Homelessness and Addiction Treatment Outcomes among Veterans

Andrew J. Saxon, M.D.

VA Puget Sound Health Care System, HSR&DCenter of Excellence in Substance Abuse Treatment and EducationUniversity of Washington

Substance use itself may be the most salient factor causing homelessness (Devine, 1997).

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)

Housing StatusExamined 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%).

Demographics by housing status

Housing Characteristics

Consistently Housed

Consistently Homeless

Housed Baseline/ Homeless Final

Homeless Baseline/

Housed Final

(n=255) (n=168) (n=51) (n=148)

n(%) or M(SD) n(%) or M(SD) n(%) or M(SD) n(%) or M(SD) p-valueAssigned 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

Demographics by housing status, cont.

Housing Characteristics

Consistently Housed

Consistently Homeless

Housed Baseline/ Homeless Final

Homeless Baseline/

Housed Final(n=255) (n=168) (n=51) (n=148)

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) <.001

Diagnoses at baseline

Housing Characteristics

Consistently Housed

Consistently Homeless

Housed Baseline/ Homeless Final

Homeless Baseline/

Housed Final(n=255) (n=168) (n=51) (n=148)

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

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

Addiction Severity Index at Baseline

Housing Characteristics

Consistently Housed

Consistently Homeless

Housed Baseline/ Homeless Final

Homeless Baseline/ Housed Final

(n=255) (n=168) (n=51) (n=148)

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) <.001

Legal .13 (.19) .07 (.15) .12 (.15) .13 (.20) .002

Psychiatric .39 (.25) .48 (.26) .48 (.26) .51 (.23) <.001

Family .19 (.20) .18 (.18) .20 (.19) .19 (.18) .975

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

12-Month Addiction Severity Index Scores

Housing Status Meanadj SEadj p-valueAlcohol Consistently Housed 0.15 0.01 ref

Consistently Homeless 0.19 0.02 .129Housed Baseline/ Homeless Final 0.15 0.04 .813

Homeless Baseline/ Housed Final 0.12 0.02 .345Drug Consistently Housed 0.04 0.00 ref

Consistently Homeless 0.06 0.01 .015Housed Baseline/ Homeless Final 0.03 0.01 .072

Homeless Baseline/ Housed Final 0.05 0.01 .350Medical Consistently Housed 0.46 0.02 ref

Consistently Homeless 0.53 0.03 .292Housed Baseline/ Homeless Final 0.63 0.05 .009

Homeless Baseline/ Housed Final 0.49 0.03 .882Psychiatric Consistently Housed 0.26 0.01 ref

Consistently Homeless 0.38 0.02 .007Housed Baseline/ Homeless Final 0.44 0.04 .011

Homeless Baseline/ Housed Final 0.37 0.02 .088

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).

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 (2

adj = 6.89, df = 1, p = .009).

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).

12-Month Service Utilization

Service Housing status n % ORadj 95% CIadj p-valueAny Inpatient Stay Consistently Housed 71 28 1

Consistently Homeless 110 66 5.05 3.24 – 7.87 <.001Housed Baseline/ Homeless Final 33 65 4.43 2.30 – 8.52 <.001

Homeless Baseline/ Housed Final 80 54 2.87 1.84 – 4.49 <.001

Any Inpatient Stay (Excluding DOM & CWT)

Consistently Housed 52 20 1Consistently Homeless 55 33 1.75 1.10 – 2.79 0.018Housed 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 1Consistently Homeless 102 61 2.12 1.41 – 3.21 <.001Housed 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

12-Month Costs at VA Puget Sound

Housing StatusMean

Dollars SD p-valueTotal Costs

Consistently Housed $ 11,621 $ 11,235

Consistently Homeless $ 21,341 $ 21,238 <.001Housed Baseline/ Homeless Final $ 20,979 $ 18,237 <.001

Homeless Baseline/ Housed Final $ 18,006 $ 18,360 <.001

Total Costs Excluding DOM & CWT

Consistently Housed $ 10,287 $ 9,071

Consistently Homeless $ 12,566 $ 11,781 0.033Housed Baseline/ Homeless Final $ 14,325 $ 12,029 0.03

Homeless Baseline/ Housed Final $ 12,283 $ 12,103 0.095

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.

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 mixedfinal 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

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

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 Trainingimproves the likelihood of maintaining housing

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 group4-year studyN=400

Aims

Compare Addiction /Housing Case Management (AHCM) to time and attention control on:

number of days housed and likelihood of obtaining long-term housingcosts and cost-effectivenessaddiction and mental health outcomes and functional status examine treatment process variables associated with improved outcomes.

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