1. Gender and the use of Veterans Health Administration homeless services programs among Iraq/Afghanistan Veterans Oni J. Blackstock, MD Yale RWJF Clinical Scholars Program/VA Connecticut Health Care System Cynthia Brandt, MD MPH, Sally Haskell, MD, Rani Desai, PhD MPH Yale School of Medicine/VA Connecticut Health Care System

2. The authors have no potential conflicts of interest to disclose Disclaimer: The views expressed in this presentation are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

3. Veterans Health Administration (VHA) specialized homeless services programs

4. The OEF/OIF Veteran cohort has the largest proportion of women to serve and to be exposed to combat of any Veteran era cohort. Operation Enduring Freedom (OEF) Operation Iraqi Freedom (OIF)

5. Homelessness Use of homeless services programs

6. Research Questions 1. What is the risk of using a VHA homeless program among OEF/OIF Veterans in VHA care? 2. Is there a difference in risk between female and male Veterans? 3. How do the characteristics of female and male Veterans who used a homeless program compare?

7. Methods: Study population OEF/OIF Veterans (~1.1 million) Nonmissing gender Nonmissing separation date At least 1 VHA clinical visit (445,319) Enrolled in VHA system 10/1/01 to 9/30/09 (~500,000)

8. Time to first use of a VHA homeless program Gender

9. Primary Outcome: Time to first use of a VHA homeless program Separation Date 1 st visit indicating use of VHA homeless program

10. Use of VHA homeless programs identified using program codes Housing and Urban Development- VA Supported Housing Health Care for Homeless Veterans Compensated Work Therapy/ Transitional Residences Domiciliary Care for Homeless Veterans Grant and Per Diem Program

11. Socio-demographic variables Rural vs. urban location, geographic region Rank (officer vs. enlisted) Age, race/ethnicity, marital status, education

12. Clinical variables Mental health conditions Service-connected disability rating

13. Survival analysis ▫ Cox proportional hazards regression ▫ Adjusting for socio-demographic & clinical variables Χ 2 and Wilcoxon rank-sum tests to compare female and male Veterans who used a VHA homeless program Data Analysis

14. Results Median age, 26 years (IQR, 23 – 37) 12% female 62% White, 18% Black, 12% Hispanic, 6% Other 56% unmarried 80% high school diploma or less 22% Post-traumatic stress disorder 2% - 8% with psychiatric /substance use disorders Study population (445,319) OEF/OIF Veterans (~1.1 million) Enrolled in VHA system (~500,000) Median duration of follow-up 3.21 years (IQR, 1.74-4.52)

15. Research Questions 1. What is the risk of using a VHA homeless program among OEF/OIF Veterans in VHA care? 2. Is there a difference in risk between female and male Veterans? 3. How do the characteristics of female and male Veterans who used a homeless program compare?

16. Risk of using a VHA homeless program Study population 445,319 Used a VHA homeless program 7,431 (1.7%) Median time to first use: 1.88 years (IQR, 0.81-3.29) IQR, interquartile range

17. Research Questions 1. What is the risk of using a VHA homeless program among OEF/OIF Veterans in VHA care? 2. Is there a difference in risk between female and male Veterans? 3. How do the characteristics of female and male Veterans who used a homeless program compare?

18. Study population (445,319) Used a VHA homeless program 961 (1.8%) Female 53,650 (12%) Risk of using a VHA homeless program by gender Male 391,667 (88%) Used a VHA homeless program 6,470 (1.7%)

19. No difference in risk of using a homeless program *Adjusted for age, race/ethnicity, marital status, education, rank, rural/urban, geographic region disability rating, mental health diagnoses FemaleMale Hazard ratio for use of a VHA homeless program

20. Time to first use of VHA homeless program Female (n=961) Male (n=6,470) p-value Time to first use, years, median (IQR) 1.88 (0.78-3.30) 1.88 (0.82-3.28) 0.53

21. Research Questions 1. What is the risk of using a VHA homeless program among OEF/OIF Veterans in VHA care? 2. Is there a difference in risk between female and male Veterans? 3. How do the characteristics of female and male Veterans who used a homeless program compare?

22. Selected characteristics of Veterans who used a VHA homeless program Characteristic Female (n=961) Male (n=6,470) p-value Age, median (IQR)25 (22-30)24 (22-31)0.10 Race/ethnicity<0.001 White30.4%51.6% Black46.9%25.6% Hispanic11.3%12.4% Other11.4%10.4%

23. Characteristic Female (n=961) Male (n=6,470) p-value Major depression20.4%14.0%<0.001 Post-traumatic stress disorder 35.7%42.6%<0.001

24. Characteristic Female (n=961) Male (n=6,470) p-value Alcohol use disorder14.9%27.7%<0.001 Substance use disorder10.9%21.2%<0.001

25. Limitations Includes only OEF/OIF Veterans in VHA care Does not capture Veterans who accessed only non-VHA-directed homeless services programs Lack of data to explore the role of dependents, military sexual trauma, and employment status

26. What we learned About 1.7% of OEF/OIF Veterans in VHA care used a VHA homeless program Overall, female Veterans were as likely as male Veterans to use a VHA homeless program Differences exist between female and male Veterans who used a homeless program Females more likely to have depression, less likely to have substance/alcohol use disorder or PTSD

27. Implications Determine whether homeless program use shortly after return represents vulnerability for this group of young Veterans Ensure homeless programs are tailored to also meet the needs of female Veterans Expand services in areas that may disproportionately affect female Veterans such as depression and programs for families

28. Stakeholders Northampton VA Medical Center

29. Acknowledgements Women Veterans Cohort Study ▫ Cynthia Brandt, MD MPH ▫ Sally Haskell, MD ▫ Rani Desai, PhD MPH ▫ Melissa Skanderson, MSW Yale RWJF Clinical Scholars Program Department of Veterans Affairs/VA Connecticut Healthcare System OEF/OIF Veterans for their service