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.

20. Young AS, Chinman MJ, Cradock-O’Leary JA, et al. Characteristics of individuals with severe mental illness who use emergency services. Community Ment Health J. 2005;41(2):159-168.

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.

30. North CS, Smith EM. A comparison of homeless men and women: different populations, different needs. Community Ment Health J. 1993;29(5):423-431.

31. Kertesz SG, Austin EL, Holmes SK, et al. Making housing first happen: organizational leadership in VA’s expansion of permanent supportive housing. J Gen Intern Med. 2014;29(suppl 4):835-844.

Discussion

The HMMM-V program for delivery of PCC to homeless veterans is an innovative pilot program designed to connect with difficult-to-reach homeless veterans and engage them in care. The deliverables provided by this project are (1) A mobile outreach vehicle to deliver care to homeless veterans and outreach to other veterans and community agencies in North Texas; (2) The P-CHI assessment tool for homeless veterans modified and adapted for use with this special population; and (3) pilot data on its first cohort of homeless veterans served, describing their baseline characteristics and their stated satisfaction and preferences about their goals and aspirations for their physical, emotional, and mental health and well-being.

The HMMM-V program successfully identified homeless veterans in need of services, and more than one-third of these veterans were not previously engaged in VA services. Compared with the “typical” veterans served at VANTHCS homeless programs, veterans served by the HMMM-V comprised a greater proportion of minorities and a higher proportion who had been exposed to combat.²⁹ Age and gender characteristics were similar.²⁹ When compared with veterans who access care at VANTHCS and have not experienced homelessness, those served by the HMMM-V were younger and more likely to belong to a minority group; however, they were similar in combat exposure and gender.¹ The veterans served by the HMMM-V program also were considerably older and had more homeless chronicity than did nonveteran homeless populations, consistent with other research.^4,29,30

The veterans served by the HMMM-V program not surprisingly made housing their top priority in need of help, consistent with the Housing First model.^22,31 They also indicated that employment/vocation and reducing substance use were of lower importance. Need for assistance with reducing substance use and social support were the domains least often identified as areas where help was needed, which seems inconsistent with the higher established rates of substance abuse problems among homeless veterans.¹

With additional fieldwork, the HMMM-V program is expected to allow refinement of procedures for identifying and serving veterans from a patient-centered care perspective. The P-CHI will be further tested and developed, and the next step will be to create and pilot intervention templates for a Patient-Centered Health Improvement Plan, based on the P-CHI results. This process parallels the original development treatment plans for the VA’s Personalized Health Plan based on the PHI.²⁵ Once the HMMM-V program is fully established in Dallas, the plans are for an expansion that will cover a broader geographic area in North Texas that includes rural areas.

The HMMM-V program was designed to address the barriers to health care that are encountered by homeless veterans. It is unique in homeless veteran care due to its patient-centered approach that partners with homeless veterans to prioritize their needs as determined by them rather than based solely on policies or provider conceptualizations of their needs. Access to services, engagement in care, and successful utilization of needed services may lead to measurable improvements in health care outcomes among homeless populations of veterans. Desired goals include remission of illness through appropriate medical intervention, preventing morbidity, achieving healthy lifestyles, recovery from addiction, stabilization of psychiatric illness, and attainment of stable housing.

The first hurdle for implementing this type of program in other settings is the identification of resources needed for these efforts. Need of additional staffing resources, however, may be circumvented by allowing employees working in other areas to rotate in community outreach shifts in the mobile unit. Another hurdle encountered in implementation of the HMMM-V initiative was the initial difficulty finding homeless veterans in community settings, especially those in unsheltered locations. The HMMM-V program addressed this issue by partnering with other agencies serving the homeless in the community. Therefore, a general recommendation for other entities seeking to implement this type of program is to reach out to these community partners from the outset.

Conclusion

The HMMM-V has the potential to engage the most difficult-to-reach homeless veterans in need of health services by delivering care and providing resources in challenging environments. Further work is needed to validate the P-CHI for use with this program and to conduct well-designed and implemented research to demonstrate effectiveness of this intervention on veteran outcomes, especially quality of life. Once this additional work is accomplished, this innovative program can potentially be implemented by VAMCs across the nation, and potentially in more general community care settings, to more effectively reach out and deliver services to homeless members of the community.

Acknowledgments
Grant support was received from the Department of Veterans Affairs, Office of Patient Centered Care. The authors would like to acknowledge all the clinicians, trainees, and support staff who have contributed to the success of the HMMM-V program: Tara Ayala, Jose Cabrera, Tony Castillo, Rachael Lynn David, Teresa DeShazo, Sylvia Figueroa, Steven Fisher, Eric Gary, Evelyn Gibbs, Kevin Hosey, JoAnn Joseph, Taly Drimer Kagan, Miranda Kelly, Michelle King-Thompson, Sharon Marcus, Shiji Mathew, Moneeza Matin, John Moreno, Joseph Neifert, Joel Price, Tiffany Price, Natalie Qualls, Reginald Robertson, Kristine Rodrigues, Jon Saffelder, Jill Stokes, Scott Stone, and John Smith.