Veteran Homelessness: the Mental Health Challenge Within Thomas

Veteran Homelessness: the Mental Health Challenge Within Thomas OToole, 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) Objectives

Show 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 Summary Kertesz: framework for multimodal responses Kilbourne: public health models for preventable mortality OToole: care needs following treatment initiation

Saxon: housing and addiction treatment Opinions are those of the presenters and do not represent positions of the US Department of Veterans Affairs Background Single-night prevalence 107,000 (2008, CHALENG) 75,609 (2009 Veteran AHAR) 33 of every 10,000 veterans (prevalence) Conditions medical mental

addiction mortality Current Mental & Addiction Disorders among Persons Experiencing Homelessness 1. Fazel. PLoS Med 5(12):e225; 2008. 2. National Survey of Homeless Assistance Providers and Clients, 2000 (data from Concerns and Responses Veterans who are homeless raise: ethical concern (civic) policy concern (utilization, system strain,

community impact) clinical concern (illness, death) Response Policy Clinical paradigms Environmental Context: Markets for jobs and housing Criminal justice and veteran policy Entitlement and

mental health policies One view of homeless causation Note: with low assets, the liabilities dont need to be that severe to slip into homelessness Components to Promote an Exit from Homelessness (all shown with equal weight) Policy 1 - Linear 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? Policy 2 Housing First 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 Treatment Trials: 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 Trials 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 Ended, 3rd Birmingham Trial (n=138, 71%) 45% p=0.11 40% No HousingProvided DuringTreatment

(n=39) 35% Percent 30% 25% HousingWithout AbstinenceRequired (n=54) 20% 15% 10%

Abstinent-Contingent Housing(n=45) 5% 0% Stably Housed Kertesz et al. J Behavioral Health Services & Research. January 2007 Percentage of Clients Stably Housed after treatment (H4) n= 206 receiving abstinence-contingent housing, work therapy. Milby, Schumacher, Wallace, Vuchinich, Mennemeyer & Kertesz. Am J Pub Health. 2010. online 3/18/2010; doi 10.2105 Linear Approach Lessons

Treatment Not success work & housing sufficient for all: Drug dependence is chronic, for many1 Housing entry standards often unattainable Treatment programs under- resourced2 1. McLellan. JAMA. 2003;25:117-21

2000. 284:1689-95. 2. McLellan JSAT. Housing First review RCTs: Housing results superior to unspecified community care in: NY severe mentally ill1

Chicago medically ill2 Health & addiction tend not to improve3 With exceptions Net cost savings achievable with some, but not all3 & not for HUD4 1. Tsemberis 2 Sadowski 2009. 3. Kertesz 2009. 4. VASH2004. Rosenheck 2003

Kertesz & Weiner. JAMA. 2009; 301:17 (1822-24) Kertesz et al. Milbank Quarterly. 2009; 87:2 (495-534) HUD-VASH HUD apartment vouchers VA Supportive Housing services 37,000 vouchers* Typically assumes participation in treatment *Approximate, email with Vince Kane, 4/2011 HUD-VASHs relation to the ideals 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 years Clients vulnerable? ----use of other 2

VA housing (OR 4.0) 1. (1992-2006). OConnell/Rosenheck. Psych Rehab J. 2010; 308-19. 2 (1990s data). Kasprow et al. Psych Services. 2000; 51: 1017-23. What might be the challenges? Mental health location and paradigm Logistics of apartment units Organizational leadership ? Upcoming

study: Housing Solutions in a VA Environment (H-SOLVE) Birmingham VA C-SMART & Boston VA COLMR The consumer voice as clarifier defining quality in primary care PC-Quality Homeless Study (VA HSR&D)

38 clients, 22 experts, 1500 I dont necessarily agree I should have pages control, but to share responsibility, thats 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. Accessibility Coordination Control

end Control What do you think about the idea that you 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 wouldnt be here today. Id be dead. I dont necessarily agree I should have control, but

to share responsibility, thats 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. Control Proposed 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 Offer? Grant and per Diem (rehabilitatively oriented housing up to 24 months) Contract Work Therapy Substance Abuse/Mental Health Treatment Domiciliary Permanent Housing (HUD/VASH) Summary Housing

and Health are addressable Addressing either one does not necessarily resolve the other Implications for future work: Organization implementation research Consumer perspectives may help better define Linear Approaches1 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 Shinseki Conference of National Alliance to End Homelessness (7/13/2010)

For the chronically-homeless Veteran, who is hard-to-servethose who may have refused care in the past, failed to complete previous programs, have a history of disruptive behaviors, or who dont fit easily into existing programsthe most effective option is HUD-VA Supportive HousingHUD-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.

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