Personal, Medical, and Healthcare Utilization Among Homeless Veterans Served by Metropolitan and Nonmetropolitan Veteran Facilities

This study assessed differences in personal, medical, and health care utilization characteristics of homeless veterans living in metropolitan versus nonmetropolitan environments. Data were obtained from a Veterans Health Administration (VHA) network sample of homeless veterans. Chi-square tests were used to assess differences in demographics, military history, living situation, medical history, employment status, and health care utilization. Moderator analyses determined whether predictors of health care utilization varied by metropolitan status. Of 3,595 respondents, 60% were residing in metropolitan areas. Age, sex, and marital status were similar between metropolitan and nonmetropolitan homeless. Metropolitan homeless were less likely to receive public financial support or to be employed, to have at least one medical problem, one psychiatric problem, or current alcohol dependency, but more likely to be homeless longer. Of the 52% of the sample who used VHA care in the last 6 months, 53% were metropolitan versus 49% nonmetropolitan (p = .01). Metropolitan status predicted at least one VHA visit within the prior 6 months (OR:1.3, CI:1.1, 1.6). Significant differences occur in the personal, medical, and health care utilization characteristics of homeless veterans in metropolitan versus nonmetropolitan areas.     

Examination of potential disparities in suicide risk identification and follow-up care within the Veterans Health Administration

To improve the identification and intervention of suicide risk, the Veterans Health Administration implemented the use of electronic patient record flags (PRF) to indicate when a veteran is identified as high risk for suicide and to increase the clinical contacts made with the veteran. The current study utilized an intersectional approach to assess potential disparities in the likelihood of receiving a PRF and the likelihood of receiving post-PRF follow-up care among veterans with substance use disorders (SUDs). Among 458,092 veterans who received a SUD diagnosis in 2012, Black veterans were less likely to receive a PRF, although Black-disabled veterans and Black-female veterans were more likely to receive a PRF. Homelessness was related to greater likelihood of receiving a PRF and post-PRF care. Hispanic/Latinx veterans who experienced homelessness were more likely to receive post-PRF care, while disabled veterans who experienced homelessness were less likely. Hispanic/Latinx, female veterans, and Black-disabled veterans were significantly less likely to receive post-PRF care. Overall, few marginalized or intersecting identities were associated with decreased PRF or decreased follow-up care. There are opportunities for specific strategies that promote engagement in VA follow-up services for veterans identifying as Hispanic/Latinx women, disabled Black veterans, and disabled homeless veterans.     

“It’s Worth It in the End”: Veterans’ Experiences in Prolonged Exposure and Cognitive Processing Therapy

Despite the efficacy of evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) and efforts to disseminate them, only 6–13% of veterans seeking care through the Veterans Affairs health care system receive these treatments. EBPs such as prolonged exposure (PE) and cognitive processing therapy (CPT) are exposure-based treatments. Provider and patient fears regarding the tolerability of exposure-based treatments likely impede their delivery and completion. The present study utilized qualitative interviews with 23 veterans who completed at least eight sessions of either PE or CPT to elicit firsthand accounts of veterans’ experiences in these EBPs. Results suggest that while a minority of veterans reported initial symptom worsening, the majority of veterans reported positive experiences and felt that, despite being stressful, these EBPs were “worth it.” Most veterans discussed thoughts of discontinuing treatment prematurely, but stated that adherence was encouraged by their commitment to finishing, desperation for relief, therapist/group support, and family support. Veterans believed exposure made an important contribution to symptom improvement, as did greater self-understanding and changing negative or unhelpful beliefs. These findings indicate veteran satisfaction with PE and CPT, and may assist providers to develop strategies to increase adherence and treatment completion.     

Family-Involved Mental Health Care Among OEF/OIF Veterans With and Without PTSD Using VHA Administrative Records

Prior research indicates that veterans are interested in including family members in health care and that family-inclusive mental health treatment can improve treatment outcomes. Consequently, the Veterans Health Administration’s (VHA) directive requires providers to offer family-inclusive mental health services to veterans. However, the extent to which veterans engage in family-inclusive mental health services at the VHA remains unclear. Using data from a longitudinal registry of male and female veterans with and without posttraumatic stress disorder, we examined the extent to which veterans included family members in their mental health care and predictors of engagement in family-involved therapy visits using VHA administrative records over a 5-year time span. Of the 1,329 veterans who received mental health care during the study, 8.4% received a family therapy visit—the number of visits per veteran ranged from 1 to 34. Results from logistic regressions indicate that relative to White veterans, Black veterans were 61.0% less likely to receive a family-involved therapy visit. Married veterans or veterans living with a partner, and veterans with poor romantic relationship functioning, were more likely to receive a family-involved therapy visit. These findings indicate that only a small percentage of veterans received a family therapy visit across 5 years. Efforts to understand barriers to family-involved therapy visits and strategies to increase engagement in family-involved visits may improve clinical outcomes and promote patient-centered care.     

Confidentiality and Mental Health/Chaplaincy Collaboration

Confidentiality can both facilitate and inhibit working relationships of chaplains and mental health professionals addressing the needs of service members and veterans in the United States. Researchers conducted this study to examine opportunities for improving integration of care within the Department of Defense (DoD) and Department of Veterans Affairs (VA). Interviews were conducted with 198 chaplains and 201 mental health professionals in 33 DoD and VA facilities. Using a blended qualitative research approach, researchers identified several themes from the interviews, including recognition that integration can improve services; chaplaincy confidentiality can facilitate help seeking behavior; and mental health and chaplain confidentiality can inhibit information sharing and active participation on interdisciplinary teams. Cross-disciplinary training on confidentiality requirements and developing policies for sharing information across disciplines is recommended to address barriers to integrated service delivery.     

Military Sexual Trauma in Treatment-Seeking Women Veterans

As the number of women serving in the military continues to grow, it is increasingly important to explore the sequelae of military sexual trauma (MST) among female veterans. The current study included 232 female veterans who sought outpatient mental health treatment at an urban Veterans Affairs hospital. The study's aims were to (a) describe and compare the demographic characteristics, health behaviors, and psychological symptoms of female veterans who have experienced MST to those veterans who do not report this experience; and (b) examine the associations between psychological symptoms and health behaviors in this sample, stratified by MST status. Results indicate that treatment-seeking women veterans who reported experiencing MST endorsed more psychological distress compared to those who did not report experiencing MST. In addition, psychological symptoms were associated with engaging in problematic health behaviors, such as binge eating and infrequent physical exercise among both those women who experienced MST and those who did not.     

Provider, veteran, and family perspectives on family education in Veterans Affairs community-based outpatient facilities

The Veterans Affairs (VA) healthcare system is dedicated to providing high-quality mental health services to all veterans, including the nearly 40% of enrolled veterans living in rural areas. Family education programs regarding mental illness and posttraumatic stress disorder, mandated for delivery in all VA medical centers and some community-based outpatient clinics (CBOCs), have been developed and provided primarily in large, urban medical centers. This qualitative investigation involved interviews with CBOC providers and veterans and families who live in rural areas and/or seek care in CBOCs to ascertain their perceptions of the benefits, feasibility, structural and cultural barriers, and logistical preferences regarding family education. The perspectives and concerns that emerged in these interviews were combined with expert knowledge to identify the resources and considerations a VAMC would want to address when translating and implementing similar programming into CBOCs. Although institutional, logistic, and attitudinal challenges were described, all three stakeholder groups endorsed the need for family education, did not see the barriers as insurmountable, and provided creative solutions. Administrators and CBOC clinicians may benefit by anticipating and problem solving around the key issues raised when developing family programming.     

Connecting Veterans at Risk for Suicide to Care Through the HOME Program

The Home‐Based Mental Health Evaluation (HOME) program, which engages veterans in care following psychiatric hospitalization, was evaluated. Thirty‐four veterans who participated in the HOME program were compared to 34 veterans from a matched archival control group on treatment engagement and implementation outcomes. Veterans who participated in the HOME program were significantly more likely to engage in care, engaged in care more quickly, and attended significantly more individual mental health appointments. Veterans reported high levels of satisfaction. Results suggest that the HOME program is effective at engaging veterans in care during the high‐risk period of time following psychiatric hospitalization.     

Self-reported changes in subjective health and anthrax vaccination as reported by over 900 Persian Gulf War era veterans

A 1999 study of United Kingdom servicemembers by Unwin, et al. recently found significant relationships between anthrax and other vaccinations, reactions to those vaccines, and later health problems for male current or former active military Gulf War veterans. Likewise, in 2000 Steele and in 1998 Gilroy found possible adverse effects of vaccinations on Gulf War veterans. However, the role of such vaccinations remains controversial; more recent government reports continue to dispute the existence of any data that might reflect adversely on the role of vaccinations on the health of Gulf War veterans. To address this controversy, the current study assessed similar relationships for over 900 Reserve Component Gulf War Era veterans from Ohio and nearby states. Gulf War veterans were more likely to report poorer health than non-Gulf veterans. Female veterans were more likely to report mild or severe reactions to vaccines than male veterans. Those veterans who received anthrax vaccine reported more reactions to vaccines than those who did not receive anthrax vaccine. Declines in long-term subjective health were associated with receipt of anthrax vaccine by Gulf War veterans but not for those who did not deploy to the Gulf, although few of the latter received anthrax vaccine. Regardless of deployment status, veterans who reported more severe reactions to vaccines were more likely to report declines in subjective health. Female veterans reported poorer health during the Gulf War than did male veterans, but sex was not related to veterans' reports of subjective health at subsequent times. It is recommended that servicemembers who experience severe reactions to anthrax vaccine be medically reevaluated before receiving further anthrax vaccine and that careful follow-ups be conducted of those receiving the vaccine currently, in accordance with Nass's 1999 recommendations. We also recommend that safer alternatives to thimerosal (a mercury sodium salt, 50% mercury) be used to preserve all vaccines.     

Characteristics and VA health care utilization of U.S. Veterans who completed suicide in Oregon between 2000 and 2005

Oregon Violent Death Reporting System data were linked with Veterans Affairs (VA) administrative data to identify and describe veterans who completed suicide in Oregon from 2000 to 2005 (n = 968), and to describe their VA health care utilization in the year prior to death. Twenty-two percent had received health care in the VA system. Of these, 57% did not have mental health diagnoses and 58% had not seen mental health professionals. A larger proportion of those who accessed care were VA-enrolled and received service-connected disability benefits. Fifty-five veterans were hospitalized during the year prior to death. Of these, 33% completed suicide within 30 days of a hospitalization. Further development of suicide prevention strategies for veterans in the community, including general medical treatment settings, is indicated.     

The Interplay Between Housing Stability and Child Separation: Implications for Practice and Policy

Greater understanding of how residential stability affects child separation and reunification among homeless families can guide both child welfare and homeless policy and practice. This article draws upon two longitudinal studies examining services and housing for homeless families and their relationship to family and housing stability. Both studies were conducted in the same state at roughly the same time with similar instruments. The first study, examining families’ experiences and outcomes following entry into the homeless service system in three counties in Washington State, found that at 18 months following shelter entry, families that are intact with their children were significantly more likely to be housed in their own housing (46%) than families that were separated from one or more of their children (31%). The second study, a quasiexperimental evaluation of a supportive housing program for homeless families with multiple housing barriers, found that the rates of reunification for Child Protective Services (CPS)‐involved families receiving supportive housing was comparable to that for families entering public housing without services, but significantly higher than the rate of reunification for families entering shelter. Taken together, the findings from both studies contribute to the evidence underscoring the importance of housing assistance to homeless families involved in the child welfare system.     

How do Housing Subsidies Improve Quality of Life Among Homeless Adults? A Mediation Analysis

Supported housing, combining rent subsidies with intensive case management, is associated with improvements in quality of life of homeless adults, but factors mediating their impact on quality of life have not been studied. Twelve‐month outcome data from a randomized trial of the Housing and Urban Development‐ Veterans Affairs Supported Housing program (HUD‐VASH) showed that access to a housing rent subsidy plus intensive case management (ICM) was associated with greater improvement in subjective quality of life than ICM alone. Multiple mediation analyses were applied to identify variables that significantly mediated the relationship between receipt of housing voucher and improvements in quality of life. Significant mediating covariates were those whose 95% bias‐corrected confidence intervals, when added to the model predicting improvement in quality of life, did not overlap zero. Increases in the number of days housed, size of social network, and availability of emotional support appear to mediate improvement in quality of life and account for 71% of the benefit attributable to having a rent subsidy. Improvement in subjective quality of life though housing subsidies is mediated by gains in both material and psychosocial factors. Mediating factors deserve special attention in supported housing services.     

Utilization of Hospital-Based Chaplain Services Among Newly Diagnosed Male Veterans Affairs Colorectal Cancer Patients

The aim of the study was to examine utilization of chaplain services among Veterans Affairs patients with colorectal cancer (CRC). In 2009, the Cancer Care Assessment and Responsive Evaluation Studies questionnaire was mailed to VA CRC patients diagnosed in 2008 (67 % response rate). Multivariable logistic regression examined factors associated with chaplain utilization. Of 918 male respondents, 36 % reported utilizing chaplains. Chaplain services were more likely to be utilized by patients with higher pain levels (OR = 1.017; 95 % CI = 0.999–1.035), younger age (age OR = 0.979; 95 % CI = 0.964–0.996), and later cancer stage (early stage OR = 0.743; 95 % CI = 0.559–0.985). Chaplain services are most utilized by younger, sicker patients.     

Comparison of two locus of control scales in predicting relapse in an alcoholic population

A 3-mo. follow-up was made of 64 male veterans who were discharged from a 21-day Alcohol Detoxification Treatment Program at the Veterans Affairs Medical Center at Lyons, NJ. Scores on the Rotter I-E and Alcohol Responsibility Scales were significantly correlated with tendencies toward a more external direction among the 13% who relapsed, significant on the I-E scale and nonsignificant on the Alcohol Responsibility Scale. When tests were compared as possible predictor variables of alcoholic relapse, the difference in favor of the I-E scale was statistically nonsignificant.     

Less Engagement in Pleasurable Activities Is Associated With Poorer Quality of Life for Veterans With Comorbid Postdeployment Conditions

The presence of multiple comorbid conditions is common after combat deployment and complicates treatment. A potential treatment approach is to target shared mechanisms across conditions that maintain poorer health-related quality of life (HRQOL). One such mechanism may be decrements in pleasurable activities. Impairment in pleasurable activities frequently occurs after deployment and may be associated with poorer HRQOL. In this brief report, we surveyed 126 veterans who had previously sought an assessment at a Veterans Affairs postdeployment health clinic and assessed pleasurable activities, HRQOL, and postdeployment health symptoms. Forty-three percent of veterans met our criteria for all 3 postdeployment conditions (posttraumatic stress disorder, depression, and chronic widespread physical symptoms). Greater engagement in pleasurable activities was associated with better HRQOL for all veterans regardless of type or level of postdeployment health symptoms. Future research should study if interventions that encourage veterans with postdeployment health conditions to engage in pleasurable activities are effective rehabilitation strategies.     

Homelessness Is Traumatic: Abuse,Victimization, and Trauma Histories of Homeless Men

Homelessness is traumatic, and trauma-informed care is an emerging best practice. Using structured interviews with day shelter clients (N = 152), this study examined trauma among homeless men. The PTSD Checklist (PCL–C) was used to assess for posttraumatic stress disorder (PTSD). Participants’ pattern of PCL–C responses suggested that 23% to 30% screened positive for PTSD. Those with positive PTSD screens had been homeless longer and were more likely to have met time criteria for chronic homelessness. They were significantly more likely to be veterans and to report violent attacks, abuse histories, and mental health problems. Importantly, only 69% of those with positive PTSD screens acknowledged current mental health problems. These individuals were much less likely to report mental health counseling in the prior year.     

Suicide Risk Documented During Veterans' Last Veterans Affairs Health Care Contacts Prior to Suicide

A total of 295 veterans who died by suicide in 2009 across 11 states and received Veterans Affairs (VA) health care in the 6 months prior to death were identified. The suicide risk factors documented and the care received at these veterans' last VA contacts are described, and the study explores whether veterans present differently to VA care (i.e., different risk factors documented or different care settings accessed) based on the proximity of their last contact to suicide. Many veterans were seen in primary care (n = 136; 46%) for routine follow‐up (n = 168; 57%). Fifty‐three (18%) were assessed for suicidal thoughts; 20 (38%) of whom endorsed such thoughts. Although higher frequencies of some risk factors at last contacts more proximal to suicide compared to those more distal were observed, findings overall highlight the challenges clinicians face detecting enhanced risk prior to suicide.     

Associations of Health-Related Quality of Life with Healthcare Utilization Status in Veterans

Evidence indicates that veterans using VA healthcare services have poor health-related quality of life (HRQOL). Little is known, however, about differences in HRQOL among those who only use VA services and those who also use non-VA services. We sought to evaluate differences in HRQOL among veterans who use: (1) only non-VA services (2) only VA services and (3) both VA and non-VA services (i.e., dual users). A cross-sectional study of 39,942 US veterans who completed the CDC’s 2004 Behavioral Risk Factor Surveillance System (BRFSS) survey was analyzed. Self-rated measures of global health status and the number of days per month that veterans were limited by physical or mental problems were extracted from BRFSS survey data as outcomes. Multivariate logistic regression demonstrated that, compared to those receiving all healthcare outside of VA, veterans receiving VA care were more likely to report poorer health outcomes, including worse global health status, greater impairments in physical functioning, and increased limitations regarding routine activities (p’s ≤ .05). Both exclusive and dual users of VA services reported poorer HRQOL than individuals not using VA services. More research is needed regarding veterans’ health status, particularly in the context of dual use.     

Who Pays for Providing Spiritual Care in Healthcare Settings? The Ethical Dilemma of Taxpayers Funding Holistic Healthcare and the First Amendment Requirement for Separation of Church and State

All US governmental, public, and private healthcare facilities and their staff fall under some form of regulatory requirement to provide opportunities for spiritual health assessment and care as a component of holistic healthcare. As often the case with regulations, these facilities face the predicament of funding un-reimbursable care. However, chaplains and nurses who provide most patient spiritual care are paid using funds the facility obtains from patients, private, and public sources. Furthermore, Veteran healthcare services, under the United States Department of Veterans Affairs (VA), are provided with taxpayer funds from local, state, and federal governments. With the recent legal action by the Freedom From Religion Foundation, Inc. (FFRF) against the Veterans Administration, the ethical dilemma surfaces between taxpayers funding holistic healthcare and the first amendment requirement for separation of church and state.     

Still living in a war zone: Perceived health and wellbeing of partners of Vietnam veterans attending partners' support groups in New South Wales,Australia

Post‐traumatic stress disorder (PTSD) in veterans is well documented, less so the long‐term impact on the health of their partners and families. The perceived health and wellbeing of women partners of Australian Vietnam veterans who were members of partners of veterans support groups is reported. This qualitative study used data from 76 participants in 10 focus groups in metropolitan, regional, and rural and remote areas of New South Wales (NSW). The data were tape‐recorded, transcribed and thematically analysed using constant comparison methods. The impact of living with a partner with war‐related PTSD appears to be significant and ongoing with women drawing parallels to living in a war zone. The biggest negative impact was on their mental health. They felt burdened as carers and struggled to find explanations for their husbands' problems. Support groups were very helpful. There are implications for partners of veterans who have returned from active military duty and from peacekeeping in current conflicts.