Program Profile

Development and Implementation of a Homeless Mobile Medical/Mental Veteran Intervention

Fed Pract. 2017 September;34(9):18-25

References

1. LePage JP, Bradshaw LD, Cipher DJ, Crawford AM, Hooshyar D. The effects of homelessness on veterans’ health care service use: an evaluation of independence from comorbidities. Public Health. 2014;128(11):985-992.

2. Fischer PJ, Breakey WR. The epidemiology of alcohol, drug, and mental disorders among homeless persons. Am Psychol. 1991;46(11):1115-1128.

3. Robertson MJ, Zlotnick C, Westerfelt A. Drug use disorders and treatment contact among homeless adults in Alameda County, California. Am J Public Health. 1997;87(2):221-228.

4. North CS, Eyrich KM, Pollio DE, Spitznagel EL. Are rates of psychiatric disorders in the homeless population changing? Am J Public Health. 2004;94(1):103-108.

5. Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS Med. 2008;5(12):e225.

6. Harpaz-Rotem I, Rosenheck RA, Desai R. The mental health of children exposed to maternal mental illness and homelessness. Community Ment Health J. 2006;42(5):437-448.

7. Pollio DE, Eyrich-Garg KM, North CS. The homeless. In: Johnson BA, ed. Addiction Medicine: Science and Practice. New York, NY: Springer; 2011:1487-1504.

8. Padgett D, Struening EL, Andrews H. Factors affecting the use of medical, mental health, alcohol, and drug treatment services by homeless adults. Med Care. 1990;28(9):805-821.

9. Baggett TP, Singer DE, Rao SR, O’Connell JJ, Bharel M, Rigotti NA. Food insufficiency and health services utilization in a national sample of homeless adults. J Gen Intern Med. 2011;26(6):627-634.

10. Folsom DP, Hawthorne W, Lindamer L, et al. Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. Am J Psychiatry. 2005;162(2):370-376.

11. Fuehrlein BS, Cowell AJ, Pollio D, Cupps L, Balfour ME, North CS. A prospective study of the associations among housing status and costs of services in a homeless population. Psychiatr Serv. 2015;66(1):27-32.

12. Pollio DE, North CS, Eyrich KM, Foster DA, Spitznagel E. Modeling service access in a homeless population. J Psychoactive Drugs. 2003;35(4):487-495.

13. U.S. Department of Housing and Urban Development Office of Community Planning and Development. The 2016 Annual Homeless Assessment Report (AHAR) to Congress. Part 1: point-in-time estimates of homelessness. https://www.hudexchange.info/resources/documents/2016-AHAR-Part-1.pdf. Published 2016. Accessed August 7, 2017.

14. Tsai J, Rosenheck RA. Risk factors for homelessness among U.S. veterans. Epidemiol Rev. 2015;37:177-195.

15. Williamson V, Mulhall E. Coming home: the housing crisis and homelessness threaten new veterans. Iraq and Afghanistan Veterans of America, January, 2009. http://media.iava.org/IAVA_coming_home_2009%20The%20Housing%20Crisis%20and%20Homelessness%20Threaten%20New%20Veterans.pdf. Accessed August 10, 2017

16. Shinseki EK. Remarks by Secretary Eric K. Shinseki. National Summit on Homeless Veterans; November 3, 2009; Washington, DC. https://www.va.gov/opa/speeches/2009/09_1103.asp. Updated August 8, 2016. Accessed August 7, 2017.

17. Shinseki EK. Remarks by Secretary Eric K. Shinseki. 2014 National Coalition for Homeless Veterans Annual Meeting; May 30, 2014; Arlington, VA. https://www.va.gov/opa/speeches/2014/05_30_2014.asp. Updated April 21, 2015. Accessed August 7, 2017.

18. Pollio DE, Spitznagel EL, North CS, Thompson S, Foster DA. Service use over time and achievement of stable housing in a mentally ill homeless population. Psychiatr Serv. 2000;51(12):1536-1543.

19. Page J. Barriers to transferring care of homeless people with serious mental illnesses to community mental health organizations: perspectives of street-based programs. Best Practices in Mental Health: An International Journal. 2007;3(1):26.

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21. Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and low-income veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461.

22. Tsemberis S, Gulcur L, Nakae M. Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health. 2004;94(4):651-656.

23. U.S. Department of Veterans Affairs, Veterans Health Administration. VA Patient Centered Care. http://www.va.gov/patientcenteredcare. Updated July 24,2017. Accessed August 7, 2017.

24. Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100-103.

25. U.S. Department of Veterans Affairs, Office of Patient Centered Care and Cultural Transformation. My story: personal health inventory. https://www.va.gov/PATIENTCENTEREDCARE/docs/VA-OPCC-Personal-Health-Inventory-final-508.pdf. Published October 7, 2013. Accessed August 7, 2017

26. North CS, Smith EM, Pollio DE. The Homeless Supplement to the Diagnostic Interview Schedule (DIS/HS). St. Louis: Washington University, 2004.

27. North CS, Eyrich KM, Pollio DE, Foster DA, Cottler LB, Spitznagel EL. The homeless supplement to the diagnostic interview schedule: test-retest analyses. Int J Methods Psychiatr Res. 2004;13(3):184-191.

28. LaSalle JL. Homeless Operations Management and Evaluation System (HOMES) user manual-phase 1. http://www.vfwsc.org/homes.pdf. Published April 19, 2011. Accessed August 7, 2017.

29. Petrovich JC, Pollio DE, North CS. Characteristics and service use of homeless veterans and nonveterans residing in a low-demand emergency shelter. Psychiatr Serv. 2014;65(6):751-757.

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Community Partnerships

The HMMM-V program benefitted from a number of partnerships with community agencies. During development of the program, HMMM-V personnel accompanied the Dallas Police Department’s Crisis Intervention Unit on typical homeless crisis services deployments into the field to learn about the locations and nature of encampments and homeless peregrination patterns in the Dallas area.

To aid in the design and selection of features for the mobile outreach vehicle, team members toured Homeless Outreach Medical Service mobile clinics from 2 local county hospitals, Parkland Hospital and John Peter Smith Hospital. The staff for these mobile clinics were interviewed about their experience with various components of their programs and their recommendations for optimal design of the mobile medical clinic for service delivery.

Numerous agencies in the Dallas area that serve the homeless population assisted with locating and connecting homeless veterans to HMMM-V programs. These partnering agencies also serve homeless individuals who do not qualify for the HMMM-V program, such as veterans with other-than-honorable military discharges.

The HMMM-V mobile outreach vehicle travels to partnering agencies and provides services on a recurring basis. These agencies are the Dallas International Street Church, a church and faith-based agency aiding the recovery of people with “broken lives”; Cornerstone Ministries, a church-based ministry serving people with adverse circumstances; and City Square’s Opportunity Center, human services and community development programs for low-income city residents. The mobile clinic also travels regularly to other areas to serve homeless veterans residing in unsheltered locations, such as homeless encampments and under bridges.

Clinical Assessment

The project used a modification of the VA Personalized Health Inventory (PHI) for general veteran populations, which assesses 8 areas of self-identified needs to address the specific concerns of homeless veterans served by a mobile clinic.²⁵Version 19 of the PHI (revised September 18, 2012), the version of the instrument available to the team at the inception of the project, was deployed with the HMMM-V personnel into the field. It imposed a heavy interview time burden (several hours), and its content areas did not seem appropriate to address the immediate concerns of homeless populations (eg, sections pertaining to personal development through hobbies, recreation, or volunteering; healthy living spaces with plenty of lighting and color; “eating healthy, balanced meals with plenty of fruits and vegetables each day”).²⁵

Based on HMMM-V personnel feedback, the team modified this tool and developed a patient-centered health inventory (P-CHI) for homeless veterans that was acceptable in length and applicable to the situational characteristics of homeless existence. The tool’s 10 “current and desired states” were revised to remove domains of exercise and flexibility, sleep and relaxation, and mind-body techniques. The intervention and prevention domains were combined. A material needs (clothing, furniture, transportation, financial benefits) domain was added, and a new domain on reducing alcohol/drug use was created by moving this material from the food and drink domain.

The remaining domains were modified to fit the homeless living situation (Food and Drink = Nutrition; Personal Development = Employment/Vocation; Family, Friends, and Co-Workers = Family/Social/Legal Support; Spirit and Soul = Personal/Spiritual Fulfillment; Surroundings = Housing). Current state ratings were revised to reflect level of satisfaction, and ratings of Desired State were replaced with level of importance.

The modifications resulted in 9 domains, which were assembled into a grid for efficient rating of both satisfaction and importance for each domain (rated 1 to 10, lowest to highest, respectively), followed by an instruction to mark an X in a designated space in all the domains with which the individual would like help (Table). The intent was to reduce the burden of the instrument by having the participant complete sections providing detailed information about only the domains selected by the participant.

The details of each domain in the original VA PHI tool were captured through open-ended questions in text responses provided by the veteran. Because open-ended text responses are not conducive for summarizing characteristics of the population served or for evaluating program activities, the detailed sections covering the domains were revised completely to capture data within categoric and numeric variables. Items from the validated Homeless Supplement Interview were added to collect information not provided in the Homeless Operations Management and Evaluation System interview that is routinely administered to all veterans accessing homeless VA services.^26-28

The information collected in these domains cover duration of current homeless episode, lifetime number of homeless episodes, current living arrangements and dissatisfactions with these arrangements, frequency and source of meals, employment history and current work status, sources of income, special material needs, medical and dental problems and sources of care, current medications, mental health problems and sources of care, urgent mental health concerns, current amount and frequency of alcohol and drug use, substance abuse treatment history, relationships with family and intimate partners, legal assistance needs, and self-identified needs for spiritual and personal fulfillment. This instrument is available on request to the authors.