1. Veteran Homelessness: the Mental Health Challenge Within Thomas O’Toole, MD 1 Amy Kilbourne, PhD, MPH 2 Andrew Saxon, MD, MSc 3 Stefan G. Kertesz, MD, MSc 4 1. Center on Systems, Outcomes & Quality in Chronic Disease & Rehabilitation (Providence, RI) 2. Center for Clinical Management Research (Ann Arbor, MI) 3. Center of Excellence in Substance Abuse Treatment and Education (Settle, WA) 4. Center for Surgical, Medical Acute Care Research and Transitions (Birmingham, AL)

2. Objectives Show how multiple paths in and out of homelessness necessitate variability in policy and clinical responses Use research examples to highlight strengths and shortcomings of novel responses focused on: ◦ Addiction ◦ Housing ◦ Mental Health ◦ Primary Care

3. Summary Kertesz: framework for multimodal responses Kilbourne: public health models for preventable mortality O’Toole: care needs following treatment initiation Saxon: housing and addiction treatment Opinions are those of the presenters and do not represent positions of the US Department of Veterans Affairs

4. Background Single-night prevalence 107,000 (2008, CHALENG) 75,609 (2009 Veteran AHAR) 33 of every 10,000 veterans (prevalence) Conditions medical mental addiction mortality

5. Current Mental & Addiction Disorders among Persons Experiencing Homelessness 1.Fazel. PLoS Med 5(12):e225; 2008. 2.National Survey of Homeless Assistance Providers and Clients, 2000 (data from 1996)

6. Concerns and Responses Veterans who are homeless raise: ◦ ethical concern (civic) ◦ policy concern (utilization, system strain, community impact) ◦ clinical concern (illness, death) Response paradigms ◦ Policy ◦ Clinical

8. One view of homeless causation Personal Assets Job skills and history Family wealth Social Support Financial supports Military/Veteran-specific Personal Liabilities Addiction Severity Childhood or family poverty Personal or familial poverty Mental Illness Military/Veteran Note: with low assets, the liabilities don’t need to be that severe to slip into homelessness Environmental Context: Markets for jobs and housing Criminal justice and veteran policy Entitlement and mental health policies

9. Components to Promote an Exit from Homelessness (all shown with equal weight) DON’T FORGET--- Sequencing? Consumer Preferences? Policy Mandates DON’T FORGET--- Sequencing? Consumer Preferences? Policy Mandates Job market Rental market Family

10. Policy 1 - Linear Policy 2 –Housing First Program entry contingent on accepting treatment, moves toward housing, through way-stations to make “housing-ready” Ethics: benevolence ??Is housing achieved? ??Fails the most needy? Rapid access to permanent supportive housing Seeks the most vulnerable Ethics: client choice, rights ??Work for all? ??Affordable for all? ??Does health improve?

11. Birmingham Drug Treatment Trials: Milby/Schumacher (1990-2006) Homeless cocaine-dependent treatment seekers ◦ 80-90% with another mental illness Housed in apartments (contingent on proven abstinence) Day therapy: 4-6 hrs/day Paid Work Therapy Milby. Drug Alc Depend. 1996;43:39-47. Schumacher. J Subs Abuse Treat. 2000;19:81-88. Milby AJPH. 2005;95:1259-5. Milby J Subst Abuse Treat In Press.

12. Summary of Birmingham Trials 1-4 Treatment reduces cocaine use in RCT comparison Post-treatment housing sometimes better in RCT comparison

13. Housing at 1 Year, 6 Months After Treatment Ended, 3rd Birmingham Trial (n=138, 71%) Kertesz et al. J Behavioral Health Services & Research. January 2007

14. Percentage of Clients Stably Housed after treatment (H4) Milby, Schumacher, Wallace, Vuchinich, Mennemeyer & Kertesz. Am J Pub Health. 2010. online 3/18/2010; doi 10.2105 n= 206 receiving abstinence-contingent housing, work therapy.

15. Linear Approach Lessons Treatment success  work & housing Not sufficient for all: ◦ Drug dependence is chronic, for many 1 ◦ Housing entry standards often unattainable Treatment programs under-resourced 2 1. McLellan. JAMA. 2000. 284:1689-95. 2. McLellan JSAT. 2003;25:117-21

16. Housing First – review RCTs: Housing results superior to unspecified community care in: ◦ NY severe mentally ill 1 ◦ Chicago medically ill 2 Health & addiction tend not to improve 3 ◦ With exceptions Net cost savings achievable with some, but not all 3 & not for HUD-VASH 4 1. Tsemberis 2004. 2 Sadowski 2009. 3. Kertesz 2009. 4. Rosenheck 2003

17. Kertesz et al. Milbank Quarterly. 2009; 87:2 (495-534) Kertesz & Weiner. JAMA. 2009; 301:17 (1822-24)

18. HUD-VASH HUD apartment vouchers VA Supportive Housing services 37,000 vouchers* Typically assumes participation in treatment *Approximate, email with Vince Kane, 4/2011

19. HUD-VASH’s relation to the ideals of Housing First Not so rapid 1 : ◦ Intake to HUD-VASH referral: m=161 days ◦ Referral to housing: m=108 days Not so permanent 2 : ◦ 73% terminate within 5 years Clients vulnerable? ----use of other VA housing (OR 4.0) 2 1. (1992-2006). O’Connell/Rosenheck. Psych Rehab J. 2010; 308-19. 2 (1990s data). Kasprow et al. Psych Services. 2000; 51: 1017-23.

20. What might be the challenges? Mental health location and paradigm Logistics of apartment units Organizational leadership ? Upcoming study: Housing Solutions in a VA Environment (H-SOLVE) ◦ Birmingham VA C-SMART & Boston VA COLMR DON’T FORGET--- Consumer Preferences? DON’T FORGET--- Consumer Preferences?

21. The consumer voice as clarifier defining quality in primary care PC-Quality Homeless Study (VA HSR&D) 38 clients, 22 experts, 1500 pages Accessibility Coordination Control I don’t necessarily agree I should have control, but to share responsibility, that’s what I think….Having a conversation with the doctor, listening to the options available, talking through the possibilities and having a say in what the final outcome is.

22. end

23. Control What do you think about the idea that you should have control in your primary care? Control means to mean like he would be a puppet on a string, like my cat or my dog… He would do what I wanted to do and only what I wanted to do. If I had control of anybody when I was drinking I wouldn’t be here today. I’d be dead. I don’t necessarily agree I should have control, but to share responsibility, that’s what I think….Having a conversation with the doctor, listening to the options available, talking through the possibilities and having a say in what the final outcome is.

24. Control Proposed Survey Items I help make the important decisions about my health care. If my primary care provider and I were to disagree about something related to my care, we could work it out.

25. What Does VA Currently Offer? Grant and per Diem (rehabilitatively oriented housing up to 24 months) Contract Work Therapy Substance Abuse/Mental Health Treatment Domiciliary Permanent Housing (HUD/VASH)

26. Summary Housing and Health are addressable Addressing either one does not necessarily resolve the other Implications for future work: ◦ Organization implementation research ◦ Consumer perspectives may help better define

27. Linear Approaches 1 Rehabilitative work makes client “housing-ready” Client transitions from supervised treatment toward independence Endpoints: ◦ Private market ◦ Supportive housing Critique: does “linear” progress make sense for nonlinear illness. What of the “treatment failures”? Ridgway, Psychosocial Rehabilitation J. 1990

28. Secretary Shinseki Conference of National Alliance to End Homelessness (7/13/2010) For the chronically-homeless Veteran, who is “hard- to-serve”—those who may have refused care in the past, failed to complete previous programs, have a history of disruptive behaviors, or who don’t fit easily into existing programs—the most effective option is HUD-VA Supportive Housing— HUD-VASH. VA will address all Veterans’ needs, no matter how difficult. We will not leave Veterans homeless while they seek treatment, but will house first, and then provide comprehensive treatment and services.