Inclusion Criteria:  Veterans who:  are on VA's Homeless Registry, which comprises those who utilized any VA homeless programs and services in the past 2 years are enrolled on a Patient Aligned Care Team (or "PACT") at a study site had a hot spotter qualifying event in two or more quarters in the past year will be eligible for participation  Exclusion Criteria:  Veterans who have a suicidal and/or behavioral flag in their medical record and those who are too cognitively impaired to understand the informed consent process and other study procedures will be excluded