Clinical Review

Predictors of VA and Non-VA Health Care Service Use by Homeless Veterans Residing in a Low-Demand Emergency Shelter

Fed Pract. 2016 March;33(3):42-48

References

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Instruments

Through structured interviews, experienced research staff collected demographics, history of homelessness, military service, and substance abuse in the previous 30 days. Data on alcohol and drug problems in the past 12 months were obtained using the Short Michigan Alcohol Screening Test (SMAST) and the Drug Abuse Screening Test. The Veterans RAND 12-Item Health Survey (VR-12) was used to measure physical and mental health functioning in the previous 4 weeks. Finally, participants reported their use of VA or non-VA medical (ED, inpatient, and outpatient), psychiatric (ED, inpatient, and outpatient), and substance abuse-related (inpatient and outpatient) services in the 12 months prior to the interview. These measures have been shown to be valid and reliable with acceptable psychometrics.^24-26

Data Analysis

Statistical analysis was completed using IBM SPSS Statistics version 19. Descriptive data were summarized using counts, percentages, means, and standard deviations. A dichotomous variable for alcohol abuse was defined as SMAST score ≥ 3. A variable representing participant’s VR-12 mental component summary scores was used as an indicator of mental health functioning.

McNemar’s test was used to compare the use of VA and non-VA medical, psychiatric, and substance-related services using dichotomous variables for each overall sector as well as respective sector subcomponent services (emergency, inpatient, and outpatient for medical and psychiatric sectors and inpatient and outpatient for the substance-related sector). Statistical significance level was set at α = .05.

Logistic regression was used to predict psychiatric and substance abuse-related service use with separate dependent variables for VA, non-VA, and both VA and non-VA services. Need-based factors included in all models as independent variables were mental health functioning, alcohol abuse, and a dichotomous variable representing cocaine use in the previous 30 days. Independent variables for the other service sectors were included as enabling factors (eg, medical and substance-related problems predicting psychiatric service use), aligning all service use variables in the model to the same provider system (eg, VA service sector independent variables with VA service sector dependent variables).

Results

The sample mean age was 49.2 years (SD = 9.2), and fewer than half (n = 45, 41%) were white. Three-fourths (n = 82, 75%) had ever been married, and few participants (n = 5, 5%) were currently married. Total mean lifetime experience of homelessness was 3.9 years (SD = 4.3). One-third of the samples participants (n = 36, 33%) reported that their current episode of homelessness had lasted 1 year or longer. Most had an adult felony conviction (n = 78, 71%) and a history of incarceration as an adult (n = 104, 95%). All military branches were represented, with 49% serving in the Army, 23% in the Marine Corps, 17% in the Navy, 10% in the Air Force, and 1% in the Coast Guard.

Most of the sample’s veterans served during the Vietnam era (n = 43, 43%) or the post-Vietnam era (n = 49, 45%), but 12 (11%) served during the Persian Gulf era (including Operation Iraqi Freedom and Operation Enduring Freedom). Few received a nonservice connected VA pension (n = 21, 19%) or service-connected disability benefits (n = 20, 18%). The mean income earned in the previous 30 days was $466 (SD = $431). None of these predisposing factors were associated with any service variables.

The sample’s mean VR-12 physical functioning score was 43.8 (SD = 9.1), which was significantly higher (t = 6.2, df = 109, P < .001) than the 38.4 (SD = 12.2) population norm used with the instrument. The sample’s mean mental health functioning score of 39.4 (SD = 14.3) was significantly lower (t = -8.6, df = 109, P < .001) than the population norm (51.1, SD = 11.4).²⁷ Substance-related problems were prevalent, with an identified alcohol problem in 62% (n = 68) and a drug problem in 79% (n = 87) of participants. More than half reported illicit drug use in the past 30 days (n = 61, 56%), especially cocaine (n = 42, 38%) and marijuana (n = 37, 33%).

The majority of veterans (n = 96, 87%) reported using some type of service in the past 12 months (Table 1). Most survey respondents used medical services. About half used psychiatric services, and almost one-third used substance-related services. More veterans used non-VA ED services than used VA ED services. More veterans used VA outpatient medical services than used non-VA outpatient medical services. Examining service sectors indicated that more veterans used VA psychiatric services than used non-VA psychiatric services, especially VA outpatient psychiatric services. More veterans used non-VA substance abuse-related services, especially outpatient services, rather than similar services offered by the VA.

When given a choice between VA and non-VA outpatient services in Fort Worth, significantly more veterans chose to use VA medical and psychiatric services, but outpatient substance abuse-related services were used equally. For ED and inpatient services, more veterans selected non-VA ED medical and inpatient substance abuse-related services located in Fort Worth than comparable VA services available in Dallas. There were no differences between use of VA and non-VA services for emergency psychiatric, inpatient medical, and psychiatric services, even though these services were available only in Dallas.