Hospitalized younger: a comparison of a national sample of homeless and housed inpatient veterans.

BACKGROUND: Homelessness is associated with high rates of hospitalizations and age-adjusted mortality. Few studies have examined whether homeless people are admitted to the hospital at an earlier age than the general population or for different diagnoses. METHODS: We compared the age at admission and the primary discharge diagnoses in a national sample of 43,868 hospitalized veterans. RESULTS: The difference in median age between homeless and housed inpatients ranged from 10-18 years for medical-surgical diagnoses and 3-4 years for psychiatric and substance abuse diagnoses (p#.005 for all diagnoses). Homeless veterans were more likely to have been admitted for psychiatric and substance abuse diagnoses (79.9%), compared with housed veterans (29.1%). CONCLUSIONS: Substance abuse and psychiatric illness account for the majority of admissions among homeless veterans. Among all diagnostic groups, homeless people were admitted at younger ages. Our findings suggest that homeless people have either a more rapid disease course, leading to earlier morbidity, or lower admission threshholds sufficient to generate hospital admission.

Factors associated with receipt of pension and compensation benefits for homeless veterans in the VBA/VHA Homeless Outreach Initiative.

Public support payments may facilitate exit from homelessness for persons with mental illness. We examined data from 10,641 homeless veterans contacted from October 1, 1995 to September 30, 2002 in a collaborative outreach program designed to facilitate access to Department of Veterans Affairs (VA) disability benefits. Those who were awarded benefits (22% of contacted veterans) were more likely to report disability, poor to fair self-rated health, and were more likely to have used VA services in the past. Thus, this program achieved only modest success and was most successful with veterans who were already receiving VA services and who might have received benefits even without the outreach effort.

Housing outcomes for hospitalized homeless veterans.

This study examines housing status at the time of hospital discharge in a national sample of 3,502 veterans who were homeless at admission to a Veterans Health Administration (VHA) medical center. A supplemental survey on homelessness was added to the annual VHA inpatient census over a 4-year period (1995 through 1998). Data from this survey were used to identify homeless veterans hospitalized on the final day of the fiscal year and to document their housing status at discharge. A signal detection technique, Receiver Operating Characteristic analysis, was used to identify predictors of housing status at discharge. At discharge, only 13% of the veterans in our analytic sample were literally homeless, 40% were doubled up, and 33% were transferred to another an institution; only 13% were living independently. Housing status at admission (specifically, staying with friends or family temporarily rather than literally homeless), treatment in a psychiatric or substance abuse program rather than a medical program, and a greater income level or access to VHA benefits were found to be associated with better housing outcomes. As one might expect, homelessness was infrequently resolved during an acute inpatient hospitalization, but few veterans returned to literal homelessness at the time of discharge.

A longitudinal perspective on monitoring outcomes of an innovative program.

OBJECTIVES: The use of outcome assessment to evaluate the performance of programs over many years of operation is becoming an increasingly important aspect of health care management. Over a five-year period of program monitoring, this study examined changes in individual client outcomes three months after discharge from a residential work therapy program for veterans with severe substance use disorders. The study also examined the relationship between these outcomes and changing program features, such as staffing, treatment variables, and follow-up rates. METHODS: Data on admissions characteristics, services delivered during treatment, and status at discharges were collected for 3,390 veterans who were treated in 25 sites in the Department of Veterans Affairs' Compensated Work Therapy/Transitional Residence program. Follow-up data were gathered three months after discharge for 1,771 veterans (52.2 percent). Hierarchical linear modeling was used to examine the association between year of discharge, site-level measures of program staffing and follow-up rate, and individual patient-level treatment variables and outcomes. RESULTS: Over the five-year monitoring period, site staff-to-bed ratios and follow-up rates dropped substantially, and veterans attended more Alcoholics Anonymous and Narcotics Anonymous meetings and had more toxicology screens. Higher staff-to-bed ratios were associated with more positive employment outcomes, and higher follow-up rates were associated with poorer outcomes in substance abuse and lower total income. However, no significant outcome trends were observed in clinical follow-up measures after the analyses adjusted for these factors, suggesting that program effectiveness did not deteriorate during a period of program change. CONCLUSIONS: Long-term evaluations of program process and follow-up status can usefully document sustained program effectiveness over many years. Such efforts should enhance their value by examining and adjusting for the impact of factors such as changing staffing levels and follow-up rates.

A national survey of the oral health status of homeless veterans.

OBJECTIVES: This study reports results from a survey designed to (1) assess the oral health needs of a national sample of homeless veterans and (2) compare the dental needs of homeless veterans participating in VA-sponsored rehabilitation programs with domiciled veterans in VA substance addiction programs. METHODS: Homeless veterans enrolled in a nationwide rehabilitation program (n = 1,152) completed a survey including questions concerning patients' perceptions of their oral health, dental service needs and use, and alcohol and tobacco use. A sample of these veterans (n = 281) subsequently received dental exams. A comparison group of domiciled veterans enrolled in VA substance abuse programs (n = 339) completed a similar survey. A sample of these veterans (n = 150) also received dental exams. RESULTS: Sociodemographic variables, patient-reported oral health information and risk behaviors, and findings from dental exams described two remarkably similar populations. CONCLUSIONS: As expected, the homeless veterans exhibited poor oral health, but it was not different from domiciled veterans enrolled in substance addiction programs. Lifestyle choices, such as heavy drinking and smoking, may contribute more to poor oral health than living conditions.

Continuity of care and clinical effectiveness: outcomes following residential treatment for severe substance abuse.

BACKGROUND: Continuity of care (COC) has often been viewed as a crucial indicator of treatment quality for patients with severe psychiatric or addictive disorders. However, the relationship between COC and clinical outcomes has received little empirical evaluation. RESEARCH DESIGN: This study used hierarchical linear modeling to examine the relationship between six indicators of COC and seven outcome measures addressing symptoms, substance abuse, and social functioning. SUBJECTS: Patient interviews were conducted with 1576 veterans 3 months after their discharge from one of 22 residential work therapy programs for the treatment of severe substance abuse. RESULTS: Few significant relationships were found between COC and outcome measures in analyses conducted at both the client and program level and fewer than half of these show better outcomes with greater COC. When a Bonferroni corrected P level of P <0.0012 was used, none of the relationships were statistically significant. CONCLUSION: Although there were significant relationships between outcomes and measures of services received during residential treatment, postdischarge COC does not seem to be related to improved outcomes, at least when examined following long term intensive residential treatment. Thus, our results are specific to the context of aftercare following long-term residential rehabilitation and indicate that the value of standard performance measures may vary by treatment context.