Latent Homeless Risk Profiles of a National Sample of Homeless Veterans and Their Relation to Program Referral and Admission Patterns

摘要

Objectives. We identified risk and need profiles of homeless veterans and examined the relation between profiles and referrals and admissions to Department of Veterans Affairs (VA) homeless service programs. Methods. We examined data from the VA’s new Homeless Operations Management and Evaluation System on 120?852 veterans from 142 sites nationally in 2011 and 2012 using latent class analyses based on 9 homeless risk factors. The final 4-class solution compared both referral and admission to VA homeless services. Results. We identified 4 latent classes: relatively few problems, dual diagnosis, poverty–substance abuse–incarceration, and disabling medical problems. Homeless veterans in the first group were more likely to be admitted to the VA’s permanent supportive housing program, whereas those in the second group were more likely to be admitted to more restrictive VA residential treatment. Homeless veterans in the third group were more likely to be admitted to the VA’s prisoner re-entry program, and those in the fourth group were more likely to be directed to VA medical services. Conclusions. The heterogeneous risk and need profiles of homeless veterans supported the diversity of VA homeless services and encouraged the development of specialized services to meet their diverse needs. Although homelessness has been an important national problem in the United States for more than 3 decades, 1,2 and various homeless services have been developed, 3 there is little understanding of the matching of the diverse needs of this heterogeneous population to different types of services. Studies have shown that there are different patterns of needs among homeless adults; developing a taxonomy of individuals based on modifiable homeless risk factors may enhance the fit and quality of services provided to this population. 4 One commonly cited study used cluster analysis to examine 73?000 homeless public shelter users in New York City and developed a 3-group typology: transitionally homeless, episodically homeless, and chronically homeless. 5 Another cluster analytic study of homeless shelter users in the Midwest found 4 groups, each with different problems: criminality, psychiatric history, transiency, or criminal victimization. 6 A handful of other studies using small homeless samples in other settings found other groups, such as those who are economically disadvantaged, those with mental health or substance abuse problems, and those with relatively few problems. 7,8 A few studies included sociodemographic characteristics in their cluster analyses that contributed to the literature, but did not identify groups with modifiable characteristics or specific needs that could be directly addressed with services. 9,10 However, there has not been a comprehensive attempt to classify homeless individuals based on their risk profiles; that is, basing the classification on well-known modifiable risk factors for homelessness. Modifiable risk factors do, in essence, reflect needs that can be addressed with services. 11 Thus, developing such a classification may allow better matching of needs and services to serve this diverse population and to guide the continued development of new services that can address their needs. A body of literature has identified numerous modifiable risk factors for homelessness, including alcohol or drug use disorders, incarceration histories, poverty, poor physical health, history of adverse childhood events, inadequate health insurance, and schizophrenia or bipolar disorder. 12–20 Schizophrenia and bipolar disorder may have the most impact on the risk for homelessness at the individual level (i.e., highest relative risk), whereas substance abuse may have the most impact on risk at the population level (i.e., highest attributable risk). 19 Military veterans are an important and overrepresented segment of the homeless adult population. 21,22 Ending homelessness among veterans has become a national concern and a top priority of the Department of Veterans Affairs (VA). In 2009, the VA declared a goal of ending homelessness among veterans and has dramatically ramped up funding for a variety of programs and services for homeless veterans. 23 Thus, it is an opportune time to further examine the risks and needs of homeless veterans and the VA-funded services created to address them. Identified modifiable risk factors for homelessness among veterans are similar to those found among homeless adults in the general population. Among veterans, risk factors include unemployment, disability, poor physical health, psychiatric disorders (especially schizophrenia or bipolar disorder), substance use disorders, and negative childhood experiences, whereas having a college education, being married, and having a total income of $600 a month or higher are protective factors. 24–28 One study that conducted cluster analysis on psychosocial characteristics of a national sample of 565 homeless veterans found 4 groups: alcoholic, psych