Risk Factors for Homelessness among Women Veterans:- 21 -Department of Veteran Affairs

Implications for Prevention and Services03-14-12 Webinar

**VA Women’s Health Research Network**

**Risk Factors for Homelessness among Women Veterans: Implications for Prevention and Services**

**03-14-12 HSR&D Cyber seminar**

Moderator:  And we are ready to get started.  So with that I am going to introduce our speakers and then I’ll turn it over to them.  Presenting for us today we have Dr. Donna Washington.  She is a physician and health services researcher at the VA Greater Los Angeles Healthcare System and a Professor of Medicine at UCLA. Her research examines healthcare access and quality care among vulnerable populations with an emphasis on women and racial ethnic minority Veterans.  

Our other presenter is Dr. Alison Hamilton.  She is a research health scientist at VA Greater Los Angeles Healthcare System and an associate research anthropologist in the Department of Psychiatry at UCLA.  Her current work focuses on women Veterans and mental health.  Dr. Hamilton is also a Fellow with the NIMH/Queri Implementation Research Institute.  

We are very grateful to both Doctors Washington and Hamilton for presenting for us today.  And if you’re all set, I’d be happy to turn the screen over to you now.

Dr. Washington:  Great. Thank you for that introduction.  We want to begin by giving a message here.  We want to begin by acknowledging the funding sources for the research that we’ll be discussing today which are listed on this slide.  And we’d really like to acknowledge the assistance of Vivian Hines who is the homeless woman Veteran’s coordinator at VA Greater Los Angeles and Ines Poza, both of whom helped us quite a bit with this research.  Neither Dr. Hamilton nor myself, Dr. Washington, have conflicts of interest to disclose.

Moderator:  Dr. Washington, I’m going to interrupt you for just a second.  We are not seeing your slides at this time.  So I believe you have multiple screens.  So you will need to select the other one.  So what I’m going to do is I’m going to take back the screen, real quick, and then I’m going to turn it back over to you.  And I believe you’ll get an option that pops up.  There we go.  Perfect.

Dr. Washington:  Great.  And I will put up the acknowledgment slide again to acknowledge the funding sources as well as Vivian Hines and Ines Poza.  So now we’ll start with the poll questions.  Poll question number one:  which category describes your current role in working with women Veterans who are homeless?  Please select all that apply; primary care provider.  The second category is mental health provider, substance abuse, or other counselor.  The third category is social worker or case manager.  The fourth category is administrator.  And the fifth category is researcher.  Please select all that apply.

Moderator:  Thank you.  We are seeing the responses pour in.  We’ve had about fifty percent of our audience respond so far.  We’ll give it just a few more seconds.  Okay and the responses have stopped coming in.  About 75 percent of people responded.  So I’m going to go ahead and close the poll now and share the results with everyone.  

Dr. Washington:  We can’t see the results?  Great.  So it looks like ten percent primary care providers; sixteen percent in the category of mental health providers, substance use or other counselor; thirty-two percent social worker or case manager; twenty-six percent administrator; and thirty-seven percent researcher. 

That’s great.  So we really have a variety of different types of providers and other staff on the line.  Going to poll question number two.

Moderator:  Okay I’m going to launch poll question number two now, and there we go.

Dr. Washington:  Great.  In which setting do you serve women Veterans who are homeless?  Category one: VA medical services such as primary care or the emergency department; category two:  VA mental health services.  Category three:  VA homeless program or housing services.  Category four:  Settings outside of the VA whether they are medical, mental health, homeless or community organizations.  And then category five, not applicable for example these would be people on the line who do not serve women Veterans who are homeless.

Moderator:  Thank you.  We have about two-thirds of people that have replied already, and they’re still coming in.  So I’m going to leave it open for just a few more seconds.  Okay about eighty percent of people have responded.  So I’m going to go ahead and close the poll.  And I’m going to share the results with everyone.  And...And, Donna, are you seeing those now?

Dr. Washington:  No, I’m not.

Moderator:  Oh, sorry.  There we go.  I appreciate our audience’s patience with me.  Thank you.

Dr. Washington:  Molly, maybe you can read them?  I’m not seeing the responses.

Moderator:  Oh, okay.  Looks like we have twenty-seven percent who chose option A: VA medical services.  We have fifteen percent that chose option B:  VA mental health.  We have twenty percent that chose option C: VA homeless program and housing services.  Five percent are in settings outside the VA.  And thirty-two percent clicked on not applicable.

Dr. Washington:  Great.  So once again we have a variety of different services represented and an important small proportion from outside of the VA which really is an important setting for homeless individuals.  

So going on to poll question number three.  For those who do not work in homeless services—so that would be everyone other than the twenty percent who indicated VA homeless programs or homeless services—how often do you screen patients or clients for homelessness?  Would you say that’s all or most of the time?  Some of the time? Rarely?  Never? Or it is not applicable because you do not work in settings where that might be applicable?

Moderator:  Okay.  It looks like just about sixty percent have voted now.  So we’ll give them a few more seconds to get in their votes.  Great.  Thanks to all of our respondents.  We’ve had about seventy percent of people respond.  So I’m going to go ahead and close this poll and share the results with everybody.  

And looks like we’ve got twenty-two percent that reported “most or all of the time”; sixteen percent reported “some of the time”; twelve percent reported “rarely”; six percent reported “never”; and forty-three percent said this is not applicable to them.

Dr. Washington:  Great.  Thank you for those numbers.  And we’ll go onto poll question number four; our final poll question.  How many people including yourself are using the computer or phone line to listen to this presentation?  We’re just interested in the audience—how people view these presentations and that’s why this question is up.

Number one:  I am viewing this presentation alone in front of my computer screen.

Number two:  It’s two.

Third category:  Three to five people sharing this viewing.

Category four:  six to ten.  And,

Category five:  more than ten.

Moderator:  Everybody has been very quick to respond.  And it looks like the majority of people are reporting that they are viewing it alone; about ninety-five percent.  One percent is viewing it with one other person.  And four percent are viewing it with three to five people.  So thank you to those respondents.  And Donna, I’ll turn the screen back over to you in just one second.  There we go; we can see your slides again.

Dr. Washington:  Great.  So we’ll start with a little bit of background about homelessness among Veterans.  Many of you on the line know that ending homelessness among Veterans has become a top federal and VA priority.  And it’s actually the focus of an inter-agency collaboration: VA HUD, Department of Labor, and DHHS among others are involved in this inter-agency collaboration.

Recent national estimates of the magnitude of homelessness among Veterans suggests that on any given night there are about 107,000 Veterans in the U.S. who are homeless.  And stretching it out over the course of the year, there are about 200,000 who are homeless.  So it’s a significant problem.

Veterans are overrepresented in general among the homeless and this is particularly true for women Veterans.  The bullet point on the slide says women Veterans are up to four times more likely to be homeless than women who aren’t Veterans.  But this is actually from a study that was conducted prior to the start of OEF/OIF and recent evidence suggests that the rates are actually much much higher.  So it’s a significant problem.

Homelessness can take many forms; being in shelters such as living on the street, being sheltered such as in traditional housing, or being doubled up such as sleeping on the couch of a friend or relative.  In health care settings it’s really often not readily apparent that a woman Veteran is experiencing homelessness, particularly if she is doubled up or sheltered.  And so it is important to know what puts women Veterans at increased risk for homelessness.  That will help in identifying women who are homeless.  It will help in identifying those who are at risk for becoming homelessness—homeless, I’m sorry.  And the goal being to either deter or prevent homelessness.

So the objectives for our cyber seminar today are to, number one, characterize risk factors for homelessness among women Veterans.  Number two, describe how these risk factors interplay and accumulate—describe how risk factors interplay and accumulate—I’m sorry for those who couldn’t see it.  I got a message on my screen.

Over women’s Veterans life course to result in homelessness.  And, number three; highlight implications of these risk factors and their interplay for prevention and services for women Veterans.

So for our first objective, characterizing risk factors for homelessness among women Veterans, we conducted a case control study.  In the study we identified women Veterans in Los Angeles County who are homeless to enroll in a cross-sectional survey study.  The enrollment criteria which are listed on this slide parallel the definition of homelessness.

We used survey data from a women’s Veterans ambulatory care use study that we had conducted two years earlier to match each homeless woman with five housed women Veteran controls.  And we matched on several different factors: geographic region meaning that we identified women Veterans who are also in the Los Angeles area.  We matched on military service period and on age group.  

We recruited participants through both VA and non-VA homeless service organization contacts.  And the homeless woman Veteran coordinator at our site was in contact with over 150 women at the time of this study.  She identified these women through outreach to settings for high numbers of individuals who are homeless such as shelters, soup lines, country jail, and the other settings that we have listed here. 

And we enrolled a total of 33 homeless women Veterans and 165 controls for this case control study with a sample of close to 200.

Most of the data collections was through in-person interviews.  We used existing survey instruments to develop our survey.  And we did that so that—we wanted to enable comparisons of women Veterans who are homeless with other groups.  So for example with women Veterans who are housed, as well as with homeless women who are not Veterans.  The homelessness measures that we assessed included length of time homeless, the number of entries into and exits out of homelessness.  And the Veteran-specific factors that we measured included period of military service, the service-connected disability rating, and then military sexual assault history.

Our analytic method is summarized on this slide.  And this next slide is the first of several result slides.  So for those who downloaded the handout, then this slide is actually not on the handout.  It was added afterwards.  It describes characteristics of the women who were homeless.

So the mean age among these women was about fifty years of age.  Ten percent or less were college graduates, were employed, or were married.  Sixteen percent, so about one in six women Veterans who were homeless had children under the age of eighteen living with them in the prior twelve months.  And then we looked at the prevalence of several different health and mental health conditions.  I’ve highlighted two of them here; the prevalence of psychotic symptoms.  This is using screeners for psychotic symptoms and for the most part this was via the interview administered survey.  The prevalence was thirty-six percent.  And the history of poly-substance abuse among our survey sample was thirty-two percent. 

So even though these rates of psychotic symptoms and poly-substance abuse is higher than in the women Veteran’s population as a whole, they’re not universal.  And that has an important implication for the types of services that are needed and the way that services should be structured.  As Dr. Hamilton will talk about a little bit later in the slide show.

The characteristics of homelessness for women Veterans are described here.  Women Veterans in our sample had an average four cycles in and out of homelessness. This is actually a really important finding.  This was a cross-sectional study. It looked at one snapshot in time of homeless individuals.  And so the finding of cyclical homelessness suggests that at any one point of time, we’re just sort of viewing the tip of the iceberg if you will, of the larger populations of Veterans who are at risk for homelessness.  So if you think about what it will take to eliminate homelessness and achieve the federal and VA objective.  It’s moving beyond identifying people who are imminently homeless to identifying those who are at risk to prevent them from cycling back into homelessness.

Some of the other characteristics include the length of time homeless over their lifetime.  It was a little over two years.  And then among the women that we interviewed, the median length of time since they were last stably housed was about one year.

So we’ll move on to the bi-variate results.  This line and the next two compare women Veterans who are homeless to women Veterans who are housed.  And starting with socio-demographic characteristics, what we found is that homeless women Veterans were significantly more likely than housed women Veterans to be unemployed, to be disabled, and to be low-income.  They were also significantly more likely to have experienced military sexual trauma.

Homeless women Veterans were significantly less likely to be college graduates, to be employed, to be married, and to have health insurance.  With respect to health characteristics, homeless women Veterans were significantly more likely to have several diagnosed medical conditions, to screen positive for anxiety disorders, post-traumatic stress disorder, tobacco use, to have lower self-reported physical or mental health.  And this was on the magnitude—we used the SF 12 for those who are familiar with it—this was on the magnitude of about ten points which is clinically significant and actually has been associated with increased short-term mortality in other Veteran’s studies.

Looking at comparative health care use in the prior twelve months, homeless women Veterans were more likely to have mental health services use via health care use and have been hospitalized.  So this is a population with several co-morbidities.  Now we conducted multivariate analysis to identify independent risk factors for homelessness.  And before I get into that, I want to tell you what was not included in our model.

We did not include matching factors; we matched women if you recall on age and military service period. And so what that means is that at least in the research that we did we cannot comment on statistically on whether there are increased rates of homelessness for example among the newest cohort of women Veterans.  Anecdotally it seems like that’s the case but we didn’t have the ability to do that with this data.

We did not have matching data for housed women Veterans on substance use or psychotic symptoms.  So even though our non Veteran populations these were important factors, we weren’t able to assess that here.

And then data was highly skewed for some things such as income.  Virtually all of the homeless women Veterans were low income and so we couldn’t include things like that in the model.

So with that little caveat, the independent risk factors for homelessness in women Veterans were unemployment, disability, not being married.  These are the largest—these are the most prominent risk factors with just an odds ratio of ten or above.  And actually it’s not at all surprising because when you think about or look at what the risk factors are for homelessness among non Veterans, then lack of financial resources and lack of social resources are significant.  So we’re seeing the same thing mirrored in homeless women Veterans.  

 Now things that are unique to Veterans are military exposures.  And so though they were somewhat weaker risk factors, having a prior military sexual assault history or screening positive for PTSD, which in women Veterans is often related to either military sexual assault or combat exposure, both of those were independent risk factors.  And that might be an important explanatory factor for why we are seeing much higher rates of homelessness among Veteran women compared with non-Veteran women.

And factors such as PTSD actually have both direct as well as indirect effects.  For example the indirect effects being the correlation with unemployment and disability.  Now before moving on to the next segment of this cyber seminar, I just want to talk a little bit about these statistics.

In the introduction you heard that I’m a physician at the VA—I’m a primary care provider in the women’s clinic.  And what I want to describe for you are a couple of my patients so that you understand how these risk factors play out in the settings that we often practice in  and how you might use them to identify your patients at risk.

So the story that I want to tell you about is one of my primary care patients, who was a new patient to me a few years ago.  She had been in the National Guard Reserves, had deployed to Iraq and came to the VA to establish primary care a few months after her deployment ended.  She was a young woman, close to thirty, was a single mother; she was unemployed but was looking for work.  She had experienced military sexual assault in the military.  And though she did not screen positive for PTSD, she did have several symptoms that suggested either adjustment disorder or that PTSD was developing because this was soon after her return from deployment and may not have been the ideal time to screen.  So I offered her mental health services, because of the adjustment disorder symptoms and then military sexual assault history.  She didn’t feel that she needed mental health services at that time.  And then she had some other physical complaints and so I followed her over time.

She got a job but a couple of years later she lost her job, was having trouble making rent payment, and this happened sort of in between visits, and when she returned for follow-up I found out that her and her son were living in a car.  So could we have seen this coming?  And maybe this should have been a poll question.  While this was around the time that we were conducting this research and now we know to screen for these things.  What this illustrates, and unfortunately this story is not unique, is that there is sort of a complex interplay among these risk factors and that things can sort of turn on a dime fairly quickly.  

And so with that it prompted us to want to delve in more depth into how these risk factors for homelessness sort of interplay in the lives of women Veterans.  And what the past way was from these risk factors to homelessness.  The goal being to then figure out what we has VA providers or professionals can do to try to prevent women from cycling into homelessness.  So with that I’m going to turn the mike over to Dr. Hamilton.

Dr. Washington:  Thank you Dr. Washington and thank you everyone for calling in today.  So as Dr. Washington mentioned, we wanted to augment the survey findings by conducting focus groups with women Veterans who are experiencing homelessness to really understand from the women’s point of view what their perspectives are on how and why they became homeless.

So we conducted three focus groups with twenty-nine—a total of twenty-nine participants.  Recruitment for the focus groups occurred concurrently with recruitment for the case-controlled study that Dr. Washington just described.  So a proportion of the women who completed the survey also participated in the focus groups and then there were additional women in the focus groups.

We audio taped the focus groups and transcribed the material.  And we used a method within grounded theory called the constant comparison method.  I’m not going to get into the details of the analysis today, but there is more information about this in the papers.  The main point that I want to make about this type of analysis is that it really emphasizes what participants themselves prioritize in their own narratives.  So it’s going from what we call the ground up; hence the term “grounded theory.”  We’re going from the ground up in terms of what women consider to be very important in their experiences.  

The characteristics of the focus group participants were very similar to the characteristics of the participants who completed the survey.  They had been discharged from the military at about 26 years of age on average.  And they experience their first homelessness approximately ten years after military discharge.  

So while those experiences—even some of those that Dr. Washington described with regard to her patients—occurred during those ten years.  And there’s a lot of points at which one might be able to intervene where maybe that first homelessness would actually not have to occur. 

The average age of the focus group participants was about 48 and you can see the rest of their characteristics here on this slide with just highlighting that most of these women were not married and none of them were employed at the time of these focus groups. 

 What I’d like to share with you today is what we learned about women; descriptions of the roots of their homelessness.  So the way that we came up with this concept is that each woman in the focus group said, “I became homeless because of such and such.”  The five main roots that we identified were what you see here.  

So the first being childhood adversity.  So approximately half of the participants described experiences in their childhood that they felt precipitated their eventual homelessness.  Some of these women had experienced domestic violence, homelessness during childhood, child sexual abuse, and in many cases women entered the military in order to escape these adverse circumstances and they considered those experiences in childhood to be the very core of their eventual homelessness.

The second root that we identified were experiences that women had during their military service.  And these included both military sexual trauma as Dr. Washington identified, and also substance abuse that was occurring during military service.  So for some women they felt that those particular experiences were the initial root of their homelessness.  

There were also experiences the women described of post-military abuse/adversity and relationship termination.   So divorce, breakup, domestic violence, and other psycho-socially adverse circumstances after they had been discharged from the military.

The fourth group that we identified were post-military mental health, substance abuse, or medical problems.  So these are individual level issues that many women ascribe to be the root of their homelessness.

And finally there was unemployment for a substantial portion of the women; where this set of women said, “I lost my job and I became unemployed.”

The final factor that is listed here, criminal justice involvement, we describe it as subsidiary not because it is necessarily less important than these other issues, but because it only came up in one of the focus groups—that’s for the women.  And in this one particular focus group, this was an especially important problem because what they encountered after being released from jail and in some cases prison was that due to the circumstances of their probation and parole, they could not go back to sources of social support and other support and therefore became homeless.

What we wanted to do with our understanding of these roots of homelessness was to develop a diagram of the pathways that went from these roots into eventual homelessness.  And that’s what you see here in this slide; what we call a web of vulnerability.  

And I’m going to walk you through this a little bit.  So I just mentioned the five roots and you can see those indicated by the numbers in the boxes.  And so for example a woman who describes childhood adverse experiences as a root.  We might have drawn out her path according to her story as she went from that experience into potentially some adverse experience in the military which led to possibly some mental health and substance abuse problems which ultimately led to homelessness.

Now it’s very important to emphasize that all of the women experienced some subset of these pathways.  So with never one particular path for each woman.  They are going in and out of all of these pathways, with some of them being bi-directional.  So Dr. Washington mentioned that there are an average of four episodes of homelessness in each woman’s life.  And you can see those pathways going back and forth especially with these bright arrows which are bi-directional.  

Where some women became homeless, then they might have come out of homelessness due to a new relationship.  And then there were problems in that relationship which might have contributed to substance abuse, which then led them back into homelessness.  So there are most likely more pathways and more bi-directional pathways, than are even reflected here, but what we try to do with this diagram was stick very closely to what the women themselves describe.

And then we can do additional work to expand this in many possible ways.  But it’s our at least initial attempt to really see how do women themselves experience their own pathways towards homelessness.  

And you see the asterisks.  Those indicate what we think of as contextual factors which wove their way into each woman’s story about how they become homeless.  Some of these contextual factors included a lack of social support which was identified as a risk factor, a very pronounced sense of isolation often times because of course when they are homeless they are not receiving any social support or finding solace with any people who could help them.  

I think what’s particularly pronounced with the women who participated in the focus group was a sense of independence that they had really honed especially during their military service and also a survivor instinct.  So they managed to survive a lot of adverse circumstances.  And in some ways that could be seen as a strength because they—perhaps they could be seen as resilient and making it through many difficult conditions.  

But one of the consequences of this very pronounced sense of independence for a lot of these women is that they didn’t seek care.  They didn’t report the problems they were having, and they didn’t find help for the problems they were having.  

So just to go back to the diagram for a minute, you can see the asterisks.  These were areas in their pathways where these contextual factors were especially important.   So for example if a woman experienced some type of relationship breakup here at box 3, her issues around feeling isolated and having no social support were especially pronounced in her pathway to homelessness.

The next part of our study that I want to talk about is this last point of the contextual factors and that’s the barriers to care that women described.  There were three main barriers to care among this group of women who participated in these focus groups.  They experienced a strong lack of information about available services.  They also described limited access to services that they did find out about.  And they experienced a lack of coordination across these services.  

And again, just to go back to the contextual factors, in their efforts to obtain help they continued to feel a sense of isolation and abandonment.  And the abandonment came at a number of different levels.  Not only their loved ones but also feeling abandoned by the system itself.  So I’m going to talk a little bit about each of these barriers now.

In terms of what women didn’t know about and what they wanted to know about, they were very confused about eligibility requirements of several different programs.  They didn’t know where programs were located and often times found that programs were not located in areas that were convenient to them.  

And they also didn’t know about the terms of use; for example how long they could stay in a given program, and again whether they were eligible for that particular program given their particular circumstances.

Focus groups are a very interesting method in that they can accomplish more than what you might even think in terms of giving you information, but they also often can end up being a venue for sharing of information among the participants.  And that was certainly the case with these focus groups where women were very heartened by this opportunity in the focus groups to share what they knew about available services.  

So a lot of the dialog that they had during the focus groups was information for one another.  So they told each other, “Oh you could go to this program.”  Or “This program will be able to help you.”  And it was a very very interesting thing to witness in terms of how excited they were to be able to tell each other what they knew.  

And to add to that they expressed very clearly that they really wanted their information about services from other women Veterans.  And they wanted help from other women Veterans.  They kind of wanted that validity that was conveyed by hearing information from their peers.  And this has really important implications for services that we might develop in this area which Dr. Washington will talk about a little bit later.

Access to services was limited in a number of different ways.  First of all, there was a lack of options for gender appropriate care.  Of course there have been a lot of developments in this area since the time of these focus groups, but at this time there were fewer options than there are even now.  And some of the issues with regard to gender appropriate care were safety issues.

So some women talked about being in mixed gender programs where they were one woman with fifty men.   And for women with military sexual trauma for example, that might not feel like a safe environment.  There were very few women only programs and women were very clear that they wanted women-only programs except for a handful who said it was actually helpful to be in mixed gender programs.  So it’s not a one size fits all type of solution. 

Access was also very limited by geographic distance which I mentioned before and inconvenience.  So sometimes people were having to leave their hometowns in order to access services that were maybe several states away from where they actually wanted to be.  

There were very few long-term housing options for these women, and they also encountered a lot of restrictive entry criteria.  So for example a lot of women found that they couldn’t get into certain programs unless they had current or past year substance abuse.  And as Dr. Washington mentioned, not all of these women did have substance abuse issues.  

So some women said they actually had to state that they had substance abuse issues even when they didn’t and then they had to comply with the programs requirements with regards to substance abuse treatment.

Another restrictive entry criteria that was a problem for some women was either a requirement for children or a requirement for having no children.  So women who had no children could not obviously get into programs that were designed for women with children.  And women with children often couldn’t get into programs that were designed for women Veterans but did not have accommodations for their children.

Finally, there was a lack of coordination across the services and this was seen in a few different ways.  There were issues for women getting to services after they had been screened for certain issues.  As I mentioned before, there were some concerns for women who had been released from jail or prison, gotten into the community, but didn’t have much coordination from their needs while incarcerated to community release.  

And there was also a lack of coordination from temporary to permanent housing.  So some women described being screened for their readiness to enter permanent housing after temporary housing, but then the ball kind of dropped and there was nothing to support them in their efforts to get into permanent housing.

Women also described a lot of challenges with money management.  And they also had some problems connecting VA and non-VA services.  And there are definitely some efforts underway in this area at a federal level at this point.

So in summary we learned through all of this research that we have conducted, that women Veterans who are homeless face a number of challenges accessing information about and entry into programs that could address their needs.  They expressed a very fundamental need for safe housing.  And they expressed a pronounced need for coordinated and women only and safe services.

So I’m going to turn over—back over to Dr. Washington who is going to talk about the implications of our findings.

Dr. Washington:  Thank you.  So the implications of our findings are in the areas of screening and prevention as well as services.  Starting with screening and prevention of women Veterans then the implications are that we should screen for homelessness in VA clinical settings, particularly primary care settings where women Veterans who are homeless might be sort of invisible with respect to their homelessness.

And in addition to screening for homelessness we need to screen for these risk factors that we identified because similar to the patient that I described, the living situations of vulnerable women can deteriorate fairly quickly.  There are several current VA efforts—there’s actually coordinated VA efforts to help provide tools to providers to do just that.  

Vince Kane is one of the discussants and will likely be touching on that.  The Women Veterans’ Health Strategic Healthcare Group and QUERI are funding us to look at tools and actually develop tools in primary care settings that see a lot of women Veterans to help providers in their screening efforts so you’ll be hearing more about that in the next few months.

In one of the poll questions early on, then five percent of the audience identifies themselves as being in non-VA settings.  And it’s really important to screen clients in those settings as well for Veteran status.  Veteran status as we mentioned confers increased risk for military sexual trauma and for PTSD.  And so identifying those women as Veterans and then referring to them to the VA, to Veteran service organizations, or the other organizations that might specifically be able to address those risk factors will be helpful.

Same thing about health services should be structured to better meet the needs of women Veterans.  Then firstly we want to just comment on existing services.  Since the federal initiative to end homelessness was rolled out in 2010, VA, HUD, and the Department of Labor, have engaged in several new initiatives to address homelessness.  Our findings suggest ways that these initiatives and aspects of services can be tailored to make them more patient centered or better meet the needs of women Veterans.  

So our findings suggest the need for greater availability of women-only programs.  This should be an option, as Dr. Hamilton mentioned.  There may not be a universal preference for women-only programs but it is an important preference and one that should be available in a more wide-spread manner.

Number two there should be attention to entry criteria into the program. So programs for women with children or for families, and then programs that don’t actually require substance abuse or mental health issues.  Though they are important, they are very important, but programs that don’t solely focus on those so that they can address needs of women who don’t have those issues.

 We found the need to tailor mixed gender programs to address the safety concerns of women Veterans, and also to improve the continuity of care at the cross-settings of care.  Or go in and out of incarcerated settings.

And then interventions that reflect homeless women Veteran’s preferences for peer support and information sharing.  I think women Veterans are a great resource for each other.  And programs would be well served to capitalize on them as a resource.

Thinking about how services are delivered, we found a need to address victimization experiences in women’s histories and to reduce or eliminate re-victimization in their post military lives.  And so ways to do this would be to incorporate trauma informed care approaches into service delivery.  To screen for domestic violence and other forms of trauma, particularly in primary care settings, and to address relationship issues that are part of the pathway for many women Veterans.

Other approaches are considering a strengths-based approach that builds on women’s problems solving skills, and an empowerment-oriented approach.

So I want to stop talking at this time and turn the mike over to our discussants, but I want to point out for those who want more information, we included a slide that lists citations for more detailed information about this research.

Our discussants are Vince Kane, the director of the National Center on Homelessness among Veterans and the director of the HUD/VASH Program.  And Robert O’Brien, the scientific program manager for mental and behavioral heath. The VA HSR&D research portfolio that includes much of the research on Veterans who are homeless.  Thank you.

Moderator:  So we’ll go ahead and turn it over to Vince at this time, if you have any comments.

Dr. Kane:  Thanks.  And thanks Dr. Washington and team for really an excellent presentation and just a fabulous overview.  And I think some of the things you’ve touched on are really pertinent, and you know, some of the updates from the program office is that issues around housing and integration of services, you know, has been a significant priority over the last year. And as you noted, many of the women, particularly, you know, that sixteen percent that you spoke of who have dependent children are choosing programs where permanent housing is an option for them in the community so that they can be with their children while they go through their own rehabilitation.  But so much more is needed in the area of making sure supports are available not only for the women but also for their dependent children.  And programs like our supportive services for Veteran’s family I think are a step in that direction—but for that kind of critical.

I think the other point that you noted was the importance of really looking at not only the housing and engagement with treatment, but how do we create more of a systems response inside of the VA to our homeless population and most particularly to women homeless.  And that we’ve been delighted to partner with you and your team through the national center in looking at risk screening assessments that will be rolled out here shortly in the back end of this fiscal year where we’ll begin with an imminent risk for homeless that will be part of the clinical reminder system in VA that will help all of us to more quickly identify those Veterans and most particularly those female Veterans that are at greatest risk for becoming homeless and how do we attach them to keep social services as well as these new prevention resources through supportive services for Veteran’s families to help them either rapidly re-house or maintain housing.  

I think that first step to getting a systems response for at-risk is going to be critical if we’re going to hit the targets of ending Veteran homelessness by the end of 2015.  And then more importantly the work that you’re spearheading which is to how to then—once we’ve engaged this at-risk population, how do we go a little bit deeper and have a more sort of longitudinal look at what are some of those other risk factors that maybe the Veterans and most particularly the female Veterans may not be at imminent risk, but is a risk factor and that we need to develop more pro-active if you will, watchful waiting models.  

Help them not only stay housed and to be safe in housing, but then also to make sure that we’re getting them engaged in the proper services from a treatment or supportive service perspective, both inside and outside of the VA.  So we’re delighted to partner with you guys on that very very important system initiative that we think will enhance the strength of that safety net that really does need to be around these female Veterans.  

  I think part of the safety net going forward as well is not only identifying the risk, but as you had noted in your slides, there’s also making sure that at least in mental health and substance abuse that opportunities for more trauma informed, trauma responsive treatment to keep the women engaged and to help them with their skill set to address and function through some PTSD or PTSD like symptomology that could impede their recovery is really critical.  

So I think the screening, the access to prevention services, the access to permanent housing, and then equally the importance of making sure that our treatment services are more trauma informed and trauma responsive is really a critical direction.  And that we in the center are delighted to be working with you and Bob O’Brien and others to really help transform our models of care to be more responsive to our female Veterans and their family members. 

So it’s exciting work that you’re doing and I think lots more to come.  So thank you.

Moderator:  Thank you very much.  And Dr. O’Brien, would you like to give some comments as well?

Dr. O’Brien:  Sure.  Thank you, Molly.  Let me first express my appreciation and support for the work of Dr’s. Washington and Hamilton.   I find that their work really highlights one critical direction that we need to take in research on homelessness among Veterans.  As Vince’s work brings the numbers of homeless Veterans down, prevention of homelessness is going to become the prime focus of our work.  However prevention is not a one-size fits all proposition.  I’ve found that the multi-method work of Dr’s. Washington and Hamilton which includes important qualitative data on women’s perspective, shows why we need to be sensitive to the particular needs of specific sub-groups within the Veteran population.  There is an—women is an important one—but I think there are other ones we can address as well.

Recognizing that there are different paths to homelessness, prevention services need to be adapted for and directed to appropriate risk groups within the Veteran population.  Thoughts of extending this work for women and other sub-groups highlights our need for new homelessness research proposals to be submitted.  I didn’t note if I recall that one of the largest groups participating on the call was researchers.  HSR&D has funded six or seven new homelessness projects within the last year.  But unfortunately there were no new homelessness projects in the most recent review cycle which just completed last week.  I’m going to be working on adding homelessness under the HSR&D priority document that a lot of people look up to see what areas we want of fund.  But I hope people feel free to submit to upcoming cycles.  We have letters of intent can be submitted started April 2, and there is a window for submitting proposals that is May 15 through June 10.  And much of this information is found in the funding section on the HSR&D website.  I also want to point out something else that is going on in an effort to promote collaboration across different centers within the VA, and that’s the startup of a Veteran’s homelessness research interest group.  And the first activity this group will take on is a phone call Monday April 2 from 12:00 to 1:00 Eastern Time.  The call in number is 1-800-767-1750 with a code of 55947.  I can we can also include you on our mailing list which would include this information.  You just need to send an email to Marjorie Carter.  And her email is Marjorie.Carter@va.gov and one thing we do have—this is new and we’re kind of getting this just off the ground. 

There’s a maximum number of phone lines to join this conference call are thirty-five.  So if you are able to have colleagues with you when you listen to that call and join it, we would appreciate that because that would just allow more people to get on.  So the primary goal of this interest group and this phone call is to share research that is ongoing and to promote collaboration.  We will also be putting together a session at the HSR&D National Meeting which —the final details have not been set but I know that it’s the week of July 16 and we will put out more information about that and more information will also be available on the website.  What we’re looking to do is have a breakfast session that would help us get some more formal activities under way.  And I also want to point out that HSR&D now has a link open on its website for a homelessness research page and what we want to do is use this as a resource for researchers and others out there who want to see what’s going on within HSR&D, what kinds of activities in one place.  So it’s highlighting not all but a number of the studies that we have going now plus a set of videos with a key set of researchers that have research ongoing.  This website will be at HSR&D.research.va.gov.  And then on the left side there is a link that says “For Researchers” and if you click on that right—in the middle of that next—that “For Researchers” page—is a link to the homelessness page.  And it’s probably the easiest way for me to tell you how to get there.  But I think that all the points we needed to make sure that we made. 

But excellent job by the presenters today because I think it’s very important for—not only for women, but I think we need to use this as a stepping stone to broaden the kinds of work that we’re going to do in terms of prevention in the future.  

Moderator:  Thank you very much Dr. O’Brien and I want to express our appreciation to both of you for making those comments.  It is very helpful to get further input.  We do have several questions that have come in, but I’m going to ask our discussants and our presenters if you have any time to stay on and answer a few questions.  And if—and then that would be to catch it on the recording so that we can archive it.  And if not, then happy to send you these questions offline and get written responses which I can then disseminate to our attendees.

Dr. Washington:  We’re able to stay on.

Dr. Kane:  Yes, I can stay on.

Moderator:  Excellent.  Thank you all very much.  And if our attendees have to leave, I understand that.  And that’s why we’re having the presenters stay on so we can capture this in the recording and you can view it then.  Also, please do respond to the survey that’s going to pop-up as you exit the session.  We appreciate your feedback and take it into consideration.  And with that we’ll get right into the questions as they came in—in the order.

The first one, “For the sake of comparison, how much more likely are male Veterans to be homeless compared to non-Veteran adult males?”

Dr. Kane:  This is Vincent — ah, I’m sorry.

Dr. Washington:  Oh, no go right ahead.

Dr. Kane:  So we do know from some data that we have related to Veterans being identified through the community based HMIS, which is the Homeless Management Information System.  That Veterans and particularly male Veterans are disproportionately represented amongst the homeless population.  The good news is that the proportion is declining as we have ratcheted up our services to the Veterans.  But unfortunately, Veterans are disproportionately represented amongst the homeless population.  

You know the causes or contributions to homelessness between Veterans and non-Veterans—at least in the older cohort—meaning the post-Vietnam and Vietnam—are more similar than dissimilar.  

We have some preliminary data now that is beginning to show that some of the risk factors among the younger cohorts, particularly those in Persian Gulf and most recently in the OEFOIF are slightly different.  We have to investigate more in that area, but certainly combat exposure is a major difference between contributing factors in those age cohorts.  

But the simple direct answer is Veterans are disproportionately represented among the homeless population, particularly the older males.

Moderator:  Thank you.  Would anybody else like to add to that?

Dr. Washington:  No.

Moderator:  Okay.  Thanks for the response.  We will move on to the next question.  “Did any of the women in the focus group consider re-entering the military or actually re-entering military service to improve their situation?”

 Dr. Washington:  As I re—this is Alison Hamilton.  As I recall some women did talk about actually re-entering or considering re-entering.  So this was looking back on their experiences from having been in the military ten years prior to their—average of ten years prior to their first homelessness.   So I don’t recall that being a prominent theme, but there were certainly some women who did go back into the military—especially after relationship issues, problems and that kind of thing.

Moderator:  Does anybody have any other comments?  Okay.  We’ll move on to the next one.  “How many total individuals are homeless?  And what percent of total Veterans are homeless?”

Dr. Washington:  Um-

Dr. Kane:  This is Vince again and again others can add to this.  A difficult question to answer.  I can tell you that over the last year we’ve worked to develop a homeless registry that really takes that longitudinal view of Veterans that the VA has identified as homeless—that’s identified data.  

I can tell you last year the VHA Healthcare System identified 187 unique Veterans that were either homeless or at risk for homeless in our systems.  And that’s through our specialized homeless programs as well as, you know, in primary care clinics or in specialty clinics like the Women’s Health Clinic.  So we’re seeing an increase in the number of contacts which isn’t necessarily a bad thing because the more we can engage the Veterans the faster we can reduce the numbers.

But it’s difficult to speak to homelessness and homelessness rates outside of the VA because the data we’re currently getting from HUD is not identified data and it’s self-report data that is suggestive that more Veterans are indicating homelessness but they may not be eligible for VA services.  We’re working on plans now to try to get some of that identified data from continuums of care so that we can more completely sort of define what the prevalent rate is.  But it’s been difficult to say beyond what we can note inside the VA through our identified data collections systems—mainly the homeless registry.

Dr. Washington: So just to expand on looking outside of the VA, then at least five years ago the national estimates were that there were 2.3 to 3.5 people experiencing homelessness in the U.S. in any given year.  And you’ll recall, similar to Veterans, homelessness is cyclical so at any one point in time the numbers would be less.  Those same estimates suggest that twenty-six percent of homeless individuals in this country are Veterans.  Now we know that those numbers have decreased over time.  Those estimates were right before the initiation of the federal plan to end homelessness among Veterans.  And so I think the numbers are now—or the proportion of homeless who are Veterans are now down in the teens in a few very short years.

Dr. Kane:  That’s correct.

Dr. Washington:  Those are sort of the best estimates for what’s happening outside if the VA.

Dr. Kane:  Yeah.  The actual point in time from the HUD VA pit count—the most recent published noted 67,395 on any given night and that approximately 145,000 were seen over the course of the year.  The Veteran population makes up about sixteen percent of the overall homeless population.  That’s some of the data from the Annual Homeless Assessment report that goes to congress and more specifically the Veteran’s chapter that’s part of the assessment report now.  And that can actually be found on our center webpage if people want to kind of get a more detailed snapshot of what the community is telling us about the prevalence of Veteran’s homelessness.

Moderator:  Thank you both for those responses.  Does anybody have anything else they would like to add?  No?  Okay.  We will move on to the next question, “Did you look at domestic violence as a risk factor?”     

Dr. Washington:  So one of the limitations over our case control study is that we used historical controls.  So we conducted a study of ambulatory care use and preferences for VA healthcare among a cross-sectional sample of women Veterans.  

Two years later we conducted the study of women Veterans who were homeless.  And of course that when we sort out all of the other risk factors that we should have assessed in the housed population.  Domestic violence or intimate partner violence, psychotic symptoms, substance abuse, factors such as that that are risk factors in non-Veterans are likely risk factors in Veterans as well but because we didn’t collect that information initially, then we can’t state what the exact risk is.

Looking at the qualitative data however, that was one of the pathways into homelessness.  Post-military adversity included intimate partner violence and other forms of violence.  And so it is an important risk factor and in fact that’s one of the important factors that’s part of the screening instrument that we’re developing.  

ACOG and other organizations call for screening of women in primary care settings for intimate partner violence.  And so incorporating brief screeners and giving primary care providers and others in the VA tools to do that is one aspect of sort of the next steps in this process that we’re engaged in.

Moderator:  Thank you for that response.  Would anybody like to add to that?  Okay.  We will move on to the next one, “If female Veterans had a childhood adversity and then entered the military and experienced MST while serving, would she be eligible for a SC pension?”

Dr. Washington:  Do you mean service-connected pension?

Moderator:  That is my assumption—they didn’t spell it out.

Dr. Washington:  Okay.  Well military sexual trauma—I won’t speak specifically to the pension—but certainly military sexual trauma, you know, legislatively that is one of the enablers for receiving care through the VA.  And so military sexual trauma independent of any pre-military adversity is sort of the key criteria here.

Moderator:  Thank you for that response.  The next question, “Are the roots of homelessness in hierarchical order of most to least?”

Dr. Washington:  No, they’re not.  They were the predominant roots that we were able to identify in women’s narratives.  But they’re not prioritized in any way.  

So we—especially because this data was collected via focus groups—we emphasized more across the focus groups, what were the predominant roots that women described.  But the data wasn’t collected in a way such that we could hierarchically organize the roots.

Dr. Washington:  If anything—just to add to that—the three categories would be pre-military, military, and post-military.  And so the first two are chronologic, but after that then with the cycles that led into and out of homelessness that are illustrated and that Dr. Hamilton discussed, then numbers three, four, and five can occur in any sort of order.

Moderator:  Thank you both for those responses.  The next question we have, “Were the focus group and survey participants the same or different?”

Dr. Washington:  There was some overlap.  Let me see—actually seventeen of the twenty-nine focus group participants also participated a detailed one hour interview which was great.  Because that allowed us to really—at least for those seventeen—understand some of the survey data and place what they told us in context.

Moderator:  Thank you both for those responses.  The next question, “When was this study done?  When was the data collected?”

Dr. Washington:  So the data was—great question—data quite old or a little bit old.  The data was collected in 2006 and, but the latest—so we’ve analyzed the focus group data.   Over time we’ve gone back and looked at—looked for new themes or looked at sort of new questions as there has been greater attention to homelessness to sort of better understand any insights that we can glean to help inform future research.  

And so 2006 is the short answer.

Moderator:  Thank you for that response—go ahead.

Dr. Washington:  We’re conducting research at the current time so hopefully in a future cyber seminar you might hear of 2012 data.     

Dr. Washington:  Also in the paper that we wrote on barriers to services, although the data was collected in 2006, we had the opportunity in that paper which just came out to describe current programs that are available many of which our discussants touched upon.  So information about those services was actually included in that paper.

Dr. Washington:  Yeah.  So the [ace] of the data I think has the most implications for thinking about the preferences and needs and how that—some of those are addressed by the HUD-VASH program.  So for example, housing first and individual housing obviates the needs for thinking about gender only or family in a larger program.  Whereas some of the preferences and some of the concerns are still relevant for sort of larger programs.

Moderator:  Thank you both for those responses.  We do look forward to the new research coming out.  We do only have five questions left, so if everybody is still available, I think we can get through them pretty quick.  But I do want to stop and give anybody the chance to duck out of the call if they need to.

Dr. Washington:  We’re—we’re-

Dr. Kane:  I’m going to have to jump off.  But thank you and-

Moderator:  I’m sorry.  Who was that?

Dr. Kane:  Vince Kane is going to have to jump off.

Moderator:  Okay.  Thank you so much for joining us. 

Dr. Kane:  Thanks, docs.  Thank you very much.

Moderator:  We really appreciate it.  Thank you. 

Dr. Kane:  All right-y.

Dr. Washington:  Thanks, Vince.  We can hang on for a few more minutes.

Dr. O'Brien:  Yeah, I can hang on too.

Moderator:  Thank you, Dr. O’Brien.  Thank you,  Dr.’s Washington and Hamilton.  We will get through this then.  The next question:  “I have heard that the definition of homelessness has changed to reduce the number of Veterans who are counted as homeless.  Is there any truth to this?”

Dr. Washington:  If you look at the latest report on the federal strategic plan to end homelessness—I’m sort of blocking on the exact name of the report—then one thing that they highlight is that different programs use different criteria for entry into the program.  And so that’s not to be confused with the federal definition for homelessness.  So if you look at entry—if you define criteria based on—I’m sorry.  If you define homelessness based on entry criteria, then they differ from one program to the next.  

What the federal inter-agency—U.S. federal inter-agency counsel on homelessness that includes Department of Labor and HUD and the VA are trying to do is to collaborate in a way that they can coordinate services irregardless of the specific criteria that each program might use.

Moderator:  Thank you for those responses.  The next question we have: “We would like to screen our patients for homelessness and risk for homelessness.  Is your screening tool available for our use?   How is your screening tool similar or different to the screening tool that Vince Kane just mentioned?”

Dr. Washington:  Great question.  Actually the two are coordinated.  So Vince Kane—and I’m sorry that he left the line—but he piloted a screening tool for imminent homelessness in four [visions].  Stage one of that tool screens for imminent homelessness meaning someone who is homeless or is at risk for becoming homeless within the next ninety days.  

So in different settings then the next step will vary.  In primary care settings in those who screen negative will then go on to be screened with the vulnerability tool that we’re currently doing cognitive testing on.  

In inpatient and emergency department settings, then those who screen positive will be referred to homeless services, those who screen negative will be referred to primary care settings.  And in outreach settings, then people will be either referred to homeless settings or primary care settings depending on the outcome of the imminent homeless screen.  

So that’s how the two are coordinated.

Moderator:  Thank you for that response.  That’s helpful.  “What is the percent of ethnic groups among homeless Veteran women?”

Dr. Washington:  I can tell you the sample that we had, but one limitation is that we conducted our study in Los Angeles.  I shouldn’t really say it’s a limitation; it’s sort of a caveat for extrapolating from our data to other women Veterans.  So the short answer is that more than fifty percent of the women in our sample were ethnic—racial and ethnic minority group members.  

What we’re in the process of doing as part of the work that we’re conducting on behalf of the Women Veteran’s Health Strategic Healthcare Group are applying some of the—some predictive probabilities in risk factor data to the national survey of women Veterans which was a population based survey of women Veterans of the US military that we conducted in 2008-2009 to help with strategic planning and programs for the Women Veteran’s Health Strategic Healthcare Group.  So we’re able to take advantage of that data set to actually come up with sort of national estimates on the rich profile of women Veterans.

That data should be available within the next two months and so then we’ll be able to come up with really much better answers and estimates.  And who knows maybe even look at geographic variations.

Moderator:  Thank you for that response.  We look forward to that data becoming available.  We just have two quick questions left.  The first one, “Has this type of focus group been done in the southeastern states and if so, where?  Would research be conducted in the southeastern region?”

Dr. Washington:  I don’t know of this type of work being done in that region.  It would certainly be great if it was being done and if it is we would love to hear about it.

Dr. O'Brien:  I have not seen any coming out of that area as well.

Moderator:  Thank you for your responses.  I believe you just answered this, but another person asked, “Are the screening tools available?”

Dr. Washington:  So they were just fielded in four [visions] and we’re doing—we’re testing the second part of the screen or the vulnerability of the screen.  So I think within the next fiscal year, I think they’re targeted for sometime in fiscal year ’13 or perhaps sooner.  So I—they’re not currently available but they will be available quite soon.

Moderator:  Thank you for that response.  And the final question is, “Is there any indication of the military occupation leading to adversity in the military?”

Dr. Washington:  I don’t understand the question.  I’m sorry.

Moderator:  I didn’t either and if the person is still on the call and wants to write in a clarifying question, that’s fine.  The last one that just came in, “Have you read the DOL Women’s Bureau Trauma Informed Care for Women Veterans Experiencing Homelessness?  It’s a guide for service providers with a self-assessment program for service providers to help them working with women Veterans.”  So again, it’s called the DOL Women’s Bureau Trauma Informed Care for Women Veterans Experiencing Homelessness. 

Dr. Washington:  Yeah. They have done excellent work.  Actually I was just on an expert panel for them that’s looking at ways to further adapt—to identify sort of best practices in services.  And so they’ve really done a great job in identifying how services can better be adapted.  I have seen it.  I don’t recall all of the details, but it is available on the Department of Labor website—Department of Labor Women’s Bureau website.

Moderator:  Excellent.  Thank you so much.  I really appreciate all of you sharing your expertise and for staying on for so long.  Although questions are still coming in, I’m going to let everybody off the call.  And I’ll send them to you off-line.  And if you ladies have an opportunity you can send me written responses and I can post those with the archive.  And I also really want to thank our discussant, Dr. O’Brien, and I’d like to give everybody a chance to give any concluding comments.  And Dr. O’Brien, we can start with you if you’d like?

Dr. O'Brien:  Well I’m just hoping that we can see more research coming forward within the, you know, that HSR&D can fund.  

One of the things which I wanted to point out that we’re really trying to do with this research group is work closely with the Homelessness National Center so that we can try to make sure the research we put together is on target for what the needs of the VA are and they’re not just questions that researchers make up.  But that it’s providing useful information in a timely way that can get down and make a difference as soon as we can.  

And when I talk about having research meetings or telephone calls, it does not only have to be researchers who are part of that, because we can have service providers come and hold our feet to the fire to make sure that we are doing something useful much like the research that was presented today is going to be helpful down the line.

Moderator:  Great.  Thank you so much for joining us.  And Drs. Hamilton and Washington would you—do you have any concluding comments you would like to make?

Dr. Washington:  Thanks for this wonderful opportunity to share the work that we’ve been doing.  It’s pretty exciting and we’re glad that there were so many interested participants.  

Moderator:  I too would like to say thank you to our participants for joining us; especially the large number who have stayed on well past the hour.  It shows how much interest there is in this topic.  

So again, I’d like to thank everyone and this does conclude our HSR&D cyber seminar.

**[End of Recording]**

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