MANAGEMENT BRIEF

Number 9 Overviews of Health Care Topics for Senior VA Managers March 1999

The Toughest Cases – Homeless, Addicted, and Mentally Ill Veterans

“Today, VHA is the single largest direct care provider for homeless persons in the country, and we are a

critically important – although often unrecognized – element in the nation’s public safety net.”

Kenneth W. Kizer, MD, MPH

Under Secretary for Health, Veterans Health Administration

“Even when homeless patients get care it may only stall an inexorable downward dive. We need more

data, new ideas – better solutions to address the problem. In this way a socioeconomic, public policy,

medical problem becomes grist for the research mill.”

John R. Feussner, MD

Chief Research and Development Officer, VHA Research and Development

How does homelessness impact veterans’ health care?

Homelessness is perhaps the most disorienting and devastating condition anyone could endure. On any given night as

many as 250,000 veterans sleep on the streets or in shelters.

Over the course of a year, perhaps twice as many veterans

experience homelessness at some point. One-third of the adult

homeless population has served their country in the Armed

Services. For veterans suffering addiction or mental illness

homelessness rapidly compounds the obstacles to well being.

Tragically, nearly 40% of these homeless veterans suffer from

severe, persistent and disabling mental illnesses – half of

them also have substance abuse disorders.

Many other veterans are considered nearly homeless or at

risk of it, from poverty, dismal living conditions, lack of

family, friends, or a support network. Currently, the homeless Vietnam era veteran population is greater than the

58,000 service persons that died during that war. A small

number of Desert Storm veterans also appear in the homeless

population. Demographically, most homeless veterans are

male, about 2% are female, the vast majority are single, with

most coming from poor, disadvantaged backgrounds. Approximately, 40% of homeless veterans are African American

or Hispanic.

Unquestionably, homelessness compromises the dignity

due the men and women veterans who so steadfastly served

their country. Homelessness is a cruel fate, yet combined with

serious mental illness (SMI), and/or addiction, it immeasurably impacts all health care services across the VA1

. The annual expenditures for inpatient mental health care clearly

show one major impact – approximately 26% of the annual

inpatient VA mental health expenditures ($404 million) are

spent on the care of homeless mentally ill veterans2.

How is health services research helping alleviate the

impact of homelessness on the VA health care system?

HSR&D research by its definition looks at how to reach

patients and how specific treatment regimens are best organized. With homelessness compounding the cost of VA health

care services in these veterans with multiple disorders, the

data generated by HSR&D research helps identify the magnitude and costs of treatment, new therapies, and innovative

strategies for treatment delivery. One example of this search

results from a project at the Little Rock HSR&D Center of

Excellence which suggests that education, along with process

of care improvements, enhance providers’ ability to identify

dual diagnosis patients. Effectively, the more the providers

know, the better they can help these veterans get the range of

services they need3

.

VA HSR&D Management Brief March 1999 Page 1 of 2
This is our ninth MANAGEMENT BRIEF. Please give us your

suggestions and comments:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Name: ____________________________________________________________

Title: ______________________________________________________________

Phone: ________________________ Fax: ____________________________

The MANAGEMENT BRIEF is produced by the Management Decision

and Research Center, a program within the VA’s Office of Research &

Development, Health Services Research and Development Service.

The purpose of the MANAGEMENT BRIEF is to provide VA senior managers with a concise and timely overview of a specific health care topic

that includes topic definition, benefits, VA activities, and resources for

further information.

VA HSR&D Management Brief Number 9, March 1999 Page 2 of 2

Below are recent findings from HSR&D research

projects addressing issues of homeless, addicted,

and seriously mentally ill veterans.

Case Managed Residential Care – Closing the

Revolving Door

When homeless, mentally ill, addicted veterans do seek

care they often resist traditional interventions, entering the

“revolving door” of recidivism. Targeting this challenging

group, a randomized controlled five-year study at the Hines

VA HSR&D Center of Excellence treated 358 homeless,

chemically dependent veterans (25% were mentally ill). As a

result of a three-month residential care program with hospital-based case management for a total of nine months of

therapy, the Case Managed Residential Care (CMRC) approach was found more effective than the usual 21-day hospital program. Researchers found the CMRC approach clearly

improved short-term outcomes in terms of health, employment, housing, and alcohol/drug use for this tough to treat

group. Evidence indicates, however, that the case management for this group needs to be intensive, continuous, community-based and last for several years to maintain or

increase the gains achieved in residential care.

Conrad KJ, Hultman CI, Pope AR, et al. Case managed

residential care for homeless addicted veterans: results

of a true experiment. Medical Care 36(1): 40-53, 1998.

IIR 92-065

Practice Pattern Research Reveals

the Magnitude and Costs of Serious Mental Illness

A national survey of residential status at time of admission

was conducted on all VA inpatients on 9/30/95. Survey data

were merged with computerized workload databases to assess

service use and cost during the 6 months before and after the

discharge date. Data from this study provides a big picture of

VA services to seriously mentally ill, homeless, addicted veterans. These data help researchers evaluate variations in practice across VA medical centers and identify ways in which

treatment might be improved. The survey found the annual

cost of care for the homeless SMI and substance abusers, or

both, is $27,206, $3,200 higher than for domiciled veterans,

with approximately 26% of annual VA mental health expenditures ($404 million) spent on the care of homeless veterans.

Rosenheck R, Seibyl CL. Homelessness: health service

use and related costs. Medical Care 36(8): 1256-1264, 1998.

PPR-002

Work as Therapy – Compensated Work

Improves Homeless Addicted Veterans’ Outcomes

Compensated work as therapy (CWT) is a strategy designed to improve outcomes and reduce total health care costs

for homeless addicted veterans. This multi-site randomized

study, by an HSR&D researcher in the Dallas VA North Texas

Health Care System, provided limited jobs in competitive and

structured work environments. The CWT project called for

participants to seek outpatient addiction treatment, reduce

References:

1. Department of Veterans Affairs, VHA, Mental Health

Strategic Health Care Group (1999). Homelessness among

veterans. Available at http://www.va.gov/health/homeless/

index.htm [January 26, 1999].

2. Rosenheck R, Seibyl, CL. Homelessness: health service

use and related costs. Medical Care 36(8): 1256-1264.

3. Kirchner JE, Owen RR, Nordquist C, Fischer EP. Diagnosis and management of substance abuse disorders among

inpatients with schizophrenia. Psychiatric Services 49(1):

82-85, 1998. PPR-002.

For additional information:

GAO. Substance abuse treatment: VA programs serve

psychologically and economically disadvantaged veterans.

GAO/HEHS-97-6. Washington, DC: General Accounting

Office, November, 1996.

For more information or to send comments contact:

Gerry McGlynn, M.Ed., MDRC, Manager, Information

Dissemination Program, 150 S. Huntington Avenue, Boston,

MA 02130. Phone: FTS 700-839-4433 or 617-278-4433.

Fax: 617-278-4438. Visit the Research and Development web

page at http://www.va.gov/resdev/prt to see additional

MDRC publications and reports.

their frequency of substance use, improve substance use-related physical health, and improve physical functioning. Researchers found that CWT substantially helps veterans

achieve these outcomes.

T. Michael Kashner, PhD, MPH; HSR&D Dallas, VAMC.

IIR 92-043