VA health service use for homeless and low-income Veterans: A spotlight on Los Angeles’ VA Supportive Housing program Sonya Gabrielian, MD, MPH,* Anita.

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Presentation transcript:

VA health service use for homeless and low-income Veterans: A spotlight on Los Angeles’ VA Supportive Housing program Sonya Gabrielian, MD, MPH,* Anita H. Yuan, PhD, MPH, Ronald M. Andersen, PhD, Lisa V. Rubenstein, MD, MSPH, Lillian Gelberg, MD, MSPH VA Greater Los Angeles, University of California, Los Angeles INTRODUCTION Acknowledgements/Disclosures: This study was funded as a Locally Initiated Project at the VA Los Angeles HS&RD Center of Innovation (COIN). The authors do not have any conflicts of interest to disclose. Veterans are overrepresented among homeless adults Homeless Veterans have high rates of mental illness & substance use disorders (SUD) The U.S. Department of Housing and Urban Development (HUD) – VA Supportive Housing (VASH) program is the VA’s Housing First program and the linchpin of the VA’s plan to end Veteran homelessness Research suggests that Housing First improves health outcomes Little is known about patterns of healthcare use associated with Housing First Placement How do rates of VA inpatient and outpatient health service utilization differ among patients by housing and income status who received care at the VA Greater Los Angeles (VAGLA) from 10/2010 – 9/2011? After adjusting for demographics, need, and primary care use, how do rates of VA inpatient and outpatient service utilization differ among patients in these groups? Stepwise negative binomial regression: Adjusted first for demographics and need (model 1), then for these variables plus primary care use (model 2) Reference Group = Housed, Not Low- Income HUD-VASH Veterans had the greatest decrease in incident rate ratios (IRR) for ED, outpatient specialty care, mental health from models 1 to 2, becoming similar to the currently homeless RESEARCH QUESTIONS CONCEPTUAL MODEL RESULTS RESULTS, cont. CONCLUSIONS Currently homeless Veterans underuse many VA services relative to housing Veterans HUD-VASH may enable needed service use for homeless Veterans, by linking these patients to both housing and primary care As HUD-VASH and other Housing First programs grow, these findings hold implications for program planning Future studies should explore longitudinal changes in VA service use with HUD-VASH participation HUD-VASH Characteristics Independent, vouchered apartments Supportive services to sustain housing placements No treatment or sobriety mandates Four Mutually Exclusive Groups (N=62,459) Formerly homeless Veterans housed in HUD-VASH Currently homeless Veterans Housed, low-income Veterans Housed, not low income Veterans (n=1,997)(n=1,760)(n=21,682)(n=37,020) Predisposing (Demographics, Housing Status) Enabling (Case management, income) Need (Perceived and Evaluated Health) Health Behaviors (VA health service utilization) METHODS Secondary database analysis of VA administrative data (VHA Outpatient Medical SAS Dataset) Excluded patients without a Diagnostic Cost Group (DCG) score Complexity measure derived from demographics and diagnoses associated with visits over the last fiscal year Main covariate: housing and income status Outcome: VA inpatient and outpatient health service utilization Analyses:  2 analysis and ANOVA Multivariate logistic regression, adjusting for predisposing and need variables Negative binomial regression, adjusting stepwise for predisposing and need variables, then these variables and primary care use HUD-VASH (n=1997) Currently homeless (n=1760) Housed, Low-Income (n=21,682) Housed, Not Low-Income (n=37,020) Age (mean)*53 years54 years62 years Gender (% male)* 91%95% 94% * p<0.001 Veterans in HUD-VASH received the most inpatient, outpatient and Emergency Department (ED) care of these four groups HUD-VASH (n=1997) Currently homeless (n=1760) Housed, Low-Income (n=21,682) Housed, Not Low-Income (n=37,020) Med/Surg Admission* (one or more) 10%6%7%4% Mental Health Admission* (one or more) 4% 1% Mental Health Visits* (mean #visits/yr)* Emergency Department Visits (1 or more visit in the year)* 37%28%20%13% * p<0.001 Adjusting for demographics and need, Veterans in HUD-VASH and the currently homeless were more likely to have inpatient and outpatient mental health/SUD service use Adjusted Odds Ratios (AOR) are below HUD-VASH (n=1997) AOR Currently homeless (n=1760) AOR Housed, Low- Income (n=21,682) AOR Mental Health Admission* 221 Mental HealthVisit* 1061 * p<0.05 Reference Group = Housed, Not Low-Income Adjusted for age, gender, race/ethnicity, marital status, and DCG REFERENCES 1.Balshem, H., Christensen, V., Tuepker, A., & Kansagara, D. (2011). A Critical Review of the Literature Regarding Homelessness Among Veterans. VA-ESP Project #05-225, 1– Kertesz, S. G., Crouch, K., Milby, J. B., Cusimano, R. E., & Schumacher, J. E. (2009). Housing first for homeless persons with active addiction: are we overreaching? The Milbank quarterly, 87(2), 495–534. doi: /j x 3.Gelberg, L., Andersen, R. M., & Leake, B. D. (2000). The Behavioral Model for Vulnerable Populations: application to medical care use and outcomes for homeless people. Health Services Research, 34(6), 1273– Rosen, A. K., et al. (2002). Diagnostic cost groups and concurrent utilization among patients with substance abuse disorders. Health Services Research;37(4),1079–1103.