homelessness among veterans with serious mental illness public health impact and outreach
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Homelessness among Veterans with Serious Mental Illness Public Health Impact and Outreach. Amy M. Kilbourne, PhD, MPH VA Ann Arbor Center for Clinical Management Research Associate Director, VA Ann Arbor SMITREC - PowerPoint PPT PresentationTRANSCRIPT
Homelessness among Veterans with Serious Mental Illness
Public Health Impact and Outreach
Amy M. Kilbourne, PhD, MPHVA Ann Arbor Center for Clinical Management Research
Associate Director, VA Ann Arbor SMITREC
University of Michigan Department of Psychiatry and Comprehensive Depression Center
Acknowledgements
VA Health Services Research and Development
VA National Center on Homelessness among Veterans
VA Office of Mental Health Services VHA Clinical Operations (10NC)
SMITREC NIMH (R01 MH 79994, MH 74509)
VA Homeless HSR Initiative
The VA has a wide range of programs and initiatives focused on addressing the President’s goal of ending homelessness among Veterans
The VA Homeless Health Services Research Initiative, starting in 2010, brings together four projects in partnership with the National Center on Homelessness among Veterans that seek to enhance the role VA research can play in ending homelessness
VA Homeless HSR Initiative Homeless Solutions in a VA Environment
Stefan Kertesz, MD, Birmingham VA
Population-based Outreach Services to Reduce Homelessness among Veterans with SMI Amy M. Kilbourne, PhD, Ann Arbor VA
Addiction Housing Case Management for Homeless Veterans Enrolled in Addiction Treatment Andrew J. Saxon, MD, Seattle VA
Aligning Resources to Care for Homeless Veterans Thomas O’Toole, MD, Providence VA
Background
Homelessness disproportionately affects Veterans with serious mental illness (SMI) Social isolation, substance abuse, incarceration,
symptom burden, limited employment
VA: largest single provider of SMI care Treatment drop-out adverse outcomes Public health models to reduce preventable
mortality
Homelessness and SMI
SMI: schizophrenia, schizoaffective disorder, bipolar disorder, other psychosis diagnosis
12.3% of Veterans with SMI had ICD-9 code or encounter for homelessness services in FY 2009
25% of the U.S. homeless population has SMI; 6% of overall U.S. population
SMI: functioning employment housing
Sources: VA National Psychosis Registry; NIMH, 2009
Homeless Veterans Health Disparities Framework
Adapted from CHERP Health Disparities Conceptual Framework (Kilbourne et al. 2006)
Intervening (Reducing Homelessness)
Individual/community (e.g., peer support, outreach programs)
Provider (e.g., outreach, collaborative care)
System (e.g., Housing First, HUD-VASH vouchers, GPD)
Detecting Define Homelessness –related outcomes, assess gaps (e.g., Stable Housing, Access, Quality of Life)
Defining Populations Vulnerable to Poor Outcomes (e.g., SMI. Dual-dx, OEF-OIF)
Understanding Identifying Determinants of reduced homelessness at the Following Levels:
Individual (e.g., sociodemographics, need)
Provider (e.g., health services encounter, training)
System (e.g., organization, cross-agency collaborations)
Understanding Risk Factors among Homeless Veterans
Veteran Factors•Sociodemographics•Preferences•Illness burden•Self-efficacy•Geographic distance
Outreach Encounter•Communication•Competing needs•Contact availability
Provider Factors•Knowledge•Competing demands•Resources
Community& Government-wide Resources
VAMC Communication and Policy Factors•Site level organization, financing, and delivery•Site level organization culture, quality improvement
Figure 2: Multi-level Determinants of Homelessness Health Disparities
Characteristics of Veteran Patients with SMI with a Recent History of Homelessness
N=234,674Homeless (N=28,805)
Not Homeless (N=205,869)
% % Women 7.7 10.6
African American 38.8 19.2Married 16.6 38.0
Service connected 36.4 55.7Substance use disorder 70.7 24.5
Any Medical co-morbidity 91.6 89.1On atypical anti-psychotics 46.6 45.4
Past-year hospitalization 49.9 23.0
Intensive case management 19.9 4.2
Mortality: Homelessness and SMI
0
5
10
15
20
25
30
2000 2001 2002 2003 2004 2005 2006 2007
Differences in Years of Potential Life Lost for All-Cause Mortality among VA Patients
Homeless SMI
Homeless Non-SMI
Non-Homeless SMI
Non-homeless Non SMI
Barriers to Treating the SMI Homeless Population
Fragmentation of Care: administrative and financial separation
Housing conditional on treatment
Lack of recovery-orientation (distrust of system)
Lack of coordination with criminal justice system
VA National Center on Homelessness among Veterans
Promote recovery-oriented care for Veterans who are homeless or at risk for homelessness
Personalized access to treatment, education and outreach
Treatment models supplement psychotherapy and medication with services for concurrent disorders (e.g., substance abuse), caregiver, and peer support
Outreach Program and Reduced Mortality among Veterans with SMI
VA Office of the Medical Inspector (OMI)
Quality improvement study from 2007-2009 led by the VA Office of the Medical Inspector
Population-based registry: identify SMI patients who had dropped out of care
Data source: VA National Psychosis Registry SMI diagnosis and last seen in VA in FY 2005, no VA
outpatient visits from 06-07 and were alive up to FY 07
Davis CL, Kilbourne AM, Pierce, JR, Blow F, Winkle B, Lang erg R, Visnic S, Lyle D, Hocked E, Philips Y. Reduced Mortality Among VA Patients with Schizophrenia or Bipolar Disorder Lost to Follow-upand Engaged in Active Outreach to Return to Care
Outreach Program Methods
Lists of patients sent to points of contact (POCs) at 138 VA medical centers
POCs contacted Veterans, scheduled appointments
Follow-up data linked to NPR and VA/SSA mortality data through 2009
Outreach Program Results
4,791 patients with SMI lost to follow-up Typically unmarried, male, and not service-
connected
Diagnosed medical comorbidities: Diabetes (14%) Dementia (6%) Cerebrovascular disease (4%) Cancers (3%)
Outreach Program Results
3,315 of the 4,791 patients (69%) contacted 2,375 (72%) had returned to VA care by 2009 Reasons for not returning to care:
Key Reasons: %
Not perceiving a need for care 33
Not satisfied with VA services 22
Lack of transportation or time 20
Wanted to solve problem by themselves
7
Outreach Program and Mortality
All-cause mortality through 2009 (N=4,791):
Veterans who returned for care0.5%
Veterans who did not return for care 6.3%
Outreach Program: Predictors of Mortality
Variable Odds RatioDid Not Return for Care 14.3**
Age >=65 (vs. <45) 3.6
Age 45-64 (vs. <45) 24.5**
Male (vs. Female) 1.3
Single (vs. Married) 1.3
Schizophrenia (vs. bipolar diagnosis) 1.4*
Charlson score = 1 (vs. 0) 2.0**
Charlson score = 2 (vs. 0) 3.3**
Charlson score = 3 (vs. 0) 2.8
*P<0.06, **P<0.001
VA Outreach Implementation2/2006 Publication of initial article (Copeland et al.)
1/2007 Outreach program launched by OMI
2009 OMI program completed, briefings
2010 OMI Program final report
1/2011 Patient Care Services replicates Outreach program (OMHS)
7/2011 OMHS Program Directive
9/2011 HSR&D/NCHV Homeless Outreach
Near real-time monitoring
Partnerships with community organizations
Implications: Practice-based Research
Veterans with SMI lost from follow-up care can be identified & engaged Reduced mortality Many POCs were VA Local Recovery Coordinators
More intensified efforts for homeless Align research with rapid implementation
Leverage existing programs Population-based panel management Local provider input