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, HSR&DCenter 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 (N=622)

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

5. Demographics by housing status, cont.

6. Diagnoses at baseline

7. Addiction Severity Index at Baseline

8. 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

9. 12-Month Addiction Severity Index Scores

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 (βadj = .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 < .001). The housed baseline/homeless final group improved more over time than the consistently housed group (p = .010).

13. 12-Month Service Utilization

14. 12-Month Costs at VA Puget Sound

15. 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.

16. 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

18. 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

19. 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 • N=400

20. 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.

21. 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