Veteran Homelessness: Veteran Homelessness: the Mental Health the Mental Health Challenge WithinChallenge WithinThomas O’Toole, MD1

Amy Kilbourne, PhD, MPH2

Andrew Saxon, MD, MSc3

Stefan G. Kertesz, MD, MSc4

1. Center on Systems, Outcomes & Quality in Chronic Disease & Rehabilitation (Providence, RI)

2. Center for Clinical Management Research (Ann Arbor, MI)

3. Center of Excellence in Substance Abuse Treatment and Education (Settle, WA)

4. Center for Surgical, Medical Acute Care Research and Transitions (Birmingham, AL)

ObjectivesObjectivesShow how multiple paths in and out

of homelessness necessitate variability in policy and clinical responses

Use research examples to highlight strengths and shortcomings of novel responses focused on:◦ Addiction◦ Housing◦ Mental Health◦ Primary Care

SummarySummaryKertesz: framework for

multimodal responsesKilbourne: public health models

for preventable mortality O’Toole: care needs following

treatment initiationSaxon: housing and addiction

treatmentOpinions are those of the presenters and do not represent positions of the US Department of Veterans Affairs

BackgroundBackgroundSingle-night prevalence

107,000 (2008, CHALENG)75,609 (2009 Veteran AHAR)33 of every 10,000 veterans (prevalence)

Conditionsmedicalmentaladdictionmortality

Current Mental & Addiction Current Mental & Addiction Disorders among Persons Disorders among Persons Experiencing HomelessnessExperiencing Homelessness

1. Fazel. PLoS Med 5(12):e225; 2008. 2. National Survey of Homeless Assistance Providers and Clients, 2000 (data from

1996)

Concerns and ResponsesConcerns and ResponsesVeterans who are homeless raise:

◦ethical concern (civic)◦policy concern (utilization, system strain,

community impact)◦clinical concern (illness, death)

Response paradigms◦Policy◦Clinical

One view of homeless causationOne view of homeless causationNote: with low assets, the liabilities don’t need to be that severe to slip into homelessness

Environmental Context:

Markets for jobs and housing

Criminal justice and veteran

policy

Entitlement and mental health

policies

Components to Promote an Exit from Components to Promote an Exit from Homelessness (all shown with equal Homelessness (all shown with equal weight)weight)

Policy 1 - Linear Policy 2 –Housing First

Program entry contingent on accepting treatment, moves toward housing, through way-stations to make “housing-ready”

Ethics: benevolence??Is housing achieved???Fails the most needy?

Rapid access to permanent supportive housing

Seeks the most vulnerable

Ethics: client choice, rights??Work for all? ??Affordable for all???Does health improve?

Birmingham Drug Birmingham Drug Treatment Trials: Treatment Trials: Milby/Schumacher (1990-2006)Milby/Schumacher (1990-2006)

Homeless cocaine-dependent treatment seekers◦ 80-90% with another mental illness

Housed in apartments (contingent on proven abstinence)

Day therapy: 4-6 hrs/day Paid Work Therapy

Milby. Drug Alc Depend. 1996;43:39-47. Schumacher. J Subs Abuse Treat. 2000;19:81-88. Milby AJPH. 2005;95:1259-5. Milby J Subst Abuse Treat In Press.

Summary of Birmingham Summary of Birmingham Trials 1-4Trials 1-4

Treatment reduces cocaine use in RCT comparison

Post-treatment housing sometimes better in RCT comparison

Housing at 1 Year, 6 Months After Treatment Housing at 1 Year, 6 Months After Treatment Ended, 3rd Birmingham Trial (n=138, 71%)Ended, 3rd Birmingham Trial (n=138, 71%)

Kertesz et al. J Behavioral Health Services & Research. January 2007

Percentage of Clients Stably Percentage of Clients Stably Housed after treatment (H4)Housed after treatment (H4)

Milby, Schumacher, Wallace, Vuchinich, Mennemeyer & Kertesz. Am J Pub Health. 2010. online 3/18/2010; doi 10.2105

n= 206 receiving abstinence-contingent housing, work therapy.

Linear Approach LessonsLinear Approach Lessons

Treatment success work & housingNot sufficient for all:

◦ Drug dependence is chronic, for many1

◦ Housing entry standards often unattainable

Treatment programs under-resourced2

1. McLellan. JAMA. 2000. 284:1689-95. 2. McLellan JSAT. 2003;25:117-21

Housing First – reviewHousing First – reviewRCTs: Housing results superior to

unspecified community care in:◦NY severe mentally ill1

◦Chicago medically ill2

Health & addiction tend not to improve3

◦With exceptionsNet cost savings achievable with

some, but not all3 & not for HUD-VASH41. Tsemberis 2004. 2 Sadowski 2009. 3. Kertesz 2009. 4.

Rosenheck 2003

Kertesz et al. Milbank Quarterly. 2009; 87:2 (495-534)

Kertesz & Weiner. JAMA. 2009; 301:17 (1822-24)

HUD-VASHHUD-VASHHUD apartment vouchersVA Supportive Housing services37,000 vouchers*Typically assumes participation in

treatment

*Approximate, email with Vince Kane, 4/2011

HUD-VASH’s relation to the HUD-VASH’s relation to the ideals of Housing Firstideals of Housing First

Not so rapid1:◦Intake to HUD-VASH referral:

m=161 days ◦Referral to housing:

m=108 days Not so permanent2:

◦73% terminate within 5 yearsClients vulnerable? ----use of

other VA housing (OR 4.0)21. (1992-2006). O’Connell/Rosenheck. Psych Rehab J. 2010; 308-19.2 (1990s data). Kasprow et al. Psych Services. 2000; 51: 1017-23.

What might be the What might be the challenges?challenges?Mental health location and paradigmLogistics of apartment unitsOrganizational leadership?

Upcoming study: Housing Solutions in a VA Environment (H-SOLVE)◦Birmingham VA C-SMART & Boston VA

COLMR

The consumer voice as The consumer voice as clarifierclarifier defining quality in primary caredefining quality in primary care

PC-Quality Homeless Study (VA HSR&D)

38 clients, 22 experts, 1500 pages

AccessibilityCoordinationControl

I don’t necessarily agree I should have control, but to share responsibility, that’s what I think….Having a conversation with the doctor, listening to the options available, talking through the possibilities and having a say in what the final outcome is.

endend

ControlControlWhat do you think about the idea that you What do you think about the idea that you should have control in your primary care?should have control in your primary care?

Control means to mean like he would be a puppet on a string, like my cat or my dog… He would do what I wanted to do and only what I wanted to do. If I had control of anybody when I was drinking I wouldn’t be here today. I’d be dead.

I don’t necessarily agree I should have control, but to share responsibility, that’s what I think….Having a conversation with the doctor, listening to the options available, talking through the possibilities and having a say in what the final outcome is.

ControlControlProposed Survey ItemsProposed Survey Items

I help make the important decisions about my health care.

If my primary care provider and I were to disagree about something related to my care, we could work it out.

What Does VA Currently What Does VA Currently Offer?Offer?

Grant and per Diem (rehabilitatively oriented housing up to 24 months)Contract Work TherapySubstance Abuse/Mental Health TreatmentDomiciliary

Permanent Housing (HUD/VASH)

SummarySummaryHousing and Health are

addressableAddressing either one does not

necessarily resolve the other

Implications for future work:◦Organization implementation research◦Consumer perspectives may help

better define

Linear ApproachesLinear Approaches11

Rehabilitative work makes client “housing-ready”

Client transitions from supervised treatment toward independence

Endpoints:◦Private market◦Supportive housing

Critique: does “linear” progress make sense for nonlinear illness. What of the “treatment failures”?

Ridgway, Psychosocial Rehabilitation J. 1990

Secretary ShinsekiSecretary ShinsekiConference of National Alliance to End Homelessness Conference of National Alliance to End Homelessness (7/13/2010)(7/13/2010)

For the chronically-homeless Veteran, who is “hard-to-serve”—those who may have refused care in the past, failed to complete previous programs, have a history of disruptive behaviors, or who don’t fit easily into existing programs—the most effective option is HUD-VA Supportive Housing—HUD-VASH. VA will address all Veterans’ needs, no matter how difficult. We will not leave Veterans homeless while they seek treatment, but will house first, and then provide comprehensive treatment and services.