1. Thomas O’Toole, MD 1 Amy Kilbourne, PhD, MPH 2 Andrew Saxon, MD, MSc 3 Stefan G. Kertesz, MD, MSc 4 1. Center on Systems, Outcomes & Quality in Chronic Disease & Rehabilitation (Providence, RI) 2. Center for Clinical Management Research (Ann Arbor, MI) 3. Center of Excellence in Substance Abuse Treatment and Education (Settle, WA) 4. Center for Surgical, Medical Acute Care Research and Transitions (Birmingham, AL)

2. Objectives Show how multiple paths in and out of homelessness necessitate variability in policy and clinical responses Use research examples to highlight both strengths and shortcomings of novel responses focused on: Addiction Housing Mental Health Primary Care

3. Overview Kilbourne: public health models for preventable mortality in homelessness Kertesz: framework for multimodal response paradigms O’Toole: evolving care needs following treatment engagement Saxon: housing and addiction outcomes after treatment

4. Context/Questions/Considerations How does our research “fit” into the Secretary’s 5 Year Initiative to End Veteran Homelessness? What research questions are relevant to ongoing policy and service delivery questions How do we organize our approaches within the continuum of need, processes of care, environment of services, and heterogeneity of the population? What are the limits, qualifications, and adaptations needed when applying evidence-based approaches to this population?

5. Presentations

6. Homeless Economic dislocation Competing needs Poor coping skills Social Isolation/Poor social networks Addiction Mental illness Physical Disabilities Pain Housed Economic Security Food security Positive social networks Substance abuse treatment/recovery Mental health hygiene Chronic disease management Self-care Better care access Identification - Prevention Engagement Resource alignment Treatment Longitudinal support Structural / Population accommodations How do we get there?

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

8. One view of homeless causation Personal Assets Job skills and history Family wealth Social Support Financial supports Military/Veteran-specific Personal Liabilities Addiction Severity Childhood or family poverty Personal or familial poverty Mental Illness Military/Veteran Note: with low assets, the liabilities don’t need to be that severe to slip into homelessness Environmental Context: Markets for jobs and housing Criminal justice and veteran policy Entitlement and mental health policies

9. Components to Promote an Exit from Homelessness (all shown with equal weight)

10. Health and Homelessness Housing Security for Homeless Persons Health Care sites as “First Stops” for newly homeless The health encounter as a “treatable moment” for behavior change and treatment engagement Health maintenance and support as a means of keeping people in housing

11. Next Steps Need for interventions that simultaneously address housing, substance use and mental health issues Assertive community treatment / intensive case management improves housing status, substance use and mental health outcomes. Life Skills Training improves the likelihood of maintaining housing

12. Comments/Questions/Discussion