Homelessness among Veterans with Serious Mental Illness

Public Health Impact and Outreach

Amy M. Kilbourne, PhD, MPHVA Ann Arbor Center for Clinical Management Research

Associate Director, VA Ann Arbor SMITREC

University of Michigan Department of Psychiatry and Comprehensive Depression Center

Acknowledgements

VA Health Services Research and Development

VA National Center on Homelessness among Veterans

VA Office of Mental Health Services VHA Clinical Operations (10NC)

SMITREC NIMH (R01 MH 79994, MH 74509)

VA Homeless HSR Initiative

The VA has a wide range of programs and initiatives focused on addressing the President’s goal of ending homelessness among Veterans

The VA Homeless Health Services Research Initiative, starting in 2010, brings together four projects in partnership with the National Center on Homelessness among Veterans that seek to enhance the role VA research can play in ending homelessness

VA Homeless HSR Initiative Homeless Solutions in a VA Environment

Stefan Kertesz, MD, Birmingham VA

Population-based Outreach Services to Reduce Homelessness among Veterans with SMI Amy M. Kilbourne, PhD, Ann Arbor VA

Addiction Housing Case Management for Homeless Veterans Enrolled in Addiction Treatment Andrew J. Saxon, MD, Seattle VA

Aligning Resources to Care for Homeless Veterans Thomas O’Toole, MD, Providence VA

Background

Homelessness disproportionately affects Veterans with serious mental illness (SMI) Social isolation, substance abuse, incarceration,

symptom burden, limited employment

VA: largest single provider of SMI care Treatment drop-out adverse outcomes Public health models to reduce preventable

mortality

Homelessness and SMI

SMI: schizophrenia, schizoaffective disorder, bipolar disorder, other psychosis diagnosis

12.3% of Veterans with SMI had ICD-9 code or encounter for homelessness services in FY 2009

25% of the U.S. homeless population has SMI; 6% of overall U.S. population

SMI: functioning employment housing

Sources: VA National Psychosis Registry; NIMH, 2009

Homeless Veterans Health Disparities Framework

Adapted from CHERP Health Disparities Conceptual Framework (Kilbourne et al. 2006)

Intervening (Reducing Homelessness)

Individual/community (e.g., peer support, outreach programs)

Provider (e.g., outreach, collaborative care)

System (e.g., Housing First, HUD-VASH vouchers, GPD)

Detecting Define Homelessness –related outcomes, assess gaps (e.g., Stable Housing, Access, Quality of Life)

Defining Populations Vulnerable to Poor Outcomes (e.g., SMI. Dual-dx, OEF-OIF)

Understanding Identifying Determinants of reduced homelessness at the Following Levels:

Individual (e.g., sociodemographics, need)

Provider (e.g., health services encounter, training)

System (e.g., organization, cross-agency collaborations)

Understanding Risk Factors among Homeless Veterans

Veteran Factors•Sociodemographics•Preferences•Illness burden•Self-efficacy•Geographic distance

Outreach Encounter•Communication•Competing needs•Contact availability

Provider Factors•Knowledge•Competing demands•Resources

Community& Government-wide Resources

VAMC Communication and Policy Factors•Site level organization, financing, and delivery•Site level organization culture, quality improvement

Figure 2: Multi-level Determinants of Homelessness Health Disparities

Characteristics of Veteran Patients with SMI with a Recent History of Homelessness

N=234,674Homeless (N=28,805)

Not Homeless (N=205,869)

% % Women 7.7 10.6

African American 38.8 19.2Married 16.6 38.0

Service connected 36.4 55.7Substance use disorder 70.7 24.5

Any Medical co-morbidity 91.6 89.1On atypical anti-psychotics 46.6 45.4

Past-year hospitalization 49.9 23.0

Intensive case management 19.9 4.2

Mortality: Homelessness and SMI

0

5

10

15

20

25

30

2000 2001 2002 2003 2004 2005 2006 2007

Differences in Years of Potential Life Lost for All-Cause Mortality among VA Patients

Homeless SMI

Homeless Non-SMI

Non-Homeless SMI

Non-homeless Non SMI

Barriers to Treating the SMI Homeless Population

Fragmentation of Care: administrative and financial separation

Housing conditional on treatment

Lack of recovery-orientation (distrust of system)

Lack of coordination with criminal justice system

VA National Center on Homelessness among Veterans

Promote recovery-oriented care for Veterans who are homeless or at risk for homelessness

Personalized access to treatment, education and outreach

Treatment models supplement psychotherapy and medication with services for concurrent disorders (e.g., substance abuse), caregiver, and peer support

Outreach Program and Reduced Mortality among Veterans with SMI

VA Office of the Medical Inspector (OMI)

Quality improvement study from 2007-2009 led by the VA Office of the Medical Inspector

Population-based registry: identify SMI patients who had dropped out of care

Data source: VA National Psychosis Registry SMI diagnosis and last seen in VA in FY 2005, no VA

outpatient visits from 06-07 and were alive up to FY 07

Davis CL, Kilbourne AM, Pierce, JR, Blow F, Winkle B, Lang erg R, Visnic S, Lyle D, Hocked E, Philips Y. Reduced Mortality Among VA Patients with Schizophrenia or Bipolar Disorder Lost to Follow-upand Engaged in Active Outreach to Return to Care

Outreach Program Methods

Lists of patients sent to points of contact (POCs) at 138 VA medical centers

POCs contacted Veterans, scheduled appointments

Follow-up data linked to NPR and VA/SSA mortality data through 2009

Outreach Program Results

4,791 patients with SMI lost to follow-up Typically unmarried, male, and not service-

connected

Diagnosed medical comorbidities: Diabetes (14%) Dementia (6%) Cerebrovascular disease (4%) Cancers (3%)

Outreach Program Results

3,315 of the 4,791 patients (69%) contacted 2,375 (72%) had returned to VA care by 2009 Reasons for not returning to care:

Key Reasons: %

Not perceiving a need for care 33

Not satisfied with VA services 22

Lack of transportation or time 20

Wanted to solve problem by themselves

7

Outreach Program and Mortality

All-cause mortality through 2009 (N=4,791):

Veterans who returned for care0.5%

Veterans who did not return for care 6.3%

Outreach Program: Predictors of Mortality

Variable Odds RatioDid Not Return for Care 14.3**

Age >=65 (vs. <45) 3.6

Age 45-64 (vs. <45) 24.5**

Male (vs. Female) 1.3

Single (vs. Married) 1.3

Schizophrenia (vs. bipolar diagnosis) 1.4*

Charlson score = 1 (vs. 0) 2.0**

Charlson score = 2 (vs. 0) 3.3**

Charlson score = 3 (vs. 0) 2.8

*P<0.06, **P<0.001

VA Outreach Implementation2/2006 Publication of initial article (Copeland et al.)

1/2007 Outreach program launched by OMI

2009 OMI program completed, briefings

2010 OMI Program final report

1/2011 Patient Care Services replicates Outreach program (OMHS)

7/2011 OMHS Program Directive

9/2011 HSR&D/NCHV Homeless Outreach

Near real-time monitoring

Partnerships with community organizations

Implications: Practice-based Research

Veterans with SMI lost from follow-up care can be identified & engaged Reduced mortality Many POCs were VA Local Recovery Coordinators

More intensified efforts for homeless Align research with rapid implementation

Leverage existing programs Population-based panel management Local provider input