1. 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 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 N=234,674 Homeless (N=28,805) Not Homeless (N=205,869) % Women7.710.6 African American38.819.2 Married16.638.0 Service connected36.455.7 Substance use disorder70.724.5 Any Medical co-morbidity91.689.1 On atypical anti-psychotics46.645.4 Past-year hospitalization49.923.0 Intensive case management19.94.2

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 SMI VA 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: Key Reasons:% Not perceiving a need for care33 Not satisfied with VA services22 Lack of transportation or time20 Wanted to solve problem by themselves 7

17. Outreach Program and Mortality All-cause mortality through 2009 (N=4,791): Veterans who returned for care0.5% Veterans who did not return for care6.3%

18. Outreach Program: Predictors of Mortality VariableOdds Ratio Did Not Return for Care14.3** Age >=65 (vs. <45)3.6 Age 45-64 (vs. <45)24.5** Male (vs. Female)1.3 Single (vs. Married)1.3 Schizophrenia (vs. bipolar diagnosis) 1.4* Charlson score = 1 (vs. 0) 2.0** Charlson score = 2 (vs. 0) 3.3** Charlson score = 3 (vs. 0)2.8 *P<0.06, **P<0.001

19. VA Outreach Implementation 2/2006 Publication of initial article (Copeland et al.) 1/2007Outreach program launched by OMI 2009OMI program completed, briefings 2010 OMI Program final report 1/2011Patient Care Services replicates Outreach program (OMHS) 7/2011OMHS Program Directive 9/2011HSR&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