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Homelessness among Veterans with Serious Mental Illness Public Health Impact and Outreach

Homelessness among Veterans with Serious Mental Illness Public Health Impact and Outreach. Amy M. Kilbourne, PhD, MPH VA Ann Arbor Center for Clinical Management Research Associate Director, VA Ann Arbor SMITREC

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Homelessness among Veterans with Serious Mental Illness Public Health Impact and Outreach

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  1. Homelessness among Veterans with Serious Mental IllnessPublic Health Impact and Outreach Amy M. Kilbourne, PhD, MPH VA Ann Arbor Center for Clinical Management Research Associate Director, VA Ann Arbor SMITREC University of Michigan Department of Psychiatry and Comprehensive Depression Center

  2. Acknowledgements • VA Health Services Research and Development • VA National Center on Homelessness among Veterans • VA Office of Mental Health Services • VHA Clinical Operations (10NC) • SMITREC • NIMH (R01 MH 79994, MH 74509)

  3. VA Homeless HSR Initiative • The VA has a wide range of programs and initiatives focused on addressing the President’s goal of ending homelessness among Veterans • The VA Homeless Health Services Research Initiative, starting in 2010, brings together four projects in partnership with the National Center on Homelessness among Veterans that seek to enhance the role VA research can play in ending homelessness

  4. VA Homeless HSR Initiative • Homeless Solutions in a VA Environment • Stefan Kertesz, MD, Birmingham VA • Population-based Outreach Services to Reduce Homelessness among Veterans with SMI • Amy M. Kilbourne, PhD, Ann Arbor VA • Addiction Housing Case Management for Homeless Veterans Enrolled in Addiction Treatment • Andrew J. Saxon, MD, Seattle VA • Aligning Resources to Care for Homeless Veterans • Thomas O’Toole, MD, Providence VA

  5. Background • Homelessness disproportionately affects Veterans with serious mental illness (SMI) • Social isolation, substance abuse, incarceration, symptom burden, limited employment • VA: largest single provider of SMI care • Treatment drop-out  adverse outcomes • Public health models to reduce preventable mortality

  6. Homelessness and SMI • SMI: schizophrenia, schizoaffective disorder, bipolar disorder, other psychosis diagnosis • 12.3% of Veterans with SMI had ICD-9 code or encounter for homelessness services in FY 2009 • 25% of the U.S. homeless population has SMI; 6% of overall U.S. population • SMI: functioning  employment  housing Sources: VA National Psychosis Registry; NIMH, 2009

  7. Homeless Veterans Health Disparities Framework Adapted from CHERP Health Disparities Conceptual Framework (Kilbourne et al. 2006)

  8. Understanding Risk Factors among Homeless Veterans

  9. Characteristics of Veteran Patients with SMI with a Recent History of Homelessness

  10. Mortality: Homelessness and SMI

  11. Barriers to Treating the SMI Homeless Population • Fragmentation of Care: administrative and financial separation • Housing conditional on treatment • Lack of recovery-orientation (distrust of system) • Lack of coordination with criminal justice system

  12. VA National Center on Homelessness among Veterans • Promote recovery-oriented care for Veterans who are homeless or at risk for homelessness • Personalized access to treatment, education and outreach • Treatment models supplement psychotherapy and medication with services for concurrent disorders (e.g., substance abuse), caregiver, and peer support

  13. Outreach Program and Reduced Mortality among Veterans with SMIVA Office of the Medical Inspector (OMI) • Quality improvement study from 2007-2009 led by the VA Office of the Medical Inspector • Population-based registry: identify SMI patients who had dropped out of care • Data source: VA National Psychosis Registry • SMI diagnosis and last seen in VA in FY 2005, no VA outpatient visits from 06-07 and were alive up to FY 07 Davis CL, Kilbourne AM, Pierce, JR, Blow F, Winkle B, Lang erg R, Visnic S, Lyle D, Hocked E, Philips Y. Reduced Mortality Among VA Patients with Schizophrenia or Bipolar Disorder Lost to Follow-up and Engaged in Active Outreach to Return to Care

  14. Outreach Program Methods • Lists of patients sent to points of contact (POCs) at 138 VA medical centers • POCs contacted Veterans, scheduled appointments • Follow-up data linked to NPR and VA/SSA mortality data through 2009

  15. Outreach Program Results • 4,791 patients with SMI lost to follow-up • Typically unmarried, male, and not service-connected • Diagnosed medical comorbidities: • Diabetes (14%) • Dementia (6%) • Cerebrovascular disease (4%) • Cancers (3%)

  16. Outreach Program Results • 3,315 of the 4,791 patients (69%) contacted • 2,375 (72%) had returned to VA care by 2009 • Reasons for not returning to care:

  17. Outreach Program and Mortality All-cause mortality through 2009 (N=4,791): Veterans who returned for care 0.5% Veterans who did not return for care 6.3%

  18. Outreach Program: Predictors of Mortality *P<0.06, **P<0.001

  19. VA Outreach Implementation 2/2006 Publication of initial article (Copeland et al.) 1/2007 Outreach program launched by OMI 2009 OMI program completed, briefings 2010 OMI Program final report 1/2011 Patient Care Services replicates Outreach program (OMHS) 7/2011 OMHS Program Directive 9/2011 HSR&D/NCHV Homeless Outreach Near real-time monitoring Partnerships with community organizations

  20. Implications: Practice-based Research • Veterans with SMI lost from follow-up care can be identified & engaged • Reduced mortality • Many POCs were VA Local Recovery Coordinators • More intensified efforts for homeless • Align research with rapid implementation • Leverage existing programs • Population-based panel management • Local provider input

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