Homelessness and Addiction Treatment Outcomes among Veterans

1
Homelessness and Addiction Treatment Outcomes
among Veterans
Substance use itself may be the most salient
factor causing homelessness (Devine, 1997).

• Andrew J. Saxon, M.D.

VA Puget Sound Health Care System, HSRDCenter
of Excellence in Substance Abuse Treatment and
Education University of Washington
2
Homelessness and Addiction Outcomes

• Data from a cohort of Veterans entering
  outpatient substance use disorders (SUD)
  treatment who participated in randomized trial
  comparing
• on-site primary care in a substance use treatment
  setting
• referral primary care in a general medicine
  clinic.
• Included participants who completed at least one
  follow-up visit (N622)

3
Housing Status

• Examined subject characteristics and outcomes by
  housing status at baseline and final follow-up
  (typically 12-months post-randomization)
• Participants classified into 4 groups
• housed at baseline and at the final follow-up
  (41)
• homeless at baseline and at the final follow-up
  (27)
• housed at baseline but homeless at the final
  follow-up (8)
• homeless at baseline but housed at the final
  follow-up (24).

4
Demographics by housing status
  Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics  
  Consistently Housed Consistently Housed Consistently Homeless Consistently Homeless Housed Baseline/ Homeless Final Housed Baseline/ Homeless Final Homeless Baseline/ Housed Final Homeless Baseline/ Housed Final  
  (n255) (n255) (n168) (n168) (n51) (n51) (n148) (n148)  
  n() or M(SD) n() or M(SD) n() or M(SD) n() or M(SD) n() or M(SD) n() or M(SD) n() or M(SD) n() or M(SD) p-value
Assigned to Onsite Primary Care 136 (53) 77 (46) 25 (49) 73 (49) .504
Mean age 45.4 (8.6) 47.0 (6.4) 46.2 (6.8) 46.2 (7.5) .166
Male 250 (98) 165 (98) 49 (96) 145 (98) .817
Race
White (non-Hispanic) 175 (69) 106 (63) 28 (55) 87 (59)
African American/Black 64 (25) 50 (30) 13 (25) 49 (33)
Other 16 (6) 12 (7) 10 (20) 12 (7) .027
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Demographics by housing status, cont.
  Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics  
  Consistently Housed Consistently Housed Consistently Homeless Consistently Homeless Housed Baseline/ Homeless Final Housed Baseline/ Homeless Final Homeless Baseline/ Housed Final Homeless Baseline/ Housed Final  
  (n255) (n255) (n168) (n168) (n51) (n51) (n148) (n148)  
  n() n() n() n() n() n() n() n() p-value
Marital Status
Divorced, separated or widowed 162 (64) 118 (71) 42 (82) 101 (69)
Never Married 57 (22) 43 (26) 5 (10) 34 (23)
Married or Remarried 35 (14) 6 (4) 4 (8) 12 (8) .005
Period of Service                  
Vietnam 144 (57) 93 (55) 31 (61) 80 (54)
Post Vietnam 82 (32) 67 (40) 17 (33) 56 (38)
Other 29 (11) 8 (5) 3 (6) 12 (8) .233
Service Connected 75 (29) 20 (12) 14 (28) 28 (19) lt.001
6
Diagnoses at baseline
  Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics  
  Consistently Housed Consistently Housed Consistently Homeless Consistently Homeless Housed Baseline/ Homeless Final Housed Baseline/ Homeless Final Homeless Baseline/ Housed Final Homeless Baseline/ Housed Final  
  (n255) (n255) (n168) (n168) (n51) (n51) (n148) (n148)  
  n() n() n() n() n() n() n() n() p-value
Primary Substance
Alcohol 175 (69) 102 (61) 32 (63) 91 (62)
Cocaine 40 (16) 42 (25) 11 (22) 33 (22)
Opioid 28 (11) 12 (7) 5 (10) 12 (8)
Other 12 (5) 12 (7) 3 (6) 12 (8) .350
Number of psychiatric diagnoses Number of psychiatric diagnoses
0 96 (38) 55 (33) 14 (28) 31 (21)
1 68 (27) 52 (31) 16 (31) 50 (34)
2 or more 91 (36) 61 (36) 21 (41) 67 (45) .044
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Addiction Severity Index at Baseline
  Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics Housing Characteristics  
  Consistently Housed Consistently Housed Consistently Homeless Consistently Homeless Housed Baseline/ Homeless Final Housed Baseline/ Homeless Final Homeless Baseline/ Housed Final Homeless Baseline/ Housed Final  
  (n255) (n255) (n168) (n168) (n51) (n51) (n148) (n148)  
  M(SD) M(SD) M(SD) M(SD) M(SD) M(SD) M(SD) M(SD) p-value
Alcohol .34 (.27) .34 (.27) .43 (.27) .29 (.27) .017
Drug .10 (.12) .10 (.11) .14 (.13) .12 (.11) .199
Medical .51 (.36) .58 (.37) .59 (.38) .61 (.36) .026
Employment .69 (.31) .85 (.18) .85 (.20) .82 (.21) lt.001
Legal .13 (.19) .07 (.15) .12 (.15) .13 (.20) .002
Psychiatric .39 (.25) .48 (.26) .48 (.26) .51 (.23) lt.001
Family .19 (.20) .18 (.18) .20 (.19) .19 (.18) .975
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Outcomes by housing status

• Analyses controlled for age, race, randomization
  location, baseline psychiatric condition, primary
  substance, baseline alcohol/drug abstinence, and
  final assessment time point (3-, 6- or 12-months)
  unless otherwise noted.
• For longitudinal measures (e.g. ASI composite
  scores) compared change over time and 12-month
  outcomes between the housing groups

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12-Month Addiction Severity Index Scores
  Housing Status Meanadj SEadj p-value
Alcohol Consistently Housed 0.15 0.01 ref
Consistently Homeless 0.19 0.02 .129
Housed Baseline/ Homeless Final 0.15 0.04 .813
  Homeless Baseline/ Housed Final 0.12 0.02 .345
Drug Consistently Housed 0.04 0.00 ref
Consistently Homeless 0.06 0.01 .015
Housed Baseline/ Homeless Final 0.03 0.01 .072
  Homeless Baseline/ Housed Final 0.05 0.01 .350
Medical Consistently Housed 0.46 0.02 ref
Consistently Homeless 0.53 0.03 .292
Housed Baseline/ Homeless Final 0.63 0.05 .009
  Homeless Baseline/ Housed Final 0.49 0.03 .882
Psychiatric Consistently Housed 0.26 0.01 ref
Consistently Homeless 0.38 0.02 .007
Housed Baseline/ Homeless Final 0.44 0.04 .011
  Homeless Baseline/ Housed Final 0.37 0.02 .088
10
Psychiatric composite score by housing status
Psychiatric composite scores showed less
improvement over time in the housed
baseline/homeless final group compared to the
consistently housed group (ßadj .01 95 CI
.00 .02 p .019).
11
Medical composite score by housing status
Medical composite scores worsened over time in
the housed baseline/homeless final group relative
to the homeless baseline/housed final group
(?2adj 6.89, df 1, p .009).
12
Drug composite score by housing status
Scores showed less improvement over time in the
consistently homeless group compared to the
consistently housed group (p .031) and the
housed baseline/homeless end group (p lt .001).
The housed baseline/homeless final group improved
more over time than the consistently housed group
(p .010).
13
12-Month Service Utilization
Service Housing status n ORadj 95 CIadj p-value
Any Inpatient Stay Consistently Housed 71 28 1
Any Inpatient Stay Consistently Homeless 110 66 5.05 3.24 7.87 lt.001
Any Inpatient Stay Housed Baseline/ Homeless Final 33 65 4.43 2.30 8.52 lt.001
  Homeless Baseline/ Housed Final 80 54 2.87 1.84 4.49 lt.001
Any Inpatient Stay (Excluding DOM CWT) Consistently Housed 52 20 1
Any Inpatient Stay (Excluding DOM CWT) Consistently Homeless 55 33 1.75 1.10 2.79 0.018
Any Inpatient Stay (Excluding DOM CWT) Housed Baseline/ Homeless Final 21 41 2.3 1.19 4.45 0.014
  Homeless Baseline/ Housed Final 45 30 1.47 .90 2.39 0.121
Emergency room visit Consistently Housed 104 41 1
Emergency room visit Consistently Homeless 102 61 2.12 1.41 3.21 lt.001
Emergency room visit Housed Baseline/ Homeless Final 30 59 1.81 .96 3.41 0.065
  Homeless Baseline/ Housed Final 76 51 1.45 .95 2.21 0.083
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12-Month Costs at VA Puget Sound
  Housing Status Mean Dollars SD p-value
Total Costs Consistently Housed 11,621 11,235
Total Costs Consistently Homeless 21,341 21,238 lt.001
Total Costs Housed Baseline/ Homeless Final 20,979 18,237 lt.001
  Homeless Baseline/ Housed Final 18,006 18,360 lt.001
Total Costs Excluding DOM CWT Consistently Housed 10,287 9,071
Total Costs Excluding DOM CWT Consistently Homeless 12,566 11,781 0.033
Total Costs Excluding DOM CWT Housed Baseline/ Homeless Final 14,325 12,029 0.03
  Homeless Baseline/ Housed Final 12,283 12,103 0.095
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Conclusions

• Homelessness is prevalent among Veterans with
  substance use disorders
• 65 of 622 Veterans spent at least one night
  homeless at some point during an 18-month period.
  
• Veterans experiencing homelessness at baseline
  had more severe alcohol, medical, employment,
  legal and psychiatric problems than participants
  with housing.

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Conclusions

• Veterans with unstable housing engaged in and
  benefited from treatment.
• short-term housing (domiciliary and community
  programs) may have increased treatment retention.
  
• Associations between housing and positive
  treatment outcomes mixed
• final ASI drug and psychiatric scores were better
  among those consistently housed when compared to
  the consistently homeless group.
• Differences not found in final ASI alcohol scores
  or abstinence rates

17
Conclusions

• Veterans with unstable housing used more services
  and had higher total costs than housed Veterans
• Significant differences remained when costs such
  as domiciliary and compensated work therapy were
  removed.
• Costs limited to one VA medical center

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Next Steps

• Need for interventions that simultaneously
  address housing, substance use and mental health
  issues
• Assertive community treatment / intensive case
  management
• improves housing status, substance use and mental
  health outcomes.
• Life Skills Training
• improves the likelihood of maintaining housing

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Next Steps

• The VA Homeless Health Services Research
  Initiative Addiction Housing Case Management for
  Homeless Veterans in Addiction Treatment
• Integrates assertive community treatment /
  intensive case management and Life Skills
  Training into a large VA addiction specialty care
  program.
• Time and attention control housing support group
• 4-year study
• N400

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Aims

• Compare Addiction /Housing Case Management (AHCM)
  to time and attention control on
• number of days housed and likelihood of obtaining
  long-term housing
• costs and cost-effectiveness
• addiction and mental health outcomes and
  functional status
• examine treatment process variables associated
  with improved outcomes.

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Potential Impact

• Identification of factors associated with
  improved outcomes could guide the care of
  Veterans with substance use and mental health
  disorders who are facing homelessness.
• Potential to inform the roles of substance use
  specialists in the Homeless Care Line.
• Help to determine if intensive case management
  services are cost-effective in this population