Rani Hoff, PhD, MPHNortheast Program Evaluation Center

Office of Mental Health Operations

Homelessness in Female Veterans—Risk Factors and Health Services in VHA

Overview

1. Overview of the history of women in the military2. Overall risk of homelessness among female

Veterans and specific potential risk factors3. VHA services available for homeless female

Veterans4. Data on women receiving homelessness services

Women in the Military

• Women have always served in this nation’s military conflicts

• Molly Pitcher received Congressional recognition of her service

• Women served in auxiliary hospital units during the Civil War

• World Wars began more formal women’s military units

• World War II was the first time

women’s units were recognized as such and given full Veteran’s benefits

• Spearheaded by Eleanor Roosevelt and Gen. Marshall

• Pearl Harbor turned the tide of opposition, 23 years after the first formal suggestion

• WAC, WAVES, SPARS, WASP, and Marine Corps Reserve

Women in the Military (cont.)

Women’s Roles

• Initial roles were relegated to state-side support (e.g. supply and repair, administration) and healthcare

• Women landed on Normandy

• Thousands served in North Africa and in the Pacific

Women in Vietnam• “The military, which prided itself

on the records it kept in Vietnam -- counting the enemy number of weapons captured, for example -- cannot to this day say with certainty how many women served. The army that sent them never bothered to count them. The estimate most frequently given is that a total of 7,500 served in the military in Vietnam."

• Laura Palmer, "Shrapnel in the Heart”

• • Women served largely in health care roles

• They were older and better educated than men in the military, due to the draft and differences in occupations

Women in Vietnam (cont.)

The “All-Volunteer Military”

• Established in 1973, when the military stopped the draft• Selective Service is still in place for boys age 18• The quotas for the proportion of women allowed was

increased• Over the next 30 years the proportion of women rose to

about 7-10%, in the current conflict it is 15-20% of active duty forces

Changing Demographics of the Military

• The all-volunteer military resulted in a force that was less educated and had increased numbers of risk factors for poor community functioning– Poverty, adverse living conditions in childhood– Substance abuse and dependence– Psychiatric illness – Violence

• This held similarly, possibly even more so, for women entering the military

The Current Conflict

• The “War on Terror” begins on 9/11/2001• October 2002 invasion of Iraq• Women are serving in roles that put them in constant danger of exposure to

combat situations

Homelessness and Female VeteransIn previous conflicts:•Female veterans were less likely than male veterans to become homeless after leaving military service•However, they were 4 times more likely to become homeless than female civiliansIn the current conflict:•Female veterans are just as likely to become homeless after leaving military service as men•This suggests a higher level of risk

Homeless women compared to men

• Women use VA homelessness services (8%) at a rate similar to their representation in the VA user population (7%)

• Women are less likely to be literally homeless (54%) than men (57%)

• Women are younger and more likely to have dependent children

• Women are more likely to have non-military related PTSD• Women are referred to supported housing more than men

Possible Reasons for homelessness• Women who enter the military may be more likely

than other women to have risk factors that put them at risk for later homelessness– Unstable families, child abuse and neglect, poverty, lack

of educational opportunities, family histories of mental illness and/or substance use

• The disruptions caused by the current conflict, especially those serving in Reserve and National Guard Units, may be disproportionately worse for women

Possible Reasons (cont.)• After leaving military service, female veterans may have

fewer resources than their civilian counterparts to prevent the onset of homelessness– They were less likely to be married and have children– They may have disrupted social ties to family or other social

supports– Their military training may not have prepared them for well-

paying civilian jobs– Preclusion from serving in combat roles (on paper) discriminated

against them for promotions and medals– Disability, unemployment, and worse physical and mental health

increase risk for homelessness

Possible Reasons (cont.)

• There may be some particular aspects of military service that put female veterans at increased risk of homelessness– Increased risk of stress-related illness– Increased risk of mental illness and/or substance abuse– Gender discrimination– Sexual harassment and sexual assault

Military Sexual Trauma (MST)

• MST refers to sexual harassment and/or sexual assault perpetrated upon an active duty soldier of any gender, and by any gender

• A history of MST is grounds for VA treatment, even if a veteran would otherwise not be eligible for VA services

• There are mandatory screening requirements of all VA patients to identify those with MST

Rates of MST• There are no stable estimates for how many female

veterans have experienced MST• There have been very few good studies of MST in veteran

populations• Rates differ widely based upon the population being

studied and the methods of assessing MST– Highest rates in those requesting VA disability and veterans of

more recent conflicts (about 40-70%)– Lowest in population samples of female veterans and VA primary

care patients (3-30%)– Screening rates in VHA female patients are about 20%

Why Is MST Particularly Problematic?

• It is an interpersonal trauma• It is perpetrated by someone who presumably is supposed

to be protecting your life• It may not be possible to report the crime, for a variety of

reasons• It may be coupled, in recent veterans, with combat

exposure as well

Homelessness Services Available to Women in VA

• MHRRTPs and Domiciliaries• Health Care for Homeless Veterans• Grant and Per Diem programs• HUD-VASH programs• VJO and Re-Entry Programs• Specialized Homeless Women’s Programs• Homeless Veterans Supported Employment Programs

Mental Health Residential Rehabilitation and Treatment (MH RRTP)

• “The MH RRTP mission is to provide state-of-the-art, high-quality residential rehabilitation and treatment services for Veterans with multiple and severe medical conditions, mental illness, addiction, or psychosocial deficits. The MH RRTP identifies and addresses goals of rehabilitation, recovery, health maintenance, improved quality of life, and community integration in addition to specific treatment of medical conditions, mental illnesses, addictive disorders, and homelessness.”

MH RRTP Stays Among Female Veterans, 2005 – 2012

•The total number of MH RRTP stays among Female Veterans increased by 74.8% between 2005 and 2012.

Female Veterans as a Proportion of MH RRTP Stays, 2005 – 2012

Fiscal Year Number of Female Veterans

Female Vets as a % of MH RRTPStays

2012 2,213 6.1%

2011 2,199 5.8%

2010 2,122 5.4%

2009 1,789 5.2%

2008 1,738 5.2%

2007 1,482 4.6%

2006 1,375 4.5%

2005 1,266 4.0%

•The proportion of MH RRTP stays that are female Veterans has been steadily increasing since 2005.

Differences Between Female and Male Veterans in MH RRTPs, 2012

Female MaleMean Age (years) 45.0 yrs 49.3 yrs

OEF/OIF/OND 16.7% 14.5%

Homeless 62.6% 65.9%

Substance Use Diagnosis 70.9% 85.6%

PTSD 47.9% 32.6%

Major Affective Disorder 19.0% 11.2%

Mental Health OPV 7 Days Post-DC 61.6% 57.1%

•Female Veterans are younger and less likely to be homeless. They are also less likely to be diagnosed with substance abuse problems, however more likely to have a serious mental illness, in particular, PTSD and depression. LOS are similar to male Veterans, however, female Veterans are more likely to follow-up with post-discharge outpatient treatment services.

Number and Proportion of Stays Among Female Veterans by MH RRTP Category, 2012

In 2012 the proportion of stays among female Veterans was 6.1% (n=2,213). The greatest proportion of women Veterans was within the PTSD MH RRTPs (8.9%), however, the greatest number of stays among female Veterans was in the SUD MH RRTPs (n=745).

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MH RRTPs Entirely Dedicated to Female Veterans, 2012

Program Location MH RRTP Bed Category Number of Beds

Boston MA CWT/TR 7 beds

Brockton MA PTSD RRTP 8 beds

Batavia NY PTSD RRTP 6 beds

Lyons NJ PTSD RRTP 10 beds

Temple TX PTSD RRTP 8 beds

Palo Alto CA PTSD RRTP 10 beds

Total 6 programs 49 beds

During 2012 there were 6 MH RRTPs (n=49 beds) totally dedicated to women.

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MH RRTPs Providing Specialized Tracks for Females, 2012*

MH RRTP Type Number of Programs Total Number of Beds

DCHV 2 as needed

SUD 2 as needed

PTSD 3 20 (plus as needed)

General 3 as needed

Total 10 20 (plus as needed)

*A Track is defined as treatment provided to a subset of Veterans within the residential program who receive the same or similar specialized treatment and rehabilitative services. Tracks do not reflect populations served, but rather targeted programming directed towards a subset of Veterans served by the program. To be considered as having a female track, a program just have had at least 2 hours/day of gender specific care.

In addition to the 6 programs entirely dedicated to the treatment of female Veterans, there were 10 MH RRTPs that provided a specialized track for female Veterans.

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MH RRTP Access for Female Veterans, 2012

206 (86.9%) programs admitted female Veterans in 2012 102 (49.5%) programs had beds for female Veterans located in a separate, secure wing

1,703 (20.3%) beds met safety and security requirements for female Veterans

683 (8.1%) beds were designated solely for the treatment of female Veterans

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MH RRTP Access for Female Veterans, 2012

31 (13.1%) programs did not admit any female Veterans during 2012

The residential treatment needs of female Veterans at these MH RRTPs were addressed by:

16 programs referred to another MH RRTP at their VAMC12 programs referred to another MH RRTP at another

VAMC 3 referred to local community providers

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Percent of Beds Designated Solely for Female Veterans and Percent of Female MH RRTP Stays by MH RRTP Bed Category, 2012

Overall, 6.1% (n=2,213) of MH RRTP stays are among female Veterans and 8.1% (n=683) of MH RRTP beds are designated solely for the treatment of female Veterans. PTSD MH RRTPs have the greatest capacity for treating female Veterans but proportionally have fewer MH RRTP stays. PTSD programs have the capacity to admit 50% more female Veterans.

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Propensity to Admit to MH RRTPs, Male to Female Ratio by VISN, 2012†

Overall , the national propensity to admit to residential treatment male to female ratio = 1.68. The ideal score would be a value of 1.00 indicating that male and female Veterans have equal access to VA residential care. Female Veterans in VISNs 1, 8, 10 and 21 generally have similar access to residential treatment as their male Veteran counterparts. † Numerator: The percentage of Veterans in the denominator who have at least one bed day in residential care . Denominator: Number of men (or women) who are in one of the following groups: 1. Total number of unique Veterans at the facility who are thought to be homeless. 2. Total number of unique Veterans who have at least one bed day in a psychiatric or substance abuse bed section (not including residential) and a primary or secondary diagnosis of PTSD 3. Total number of unique Veterans who have at least one bed day in a psychiatric or substance abuse bed section (not including residential) and a primary or secondary diagnosis of substance use disorder 4. Total number of Veterans on the National Psychosis Registry. Second stage is the ratio of male to female rates from above. {Home facilities were assigned for this measure and thus referrals were counted.} †Data were extracted from the MH Information System dashboard.

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Services Offered by the HCHV Program• The central goal of the HCHV program is to reduce homelessness among

Veterans by conducting outreach to those who are not currently receiving services and engage them in treatment and rehabilitative programs. While the approach taken at each medical center is designed to fit into the particular community setting and to integrate with local services, the central activities of HCHV teams include:

• Outreach to identify Veterans among homeless persons encountered in shelters, soup kitchens, and other community locations;

• Clinical assessments, to determine the needs of each Veteran seen by the team and to give priority to those who are most vulnerable;

• Referral to medical and psychiatric inpatient and outpatient treatment and to social services and entitlement programs;

• Rehabilitation in community-based residential treatment facilities or other community housing, through any of the HCHV components; and

• Follow-up case management, to help Veterans identify resources which will facilitate their community re-entry.

Female Veterans Served by HCHV

Veterans FY06 FY07 FY08 FY09 FY10

(N=38,819) (N=39,364) (N=40,422) (N=40,216) (N=42,858)

Male 96% 95.7% 95.6% 95.4% 94.3%

Female 4% 4.3% 4.4% 4.6% 5.7%

• While male Veterans comprise the vast majority of those served by HCHV, the number of female Veterans being served by HCHV has been steadily increasing since 2006.

Grant and Per Diem Services

• For the majority of Grant and Per Diem (GPD) programs, the principal mission is to provide time-limited housing with supportive services as an aid to the transition to permanent housing.

• Veterans may receive relatively intensive residential treatment in a GPD facility. • However, programs with alternate missions have been funded. For example,

programs have been funded to specifically serve women and their families.• Yet other programs are intended to provide stable housing, but offer minimal

supportive services. • Thus, the GPD represents a heterogeneous group of programs that have the

common goal of providing flexible housing and support services.

Women in Grant and Per Diem Programs

• Nationally, 4.5% of Veterans placed into GPD programs are female

• Many programs do not have the capacity to handle women due to structural or physical limitations

• Many programs also cannot handle families, which restricts access for women

Women in HUD-VASH Programs

• In 1992, VA and the Department of Housing and Urban Development (HUD) established the HUD-VASH Program.

• VA provides case management services to Veterans experiencing homelessness, while HUD provides permanent housing subsidies to Veteran participants and their immediate families through its “Housing Choice” voucher program.

• The primary goal of HUD-VASH is to assist Veterans and their families exit homelessness and fully reintegrate back into the community of their choosing. A key component of the program is VA’s case management services.

• Case management services are designed to support the Veteran’s recovery process through enhancing housing stability in safe, decent and affordable permanent housing and through engagement of the Veteran to address physical and mental health and/or substance use disorder concerns.

Outcomes of women in transitional housing programs

• Women in transitional housing were younger, had higher psychiatric symptoms, fewer days homeless, fewer days drinking alcohol and less alcohol dependence, and were more likely to have been recently hospitalized

• Women and men had similar 12 month outcomes on housing, work activity, substance use, overall physical and mental health, or quality of life

• Women were similar to men for 6 months, but then worse, on employment income and psychiatric symptoms

Veterans Justice Outreach and Re-entry Programs

• The purpose of the Veteran Justice Outreach (VJO) Initiative is to avoid the unnecessary criminalization of mental illness and extended incarceration among Veterans by ensuring that eligible justice-involved Veterans have timely access to VHA mental health and substance use services when clinically indicated, and other VA services and benefits as appropriate.

• VA is requiring justice-focused activity at the medical center level. VA Medical Centers have been strongly encouraged to develop working relationships with the court system and local law enforcement and must now provide outreach to justice-involved Veterans in the communities they serve.

• Each VA medical center has been asked to designate a facility-based Veterans' Justice Outreach Specialist, responsible for direct outreach, assessment, and case management for justice-involved Veterans in local courts and jails, and liaison with local justice system partners.

Women in Veterans Justice Outreach Programs

• There were 542 women served by VJO programs in FY12

• 55% are between 31 and 50 years old, 54% served in the Army, and 30% served in Iraq or Afghanistan

• 24% had been in combat (hostile or friendly fire) • 45% have an alcohol use disorder, 35% drug• 8% have schizophrenia or other psychotic disorder,

21% are bipolar• 33% have military-related PTSD, 14% non-military

related PTSD• 46% depression, 29% anxiety

Specialized Homeless Women’s Programs

• Very few specialized women’s homeless programs in the country (about 10), funded in large urban areas

• Established through special needs funding for women and families through the G&PD program

• Community providers reserve beds for homeless women Veterans• Women are served largely in alternate settings