Assessing the Meaning of Housing Instability Among Veterans Ann Elizabeth Montgomery, PhD National Center on Homelessness Among Veterans Birmingham VA Medical Center, Health Services Research & Development University of Alabama at Birmingham, School of Public Health

VA’s Strategy to Address Homelessness Tertiary Provide PSH to chronically homeless Veterans through HUD-VASH Secondary Prevent or rapidly end homelessness among Veteran families through SSVF Primary Identify Veterans experiencing housing instability via universal screen

Homelessness Screening Clinical Reminder Objective: Identify Veterans accessing outpatient healthcare who are experiencing housing instability and link them with appropriate services Process Developed a brief universal screen for housing instability—Homelessness Screening Clinical Reminder (HSCR)—deployed nationally via Veterans’ electronic medical records Preliminary field test assessed relationship between positive screen and indicators of homelessness risk Monitored rates of housing instability based on HSCR responses Evaluated relationship between positive screens and Veterans’ living situations Assessed Veterans’ interpretation of HSCR questions

Homelessness Screening Clinical Reminder Universal Screening Questions Followup Questions For the past 60 days, have you been living in stable housing that you own, rent, or stay in as part of a household? Yes  Question 2 No  Homeless Are you worried or concerned that in the next 60 days you may not have stable housing that you own, rent, or stay in as part of a household? Yes  At risk No  Negative Where have you lived for most of the past 2 months? Apartment/house/room With friend/family Motel/hotel Hospital, other institution Homeless shelter Anywhere outside Other Would you like to be referred to talk more about your housing situation?

Preliminary Field Test (N=379) Risk Factors Predicting Positive Screen for Homelessness or Risk (OR) (Montgomery, Fargo, Kane, et al., 2014)

Positive Screen & Living Situation Homeless Screen 45,282 Homeless Living Situation 61.6% Requested Assistance 39.9% Accessed Homeless Program 26.0% 5,771,496 Veterans responded to HSCR in 2-year period 0.95% screened positive for risk 0.78% screened positive for homelessness ¼ reported living in their own home ¼ met the strictest criteria for homelessness What about Veterans who screened positive for homelessness but were not literally homeless? (Fargo, Montgomery, Byrne, et al., 2017)

ELEMENTS OF HOUSING STABILITY I just think it’s tight, it’s right, it’s good, it’s what you want. [056]

Affordable Stable housing is when you month-by-month pay your rent...You do not have to worry about [someone] saying “get out…” unless you do not pay your bills. [35] Are you able to support a stable house? Are you being able to maintain enough finances to rent a house? Are you living with relatives or friends? How are you coping? [53]

Affordable In the context of other financial obligations, such as utilities, insurance, transportation, and food: For me it would be independent living. I have my own responsibilities as far as paying my bills and things like that. [30] You have to be able to heat your home. You have mortgage payments, car insurance payments, food. There are a lot of things that play into stable housing. [20]

Permanent Housing permanency along a continuum: Having a roof over [one’s] head [34] Something that you can go to every day [58] [Being] settled in…not moving around [57]

Comfortable & Safe Having own space, privacy; a sense of peace, security, freedom, and comfort: I guess stable to me is a nice house, a nice living room, somewhere you can call home…their own space, somewhere they think that they know it’s going to be peace and not chaos, somewhere warm. [14] I think, “have I had somewhere to go and relax, somewhere where I feel a safe haven?”…A safe haven is a place where you can close your door to the world. You can go and do what you want to do…private, somewhat secure. [17]

Comfortable & Safe Personal safety; being in a safe neighborhood and in a safe housing unit: For me, the idea of safety is ensuring that I’m not watching over my shoulder when I’m getting out of my car...I can park my car at night and ensure that nothing’s going to happen to it. I can walk around the block and not worry about if somebody’s going to hit me in the head and try to steal my purse. [05] A good environment, nobody abusing you or nothing like that, and…a pretty safe area. [15]

Structurally & Functionally Adequate A decent place to live [28]. Even though I do have housing, it’s not stable because…it’s infested with mice. [29]   Maybe "livable" would be a better term to use because stable means you're making ends meet…Livable would be more concrete…Because I'm sure people rent apartments and have bugs and stuff, especially in the city. I've got so many roommates that have to deal with their own issues in their own apartments and they call it stable, but is it livable? [47] It is a secure building. I mean it is not one that is completely drafty or leaking or something like that. [043]

Structurally & Functionally Adequate Functional adequacy and amenities such as a kitchen, bathroom, running water, and heat—features that are typically lacking when people are experiencing homelessness: Safe, secure, where you have running water, where you have heat, where you have access to food and a bathroom and you have a bed to sleep in. [05]   I think of an ideal, a place where you go in, it is warm, it is clean, and you have up-to-date additions where you can take care of your personal hygiene. The diet is balanced and you eat and it is diversified. You have some place to sleep that is comfortable. [32] Everything is there. You got your bathroom. You got your toiletries. You got your kitchen. That is stable housing. [35] Adequate lodging as far as bedding, refrigerator, stuff like that and everything...the small simple things. [53]

THREATS TO housing STABILITY Not know[ing] what is going to happen tomorrow or the next day, where are they going to be at or where they are going to be staying” [60]. You always worry you might not have stable housing…in this situation, you know…under somebody else’s gun. [10]   I'm on day-to-day now. I don't have any idea. [18] I could be homeless at any time, and that is how I feel to be honest. [30]

Uncertain Finances Uncertain financial situations due to competing demands such as food and healthcare, increases in the costs of these goods, struggles living on a fixed income: You think you are about to be evicted or you know in the near future you are not going to be able to have the finances to sustain your housing, that could definitely be an issue…You are stable as long as your finances will fulfill your needs. [02] I think of situations where someone might not have enough money because they are living off disability. And, to be quite frank, disability is not a lot of money to live off of, especially with how rents have increased, utilities have increased, and the cost of food…A lot of people are really one rent receipt away from homelessness. [05]

Uncertain Finances Unexpected circumstances occurring in the context of an already precarious housing situation: One second...everything was going as planned and then something drastic happened” [01] Anything can happen within two months. I think your situation could change significantly. You may not be able to afford to stay where you are at or circumstances may come and you might [lose your housing]. [15]

Volatility of Available Housing Housing-specific beyond personal control, often associated with living in housing without a legal right or concerns about landlords’ ability to financially maintain properties: We’re just one argument away. That’s how I feel…And it weighs on my mind constantly. [21] I am afraid that I might be homeless because… the owner of the home is behind a few years in taxes. I keep seeing mail coming in stating that the home is going to be on a Sheriff’s sale if they do not pay the taxes. I am very afraid of that. [22]

Personal Stressors Chronic health conditions, mental health issues, and substance use disorders; living with a disability on a fixed income: I could not even sustain myself with my income. I have not worked in 5 years. My Social Security Disability is pending. I have a lot of illnesses that I am dealing with. I take a lot of medications. I cannot work anymore. [30]   So many mental health concerns…that might cause them not to have a stable environment or home for the next 2 months…Or just being able to comprehend how to take care of themselves and pay their rent and make sure these things are taken care of. [05] I know I have money coming in from [Social Security Disability] and the VA that, as long as I do not blow it on drugs and alcohol, I will be able to pay my rent, but that is always an issue for me because of my addiction…So stability has to do with being able to pay the rent and doing the right thing so I have the money to pay the rent. [44]

Implications Perceptions of housing stability include both physical elements and psychological features of home Ensuring housing stability requires more than offering a place to live Affordability and uncertain finances were especially important to Veterans’ perceptions of housing stability Interventions should connect Veterans with resources or provide ongoing safety net

References Fargo, J. D., Montgomery, A. E., Byrne, T. H., Brignone, E., Cusack, M. C., & Gundlapalli, A. V. (2017). Needles in a haystack: Screening and healthcare system evidence for homelessness. Studies in Health Technology and Informatics, 235, 574–578. doi:10.3233/978-1-61499- 753-5-574 Montgomery, A. E., Fargo, J. D., Kane, V., & Culhane, D. P. (2014). Development and validation of an instrument to assess imminent risk of homelessness among Veterans. Public Health Reports, 129, 439– 447. doi:10.1177/003335491412900506