Office of Research & Development

VA research on

Homelessness


Introduction

Being homeless, or being at risk of homelessness, is one of the most difficult problems any Veteran can face. VA has made ending Veterans' homelessness a top priority. The department and its federal, state, local, and nongovernmental partners recognize that ending Veteran homelessness is not a single event in time, but rather a deliberate ongoing effort toward achieving and maintaining the goal,.

The U.S. Department of Housing and Urban Development's annual point-in-time estimate of America's homeless population found that fewer than 40,000 Veterans were experiencing homelessness (including those living on the street or in a shelter, temporary safe haven, or any place unfit for habitation) on a given night in January 2016. The January 2016 estimate found just over 13,000 unsheltered homeless Veterans actually living on the streets, a 56 percent decrease since 2010.

VA's National Center on Homelessness Among Veterans (NCHAV), established in 2009, works to promote recovery-oriented care for Veterans who are homeless or at risk for homelessness by developing and disseminating evidence-based policies, programs and best practices.

In 2012, the center helped establish Homeless Patient Aligned Care Teams (H-PACTs) at VA medical centers throughout the nation. H-PACT teams provide homeless Veterans with comprehensive, individualized care, including services that lead to permanent housing.

VHA offers many health care programs for homeless Veterans. The Domiciliary Care for Homeless Veterans program has been providing medical services to disadvantaged Veterans since the close of the Civil War.

VA's Health Care for Homeless Veterans program offers examinations treatment, referrals, and case management services to homeless Veterans at more than 135 locations. And VA's Homeless Veterans Dental Program provides dental treatment for eligible homeless Veterans.

The National Call Center for Homeless Veterans (1-877-4AID-VET) is staffed by trained responders providing support and resources to Veterans and their families who lack secure housing. Live chat with trained responders is available at the Veterans Crisis Line website.

Selected Major Accomplishments

  • 1987: Initiated the Northeast Program Evaluation Center (NEPEC) to serve homeless Veterans
  • 1991: Established that, in Vietnam Veterans, there does not appear to be a causal relation between homelessness and military service, including exposure to combat
  • 2013: Determined there is an association between homelessness among Veterans and childhood problems such as abuse and family instability
  • 2015: Learned that 30 percent of female and 9 percent of male homeless Veterans have children in their custody
  • 2015: Found that Veterans who had been discharged from the military for misconduct had dramatically higher rates of homelessness than those who left under normal circumstances

New, Ongoing, and Published Research

As part of meeting the challenge of eliminating homelessness among Veterans, VA is developing new research and supporting ongoing work on health conditions and risk factors that relate to homelessness.

VA research on the topic looks at the causes and risks of homelessness among Veterans, and ways to prevent Veterans from becoming homeless. Researchers help develop interventions to improve homeless Veterans' health and provide resources and training to those who work with them.

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➤ Risks of becoming homeless

Since 1987, VA's Northeast Program Evaluation Center (NEPEC), based in West Haven, Conn., has investigated a range of health issues and VA programs with a heavy focus on mental health, including posttraumatic stress disorder (PTSD) and substance abuse. These issues often intertwine with homelessness.

No causal link between homelessness and combat—In 1991, NEPEC researchers found the proportion of homeless Veterans who had served in Vietnam and been exposed to combat was the same as among non-homeless Veterans. Based on this, the researchers concluded that there does not appear to be a causal relation between homelessness and military service, especially Vietnam service and exposure to combat.

Veterans at greater risk for homelessness—According to a 2015 study by researchers with the VA Connecticut Health Care System and Yale University, both male and female Veterans are at greater risk for homelessness than their non-Veteran counterparts, although the disparity has declined over time. This disparity is most prominent among Veterans of the all-volunteer force—those who signed up for the armed services after July 1, 1973, when the draft was eliminated.

The researchers stated that Veterans appear to have many of the same major risk factors for homelessness as other adults, with the strongest and most consistent ones being substance abuse, severe mental illness, and low income.

They identified risk factors unique to Veterans such as problematic military discharges, low military pay grade, and social isolation after their discharge from the military. However, they noted that combat exposure and PTSD "do not seem to play a distinctively strong role in Veteran homelessness," and hypothesized that this may be because Veterans with these issues have special access to VA services designed to meet their needs.

Veterans discharged for misconduct have higher homelessness rates—Researchers with VA's Salt Lake City Health Care system and NCHAV conducted a study indicating that Veterans who had been discharged from the military between 2001 and 2012 for misconduct had dramatically higher rates of homelessness than those who left under normal circumstances.

The study, published in the Journal of the American Medical Association in 2015, looked at the 448,290 Iraq and Afghanistan Veterans who had used VA for care since their discharge. It found that 5.6 percent of those Veterans had been discharged for misconduct, usually drug or alcohol abuse—but that those patients accounted for 28.1 percent of those who became homeless within a year of their discharge.

Overall, 1 percent of VA patients were homeless at some point within a year of their discharge, but 5.4 percent of those discharged for misconduct fell in that category. Misconduct is defined as a discharge related to drugs, alcoholism, offenses against the military code of conduct, infractions of the law, and other misbehaviors.

According to the team, military misconduct may be a proxy indicator for a variety of risk factors associated with homelessness, including adverse deployment experiences, mental health issues, alcohol and substance abuse, post-deployment financial instability and unemployment.

The team did not consider Veterans who received dishonorable discharges, which makes them ineligible for VA health care. According to the Department of Defense, more than 142,000 service members have been dismissed from the military with such discharges since 2001.

They suggest VA identify Veterans with misconduct-related separations at the time they leave the service, and provide them with case management and rehabilitative services during their transition to help keep them from becoming homeless.

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➤ Homelessness and opioid addiction

Opioids are medications that relieve pain. Taken as prescribed, opioids can be used to manage pain safely and effectively. When abused, however, they can be dangerous. Even a single large dose can cause severe respiratory depression and death. Regular or longer-term use and abuse of opioids can lead to physical dependence, and in some cases addiction.

VA medical centers nationwide have treatment programs for opioid addiction. In 2013 and 2014, these treatment programs screened 2,699 Veterans participating in the programs to determine if they were homeless or at imminent risk of being homeless.

Homeless Veterans more likely to have opioid addiction—A research team led by VA's Center for Health Equity Research and Promotion and NCHAV found, in a study published in 2015, that 10.2 percent of the Veterans screened were homeless, and another 5.3 percent were at risk for homelessness—approximately 10 times the rate of the general Veteran population accessing VA care.

Compared with male Veterans, women Veterans were less likely to report homelessness (8.9 percent versus 10.3 percent), but more likely to be at risk (11.8 percent versus 4.9 percent.) By age group, Veterans aged 18-34 and 45-54 years most frequently reported homelessness (12.0 and 11.7 percent, respectively) and Veterans aged 45-54 and 55-64 years were most frequently at risk (6.5 and 6.8 percent, respectively.)

The team recommended that programs addressing Veteran homelessness engage with Veterans who are seeking treatment for addiction, and that the integration of homelessness services into addiction treatment settings may improve outcomes in both areas.

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➤ Trauma in homeless Veterans

VA's National Center for PTSD has published two studies on trauma in homeless Veterans. In a 2013 study of 115 homeless Veterans, researchers found that 82 percent had experienced interpersonal violence as adults, and 62 percent had experienced it as children. In addition, 53 percent experienced highly stressful events during their service in the military.

Another 2013 study by NCPTSD researchers looked at more than 126,000 homeless Veterans who used VA health care in 2010. Of these, 40 percent of female Veterans and 3 percent of males had experienced sexual trauma while in service. Those numbers are higher than those of the general Veteran population.

Researchers from the New England VA Mental Illness, Research, Education and Clinical Center (MIRECC) also published a study in 2013 that found homelessness among Veterans was associated with childhood problems such as abuse and family instability.

Using data from 1,161 Veterans enrolled for supportive housing, the researchers found that about half of these formerly homeless Veterans reported instability in their families, and 40 percent reported that they had been abused as children.

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➤ Formerly incarcerated Veterans

New England MIRECC researchers conducted a study, published in 2013, that suggested incarceration was not a major barrier to exiting homelessness. The research team studied 14,557 Veterans who were part of the Housing and Urban Development-Veterans Affairs Supportive Housing program during 2008 and 2009, 65 percent of whom had been incarcerated in the past.

Overall, the researchers found that a history of incarceration did not appear to affect progression through the program, or a Veteran's chances of obtaining housing. Veterans with a history of incarceration were just as successful at obtaining hosing in similar time frames when compared to Veterans who had not been incarcerated in the past.

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➤ Homeless women Veterans

Women Veterans are up to four times more likely than civilian women to experience homelessness. A research group led by Dr. Donna Washington of the Greater Los Angeles VA Healthcare System has worked to understand the reasons for this. Washington and her group have held focus groups with homeless women Veterans and learned that unemployment is the biggest single risk factor for homelessness in this population.

Another risk factor for homelessness among women Veterans is sexual trauma, especially trauma that occurred during military service. Also, because women who are homeless are more likely to be primary caretakers for children, their housing options are more restricted. Most homeless women Veterans with children tend to place the safety and well-being of their children first, research has shown

A 2015 study by researchers with the VA Connecticut Health Care System and Yale University found that 30 percent of female and 9 percent of male homeless Veterans have children in their custody, raising concerns about the parenting environment for these children. Among Veterans with unstable housing, 45 percent of women and 18 percent of men had children in custody. Psychotic disorders were found in 11 percent of homeless Veterans with children in custody.

The researchers suggested that those who provide care for homeless Veterans need to consider the practical and ethical implications of serving homeless parents and their children, with a particular focus on VA's supported-housing program.

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➤ Housing First

Traditional housing options for homeless Veterans often require participants to be sober or to be taking part in treatment programs. This leaves many homeless Veterans unable to receive housing that might otherwise be available to them.

In 2011, VA began adopting the Housing First mode of care, which enables people who have not yet achieved sobriety or are still exhibiting symptoms of mental health problems to receive permanent housing through government-funded rental vouchers.

Implementing Housing First—In 2014, VA researchers from the Birmingham VA Medical Center and their colleagues published the results of a survey of nearly 100 VA employees who were directly involved in the Housing First program. They found that front-line staff faced challenges in housing homeless Veterans quickly because of difficult rental markets, the need to coordinate with local public housing authorities, and a lack of available funds for move in costs.

They also found, however, that 80 to 90 percent of Veterans housed in this program were able to remain in that housing, keeping them out of hospitals or prison or both.

Later in 2014, the team published the results of another study finding that VA medical centers that had successfully implemented Housing First shared several significant characteristics.

The leaders of successful medical centers joined front-line staff in the work of finding acceptable housing; elevated people knowledgeable about homelessness into senior leadership positions; and worked to resolve logistical challenges.

They also helped ensure that work groups dealing with homelessness were properly aligned and integrated into their organizations.

In addition, the commitment of staff members to ending homelessness was high in successful VA facilities. The research team is now conducting a longer-term study to assess current VA practices with regard to providing permanent housing to homeless Veterans, with an eye toward refining how Housing First is implemented by the department.

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➤ New ways to reach homeless Veterans

Homeless Veterans and mobile phones—Many people living on the streets prioritize having a mobile phone, to give them an identity and a way of communicating with the world. In a study completed in 2014 by VA's Center for Healthcare Organization and Implementation Research in Bedford, Massachusetts, researchers interviewed 106 Veterans in a variety of homeless programs in Massachusetts.

The team found that 89 percent of those surveyed owned a mobile phone, and 76 percent used the Internet. Of those who owned a mobile phone, 71 percent said they used text messaging.

Of those with phones, 93 percent were interested in receiving either text messages or phone calls about upcoming medical appointments, and 88 percent wanted to be asked by phone if they would like to schedule an appointment if they had not been seen by a health care provider in over a year.

The findings suggest new avenues to communicate with and intervene on behalf of homeless Veterans.

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➤ Homeless Veterans and HIV

Homeless Veterans are infected with HIV, the virus that causes AIDS, at least three times more often than the rest of the U.S. population. A study led by researchers at the VA Greater Los Angeles Healthcare System, published in 2015, looked at a new way to identify Veterans with HIV and get them quickly into treatment programs.

Because traditional HIV testing involves several appointments at health care facilities, including taking the test, receiving the results, and receiving counseling and links to care if the results are positive, this kind of testing is neither practical nor feasible for a highly transient population of homeless individuals.

Instead, the research team, along with counselors from two municipal offices, repeatedly visited three Los Angeles shelters to provide AIDS testing, results and follow-up if necessary to Veterans and other residents.

The team tested 817 shelter residents, 37 of whom were Veterans. None of the Veterans had HIV; seven of the other residents' tests came back positive, and five of them were linked to care.

The Cost of the screening program was $48.95 per client, and the team believes that given the high costs and health risks of untreated HIV infection, the program is cost-effective, and could have a "massive" effect on reducing HIV rates among homeless Veterans and others.

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➤ Dental care

The dental needs of homeless Veterans are well-documented. In surveys listing and ranking the 10 highest unmet needs for homeless Veterans, dental care is consistently ranked by homeless Veterans as one of their top three unmet needs, along with long-term permanent housing and child care.

Homeless Veterans Dental Program—Dental problems such as pain and missing teeth can be tremendous barriers to looking for and finding work. VA's Homeless Veterans Dental Program provides dental treatment for eligible Veterans in a number of programs, including domiciliary residential rehabilitation treatment and compensated work therapy/transitional residence programs.

Dental care improves several outcomes—A December 2013 article included the results of a study on the impact of dental care on homeless Veterans who had been discharged from a VA transitional housing intervention program. The research team for the study included researchers with VA's national Office of Dentistry, NCHAV and the Fayetteville, Ark., and Bedford, Massachusetts, VA medical centers.

The study cohort included 9,870 Veterans, of whom 4,482 received dental care during the program. Veterans who received dental care were 30 percent more likely to complete the intervention program; 14 percent more likely to be employed or financially stable; and 15 percent more likely to have found residential housing.

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More on Our Website

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Selected Scientific Articles by Our Researchers

Vietnam era and Vietnam combat Veterans among the homeless. Rosenheck R, Gallup P and Leda CA. The proportion of homeless Veterans who served in the Vietnam theater and the proportion exposed to combat fire were similar to those of non-homeless Veterans. Am J Public Health, v.81(5); May 1991.

Incarceration histories of homeless veterans and progression through a national supported housing program. Tejani N, Rosenheck R, Tsai J, Kasprow W, McGuire JF. Supported housing programs appear to be able to overcome impediments faced by formerly incarcerated homeless Veterans and therefore should be considered a good model for housing assistance programs. Community Ment Health J. 2013 Jul 3.

Military sexual trauma among homeless Veterans. Pavao J, Turchik JA, Hyun JK, Karpenko J, Saweikis M, McCutcheon S, Kane V, Kimerling R. In a national sample of female and male homeless VHA users, the prevalence of military sexual trauma among homeless VHA users was higher than the prevalence of such trauma among all VHA users. J Gen Intern Med. July 2013; 28(Suppl 2):536-541.

Evaluating the impact of dental care on housing intervention program outcomes among homeless veterans. Nunez E, Gibson G, Jones JA, Schinka JA. Provision of dental care has a substantial positive impact on outcomes among homeless Veterans participating in housing intervention programs. Am J Public Health. 2013 Dec; 103 Suppl 2:S368-73.

VA's expansion of supportive housing: Successes and challenges on the path toward housing first. Austin EL, Pollio DE, Holmes S, Schumacher J. White B, Lukas CV, Kertesz S. The study highlights the considerable practical challenges and innovative solutions arising from a large-scale effort to implement Housing First. Psychiatr Serv. 2014 May 1;65(5):641-7.

The potential for health-related uses of mobile phones and Internet with homeless Veterans: results from a multisite survey. McInnes DK, Sawh L, Petrakis BA, Rao S, Shimada SL, Eyrich-Garg KM, Gifford AL, Anaya HD, Smelson DA. Most homeless Veterans have mobile phones and use the Internet, suggesting new avenues for communication and health interventions for hard-to-reach homeless Veterans. Telemed J E Health, 2014 Sep:20(9):801-9.

Making housing first happen: organizational leadership in VA's expansion of permanent supportive housing. Kertesz SG, Austin EL, Holmes SK, Pollio DE, Schumacher JE, White B, Lukas CV. Key organizational practices throughout VA correlated with more successful implementation of housing first for homeless Veterans. J Gen Intern Med. 2014 Dec;29 Suppl 4:835-44.

Implementing an HIV rapid testing-linkage-to-care project among homeless individuals in Los Angeles county: a collaborative effort between federal, county and city government. Anaya HD, Butler JN, Knapp H, Chan K, Conners EE, Rumanes SF. Rapid HIV testing is a cost-effective way to link homeless Veterans who are HIV-positive with care. Am J Public Health. 2015 Jan.;105(1):85-90.

Risk factors for homelessness among US Veterans. Tsai J, Rosenheck RA. A systematic review summarizing research on risk factors for homelessness among U.S. Veterans, evaluating the evidence for these risk factors. Epidemiol Rev. 2015:37:177-95.

Military misconduct and homelessness among US Veterans separated from active duty, 2001-2012. Gundiapalli AV, Fargo JD, Metraux S, Carter ME, Samore MH, Kane V, Culhane DP. This study establishes an association between a history of military misconduct and subsequent homelessness among active-duty Veterans who returned from Iraq and Afghanistan and were eligible for VHA benefits. JAMA, 2015 Aug. 25;314(8):832-4.

Characteristics and use of services among literally homeless and unstably housed U.S. Veterans with custody of minor children. Tsai J, Rosenheck RA, Kasprow WJ, Kane V. A substantial proportion of homeless Veterans served by VA have severe mental illness and children in custody, which raises concerns about the parenting environment for their children. Psychiatr Serv. 2015 Oct;66(10):1083-90.

Screening for homelessness among individuals initiating medication-assisted treatment for opioid use disorder in the Veterans Health Administration. Bacchuber MA, Roberts CB, Metraux S, Montgomery AE. The prevalence of homelessness in Veterans receiving opioid use disorder treatment is approximately 10 times that of the general Veteran population accessing VA care. J Opioid Manag. 2015 Nov-Dec;11(6):459-62.

Increased mortality among older Veterans admitted to VA homelessness programs. Schinka JA, Bossarte RM, Curtiss G, Lapcevic WA, Casey RJ. Substantially more Veterans who were homeless died compared to a control sample, and were approximately 2.5 years younger at time of death. Psychatr Serv. 2015 Dec. 1;appips20150095.

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Homelessness Fact Sheet


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VA Research in the News

What puts Veterans at risk for homelessness? Oxford University Press blog, May 14, 2015

Service members discharged for misconduct have much higher rates of homelessness, study says. Los Angeles Times, Aug. 26, 2015

VA: data validates Hampton 'Veteran X' program, Daily Press, Nov. 2, 2015

Number of homeless Veterans declines across Pittsburgh region, Pittsburgh Post-Gazette, Nov. 10, 2015

VA Pittsburgh exhibit chronicles support for destitute Vets, Trib Live, Nov. 10, 2015

How cities and states are fighting Veteran homelessness, Huffpost Politics, Dec. 21, 2015

Screening program hopes to aid Veteran homelessness, Yale Daily News, March 9, 2016

Penn researcher says ending homelessness is possible, University of Pennsylvania website (undated)

VA and other U.S. Government Online Resources

Homeless Veterans, U.S. Department of Veterans Affairs

Homeless Resources: Veterans Crisis Line, U.S. Department of Veterans Affairs

Homeless Veterans benefits fact sheet, U.S. Department of Veterans Affairs

Homeless Veterans: upcoming events and stand downs, U.S. Department of Veterans Affairs

Homeless Veterans: housing assistance, U.S. Department of Veterans Affairs

Homeless Veterans Reintegration Project, U.S. Department of Labor

HUD-VASH Vouchers, U.S. Department of Housing and Urban Development

Ending Veteran Homelessness, The White House

Homeless Populations: Veterans, Substance Abuse and Mental Health Services Administration


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