (CRIS-CAT). Neuropsychological components were derived using Principal Component Analysis. Bivariate Pearson correlations between neuropsychological variables, neurobehavioral symptoms, and CRIS-CAT scales (Extent of Participation, Perceived Limitations, and Satisfaction) were used to determine significant correlates of community reintegration. Regression models were used to examine associations between bivariate-significant neuropsychological components, neurobehavioral symptoms, and CRIS-CAT scales. Results: Bivariate analyses revealed that better community reintegration was associated with better performance in attention/executive functioning and fewer neurobehavioral symptoms. Three regression models examining predictors of variance in Extent of Participation, Perceived Limitations, and Satisfaction in community reintegration were statistically significant overall, with only fewer affective symptoms emerging as significantly and uniquely associated with greater participation and greater satisfaction in community functioning. Conclusions: Veterans with fewer affective symptoms reported greater participation and satisfaction with community functioning. Future longitudinal research examining associations between neurobehavioral symptoms, cognition, and risk factors of poorer community reintegration in unstably housed Veterans is warranted.

Predictors of dropout from treatment among patients using specialized addiction treatment centers

OBJECTIVES

This study investigated the use of outpatient care, and sociodemographic and clinical characteristics of patients with substance-related disorders (SRD) to predict treatment dropout from specialized addiction treatment centers. The study also explored risks of adverse outcomes, frequent emergency department (ED) use (3+ visits/year), and death, associated with treatment dropout within the subsequent 12 months.

METHODS

The study examined a cohort of 16,179 patients who completed their last treatment episode for SRD between 2012 and 13 and 2014-15 (financial years: April 1 to March 31) in 14 specialized addiction treatment centers using Quebec (Canada) health administrative databases. We used multivariable logistic regressions to measure risk of treatment dropout (1996-96 to 2014-15), while we used survival analysis controlling for sex and age to assess the odds of frequent ED use and death in 2015-16.

RESULTS

Of the 55 % of patients reporting dropout from SRD treatment over the 3-year period, 17 % were frequent ED users, and 1 % died in the subsequent 12 months. Patients residing in the most socially deprived areas, having polysubstance-related disorders or personality disorders, and having previously dropped out from specialized addiction treatment centers had increased odds of current treatment dropout. Older patients, those with a history of homelessness, past SRD treatment, or more concurrent outpatient care outside specialized addiction treatment centers had decreased odds of treatment dropout. Patients who dropped out were subsequently at higher risk of frequent ED use and death.

CONCLUSIONS

This study highlighted that patients with more severe problems and previous dropout may need more sustained and adequate help to prevent subsequent treatment dropout. Specialized addiction treatment centers may consider enhancing their follow-up care of patients over a longer duration and better integrating their treatment with other outpatient care resources to meet the multiple needs of the more vulnerable patients using their services.

“It's no foundation, there's no stabilization, you're just scattered”: A qualitative study of the institutional circuit of recently-evicted people who use drugs

People who use drugs (PWUD) commonly experience housing instability due to intersecting structural vulnerabilities (e.g., drug prohibition, discriminatory housing policies), and prejudicial or illegal evictions are common. In Vancouver, Canada, evictions have proliferated in the Downtown Eastside, a historically low-income neighbourhood with high rates of drug use and housing instability, resulting in many PWUD being evicted into homelessness. This study characterizes housing trajectories of recently-evicted PWUD through the lens of the institutional circuit of homelessness, and explores how wider contexts of structural vulnerability shape experiences within this. Qualitative interviews were conducted with PWUD recently evicted in the Downtown Eastside (<60 days). Peer research assistants recruited 58 PWUD through outreach activities. All PWUD participated in baseline interviews on the causes and contexts of evictions. Follow-up interviews were completed with 41 participants 3-6 months later, focusing on longer-term impacts of eviction, including housing trajectories. Most participants were evicted into homelessness, remaining so at follow-up. Participants described patterns of residential instability consisting of frequent cycling between shelters, streets, and kin-based networks. While participants normalized this cycling as characteristic of their marginalized social positions, narratives revealed how the demands of the institutional circuit deepened vulnerabilities and prolonged experiences of homelessness. Experiences were framed by participants' (in)ability to navigate survival needs (e.g., shelter, drug use), with tensions and trade-offs between needs increasing participants' and their peers' risks of harms. Constructions of agency further shaped experiences; accounts highlighted tensions between the control inherent to indoor spaces and participants' need for autonomy. Findings demonstrate how the demands of the institutional circuit foregrounded structural vulnerabilities to perpetuate cycles of instability. Interventions that address survival needs and preserve agency will be necessary to mitigate risks within the institutional circuit, in tandem with upstream interventions that target housing vulnerability and broader social-structural conditions (e.g., poverty, affordability) that entrap recently-evicted PWUD in the institutional circuit.

Health Service Access Among Homeless Veterans: Health Access Challenges Faced by Homeless African American Veterans

Veteran homelessness is a public health crisis, especially among the disproportionate number of minority veterans in the homeless veteran population. African American homeless veterans in particular face unique challenges accessing appropriate health care services to meet their medical needs. Their needs are often underrepresented in the literature on veteran homelessness. Drawing together over 80 studies and government reports from the last two decades, this review provides a timely synopsis of homeless veterans' health care access, with a particular focus on the barriers faced by African American veterans. This review employs Penchansky and Thomas' Access Model to frame health access barriers faced by homeless veterans, dialing in on what is known about the experience of African American veterans, within the five dimensions of access: Availability, Accessibility, Accommodation, Affordability, and Acceptability. Actionable guidance and targeted interventions to address health access barriers for all veterans are delineated with a focus on the need to gather further data for African American homeless veterans and to consider tailoring interventions for this important and underserved group.

Frequent Episodic Utilizers of Veterans Health Administration Homeless Programs Use: Background Characteristics and Health Services Use

OBJECTIVE

To assess sociodemographic, diagnostic, and services use factors associated with veterans' repeated, episodic use of Veterans Health Administration (VHA) Homeless Programs.

DESIGN

This retrospective cohort study used stepwise multivariate logistic regression to assess the odds of veterans being frequent episodic utilizers of VHA Homeless Programs (ie, ≥4 services use episodes during the observation period).

SETTING

The study used administrative data from veterans who accessed VHA services across the United States.

PARTICIPANTS

The sample comprised 31 098 veterans who completed a VHA Homeless Program intake assessment in 2013 and accessed VHA Homeless Programs during 2013-2016.

MAIN OUTCOME MEASURE

Frequent episodic use of VHA Homeless Programs (ie, ≥4 services use episodes during the observation period).

RESULTS

Only 2.4% of the study sample had 4 or more episodes of VHA Homeless Program use during the observation period; risk factors included experience of military sexual trauma, history of incarceration, diagnosis of psychosis and substance use disorder, and use of acute care.

CONCLUSIONS

Addressing veterans' needs related to poverty, income, and postincarceration reintegration may reduce the frequent episodic use of VHA Homeless Programs. Interventions embedded in emergency departments and inpatient units may also be considered.

Housing outcomes among homeless-experienced veterans engaged in vocational services

Though unemployment and homelessness are closely intertwined, vocational services are rarely prioritized for homeless-experienced individuals engaging in housing services. Our goal was to examine associations between vocational service use and housing outcomes among homeless-experienced Veterans engaged in permanent supportive housing. We obtained data from Veterans Health Administration (VHA) medical record and homelessness registry data for homeless-experienced Veterans engaged in U.S. Department of Veterans Affairs (VA) Greater Los Angeles' permanent supportive housing program from October 2016 to September 2017 (n = 1,200). We used multivariate logistic regression to examine whether vocational service use was associated with housing attainment and/or premature permanent supportive housing exits. We found that Veterans in permanent supportive housing who used vocational services were more likely to attain housing (OR = 2.52, p < .001) than their peers who did not use these services. There were no between-group differences in the odds of premature exits from the permanent supportive housing program (OR = 1.92, p = .425). Our study suggests that, among homeless-experienced Veterans engaged in permanent supportive housing programs, those who use vocational services potentially may be more likely to attain housing. However, future research can better elucidate the pathways underlying vocational service use and housing outcomes for individuals in permanent supportive housing programs. Greater integration of vocational services and permanent supportive housing programs, and encouragement of vocational service use may enhance housing outcomes among permanent supportive housing participants. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Exploring factors related to supportive housing tenure and stability for people with serious mental illness

Overall, the retention of people with serious mental illness (SMI) in supportive housing is high. However, some supportive housing settings report average stays of only 15 months, and others report declines in housing retention over time. Many studies report variables associated with supportive housing stability and tenure, but there are few extensive, focused investigations on the subject. Hence, a literature review was conducted to investigate factors associated with supportive housing stability and tenure among people with SMI. The review of the included 28 papers reveals that the factors associated with supportive housing stability and tenure fell into two general categories of individual factors (including psychiatric factors and prior homelessness), and contextual factors (including program characteristics and sense of community and social support). In conclusion, further focus on contextual factors, as well as a potential reframing of individual factors as contextual, may be helpful in addressing issues related to supportive housing stability and tenure for people with SMI.

Temporary Financial Assistance Decreased Health Care Costs For Veterans Experiencing Housing Instability

Compared with housed people, those experiencing homelessness have longer and more expensive inpatient stays as well as more frequent emergency department visits. Efforts to provide stable housing situations for people experiencing homelessness could reduce health care costs. Through the Supportive Services for Veteran Families program, the Department of Veterans Affairs partners with community organizations to provide temporary financial assistance to veterans who are currently homeless or at imminent risk of becoming homeless. We examined the impact of temporary financial assistance on health care costs for veterans in the Supportive Services for Veteran Families program and found that, on average, people receiving the assistance incurred $352 lower health care costs per quarter than those who did not receive the assistance. These results can inform national policy debates regarding the proper solution to housing instability.

Explaining Service Use and Residential Stability in Supported Housing: Problems, Preferences, Peers

BACKGROUND

The behavioral model of health service use identified health needs, service preferences (predispositions), and service availability (enabling factors) as important predictors, but research has not conceptualized consistently each type of influence nor identified their separate effects on use of substance abuse and mental health services or their value in predicting service outcomes.

OBJECTIVES

To test hypotheses predicting use of substance abuse and mental health services and residential stability and evaluate peer specialists' impact.

RESEARCH DESIGN

Randomized trial of peer support added to standard case management in VA-supported housing program (Housing and Urban Development-VA Supportive Housing program).

SUBJECTS

One hundred sixty-six dually diagnosed Veterans in Housing and Urban Development-VA Supportive Housing program in 2 cities.

MEASURES

Average VA service episodes for substance abuse and mental illness; residential instability; preferences for alcohol, drug, and psychological services; extent of alcohol, drug, and psychological problems; availability of a peer specialist.

RESULTS

Self-assessed health needs, mediated by service preferences, and assignment to a peer specialist predicted use of VA behavioral health services and residential stability, as did chronic medical problems, sex, and race.

CONCLUSIONS

The behavioral model identifies major predictors of health service use and residential stability, but must recognize the mediating role of service preferences, the differing effects of alcohol and drug use, the unique influences of social background, and the importance of clinical judgment in needs assessment. Service availability and residential stability can be increased by proactive efforts involving peer specialists even in a health care system that provides services without a financial barrier.

"I achieved being an adult": A Qualitative Exploration of Voluntary Transitions from Permanent Supportive Housing

This study examined how individuals voluntarily leaving permanent supportive housing (PSH) through a Moving On initiative experienced the transition from PSH services to mainstream housing. Participants (N = 25) were purposively sampled from five supportive housing agencies in a Moving On initiative. A modified grounded theory approach was used to analyze semi-structured, post-move interviews. Participants described the transition from PSH as a process that involved gaining freedom from negative aspects of the PSH environment and a stagnation in services, adjusting to a new environment and the loss of familiar supports, taking on new responsibilities of self-advocacy and managing new financial burdens, and feeling empowered to move on to next steps, which ultimately, led to achievement of independence. Various contextual conditions, including PSH- and postmove housing type, influenced participants' experience of this process. Findings can inform future Moving On initiatives, implementation of PSH programs, as well as the design of the larger homeless service system.

Systematic review of psychosocial factors associated with evictions

Evictions from rented accommodations are a common pathway to homelessness and can negatively impact the lives of individuals and communities worldwide. There have been only few interventions developed to address evictions, and it is important to first understand factors associated with evictions. This systematic review included all available peer-reviewed articles on the topic published in the international literature from 1900 to 2017 and identified 10 peer-reviewed studies of evictions conducted in the United States, Canada, Amsterdam and Britain. From these studies, four categories of factors associated with evictions were identified. These factors were financial hardships, sociodemographic characteristics, substance use and other health problems. While many studies had large sample sizes, the majority of studies were cross-sectional. Together, our review found that there were several salient factors known to be associated with evictions which may benefit from intervention. However, more prospective studies on evictions and development of interventions are needed.

Motivational and cognitive correlates of community integration in homeless veterans entering a permanent supported housing program

Homelessness is a major public health problem, and serious mental illness (SMI) is highly prevalent in the homeless population. Although supported housing services-which provide permanent housing in the community along with case management-improve housing outcomes, community integration typically remains poor, and little is known about the underlying determinants of poor community integration postresidential placement. The general SMI literature has indicated that motivational and cognitive ability factors are key determinants of successful community integration, which provides a foundation for examining this issue. This study evaluated whether interview- and performance-based assessments of motivation, nonsocial and social-cognitive ability, and psychiatric symptoms were associated with community integration indices in 2 samples of homeless veterans either with (N = 96) or without (N = 80) a psychotic disorder who had recently been admitted to a supported housing program but who had not yet attained housing. Motivation indices, including experiential negative symptoms and defeatist performance attitudes, stood out as the most robust correlates (rs = -.30 to -.69) of community integration across both samples, particularly for social role participation. Demographics, general psychiatric symptoms, and nonsocial cognition showed generally weak relations with community integration, though social cognition showed a few relations. The consistent findings across samples point to the importance of motivational factors for understanding the determinants of poor community integration in this complex population. Further, interventions that target motivational challenges may have widespread usefulness for enhancing community integration outcomes beyond obtaining housing. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Permanent Supportive Housing and Specialized Co-Occurring Disorders Wraparound Services for Homeless Individuals

OBJECTIVE

Among individuals experiencing chronic homelessness, there is a high rate of co-occurring mental health and substance use, which has traditionally been addressed through the delivery of permanent supportive housing along with substance use and mental health services. However, this population often has difficulty engaging in treatment for co-occurring disorders, which can result in exacerbation of symptoms and housing loss. Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking (MISSION) is a co-occurring mental health and substance use wraparound approach that was pilot-tested alongside Permanent Supportive Housing (PSH) to improve treatment access and engagement. This pilot was part of a state plan to end homelessness in the Boston metro area.

METHODS

This open pilot study enrolled 136 individuals who were chronically homeless and offered one year of MISSION along with PSH. Program participants also received baseline and 6- and 12-month follow-up assessments.

RESULTS

At one-year follow-up, 82.4% of the program participants were housed in PSH. However, due to limited affordable housing in the Boston metro area, it took on average 6.20 months to house the program participants. Furthermore, while MISSION was feasible to implement alongside PSH, fidelity to the MISSION model was lower than expected. This pilot also examined the role of housing status on clinical outcomes and found that the program participants who were housed at the time of discharge displayed a statistically significant improvement in emergency room visits for mental health complaints, the Psychosis subscale of the Behavior and Symptom Identification Scale (BASIS-32), illegal drug use, and pharmacotherapy treatment.

CONCLUSIONS

This pilot study demonstrated that systematically integrating PSH and MISSION can improve access and engagement in care, housing retention, and mental health outcomes. Despite the preliminary success and while taking into account the limitations of the open single-group pre/post design, this study also identified the lack of affordable housing as a potential barrier to placement as well as the critical role of housing for improved clinical outcomes. Randomized controlled trials are needed to test MISSION with PSH as well as perhaps PSH with and without MISSION to tease apart the effects of integrating both approaches simultaneously.

Barriers and facilitators to housing access and maintenance in HUD-VASH: Participant and staff perspectives

Though the U.S. Departments of Housing and Urban Development (HUD) and Veterans Affairs (VA) supportive housing (HUD-VASH) program endeavors to address barriers to Veterans accessing and maintaining housing, participants report challenges that lead to program exits. This study aims to understand participants' views on the factors contributing to their exits from HUD-VASH, as well as how program staff may respond to challenges. This mixed methods study includes four sources of data: (1) surveys with Veterans, (2) semi-structured interviews with a subsample of surveyed Veterans, (3) Veterans' administrative data from VA electronic data systems, and (4) focus groups with staff from local public housing authorities and VA case management teams. Veterans reported barriers to housing access (e.g., difficult procedures, lack of communication, lack of affordable and adequate housing stock) and housing maintenance (e.g., program rules, mental health and substance use, access to resources), and staff described strategies devised, at the local level, in response to these issues (e.g., better engagement with property owners, funds for deposits and household goods, increased interagency collaboration through HUD-VASH Boot Camps). Findings can inform communities seeking to eliminate Veteran homelessness through HUD-VASH and other supported housing programs.

Mental health supported accommodation services: a systematic review of mental health and psychosocial outcomes

BACKGROUND

Post-deinstitutionalisation, mental health supported accommodation services have been implemented widely. The available research evidence is heterogeneous in nature and resistant to synthesis attempts, leaving researchers and policy makers with no clear summary what works and for whom. In this context, we undertook a comprehensive systematic review of quantitative studies in order to synthesise the current evidence on mental health and psychosocial outcomes for individuals residing in mental health supported accommodation services.

METHODS

Using a combination of electronic database searches, hand searches, forward-backward snowballing and article recommendations from an expert panel, 115 papers were identified for review. Data extraction and quality assessments were conducted, and 33 articles were excluded due to low quality, leaving 82 papers in the final review. Variation in terminology and service characteristics made the comparison of service models unfeasible. As such, findings were presented according to the following sub-groups: 'Homeless', 'Deinstitutionalisation' and 'General Severe Mental Illness (SMI)'.

RESULTS

Results were mixed, reflecting the heterogeneity of the supported accommodation literature, in terms of research quality, experimental design, population, service types and outcomes assessed. There is some evidence that supported accommodation is effective across a range of psychosocial outcomes. The most robust evidence supports the effectiveness of the permanent supported accommodation model for homeless SMI in generating improvements in housing retention and stability, and appropriate use of clinical services over time, and for other forms of supported accommodation for deinstitutionalised populations in reducing hospitalisation rates and improving appropriate service use. The evidence base for general SMI populations is less developed, and requires further research.

CONCLUSIONS

A lack of high-quality experimental studies, definitional inconsistency and poor reporting continue to stymie our ability to identify effective supported accommodation models and practices. The authors recommend improved reporting standards and the prioritisation of experimental studies that compare outcomes across different service models.

An evidence-based co-occurring disorder intervention in VA homeless programs: outcomes from a hybrid III trial

BACKGROUND

Evidence-based treatment for co-occurring disorders is needed within programs that serve homeless Veterans to assist with increasing engagement in care and to prevent future housing loss. A specialized co-occurring disorders treatment engagement intervention called Maintaining Independence and Sobriety Through Systems Integration, Outreach and Networking - Veterans Edition (MISSION-Vet) was implemented within the Housing and Urban Development - Veterans Affairs Supportive Housing (HUD-VASH) Programs with and without an implementation strategy called Getting To Outcomes (GTO). While implementation was modest for the GTO group, no one adopted MISSION in the non-GTO group. This paper reports Veteran level outcome data on treatment engagement and select behavioral health outcomes for Veterans exposed to the MISSION-Vet model compared to Veterans without access to MISSION-Vet.

METHODS

This hybrid Type III trial compared 81 Veterans in the GTO group to a similar group of 87 Veterans with mental health and substance use disorders from the caseload of staff in the non-GTO group. Comparisons were made on treatment engagement, negative housing exits, drug and alcohol abuse, inpatient hospitalizations, emergency department visits and income level over time, using mixed-effect or Cox regression models.

RESULTS

Treatment engagement, as measured by the overall number of case manager contacts with Veterans and others (e.g. family members, health providers), was significantly higher among Veterans in the GTO group (B = 2.30, p = .04). Supplemental exploratory analyses between Veterans who received "higher" and "lower" intensity MISSION-Vet services in the GTO group failed to show differences in alcohol and drug use, inpatient hospitalization and emergency department use.

CONCLUSIONS

Despite modest MISSION-Vet fidelity among staff treating Veterans in the GTO group, differences were found in treatment engagement. However, this study failed to show differences in alcohol use, drug use, mental health hospitalizations and negative housing exits over time among those Veterans receiving higher intensity MISSION-Vet services versus low intensity services. This project suggests that MISSION-Vet could be used in HUD-VASH to increase engagement among Veterans struggling with homelessness, a group often disconnected from care.

TRIAL REGISTRATION

Clinicaltrials.gov, registration number: NCT01430741 , registered July 26, 2011.