Rani Hoff, PhD, MPH

1
Homelessness in Female VeteransRisk Factors and
Health Services in VHA

• Rani Hoff, PhD, MPH
• Northeast Program Evaluation Center
• Office of Mental Health Operations

2
Overview

1. Overview of the history of women in the military
2. Overall risk of homelessness among female
   Veterans and specific potential risk factors
3. VHA services available for homeless female
   Veterans
4. Data on women receiving homelessness services

3
Women in the Military

• Women have always served in this nations
  military conflicts
• Molly Pitcher received Congressional recognition
  of her service
• Women served in auxiliary hospital units during
  the Civil War
• World Wars began more formal womens military
  units

4

Women in the Military (cont.)

• World War II was the first time womens units
  were recognized as such and given full Veterans
  benefits
• Spearheaded by Eleanor Roosevelt and Gen.
  Marshall
• Pearl Harbor turned the tide of opposition, 23
  years after the first formal suggestion
• WAC, WAVES, SPARS, WASP, and Marine Corps Reserve

5
Womens Roles

• Initial roles were relegated to state-side
  support (e.g. supply and repair, administration)
  and healthcare
• Women landed on Normandy
• Thousands served in North Africa and in the
  Pacific

6
Women in Vietnam

• The military, which prided itself on the records
  it kept in Vietnam -- counting the enemy number
  of weapons captured, for example -- cannot to
  this day say with certainty how many women
  served.  The army that sent them never bothered
  to count them.  The estimate most frequently
  given is that a total of 7,500 served in the
  military in Vietnam."
• Laura Palmer, "Shrapnel in the Heart

7

Women in Vietnam (cont.)

• Women served largely in health care roles
• They were older and better educated than men in
  the military, due to the draft and differences in
  occupations

8
The All-Volunteer Military

• Established in 1973, when the military stopped
  the draft
• Selective Service is still in place for boys age
  18
• The quotas for the proportion of women allowed
  was increased
• Over the next 30 years the proportion of women
  rose to about 7-10, in the current conflict it
  is 15-20 of active duty forces

9
Changing Demographics of the Military

• The all-volunteer military resulted in a force
  that was less educated and had increased numbers
  of risk factors for poor community functioning
• Poverty, adverse living conditions in childhood
• Substance abuse and dependence
• Psychiatric illness
• Violence
• This held similarly, possibly even more so, for
  women entering the military

10
The Current Conflict

• The War on Terror begins on 9/11/2001
• October 2002 invasion of Iraq
• Women are serving in roles that put them in
  constant danger of exposure to combat situations

11
Homelessness and Female Veterans

• In previous conflicts
• Female veterans were less likely than male
  veterans to become homeless after leaving
  military service
• However, they were 4 times more likely to become
  homeless than female civilians
• In the current conflict
• Female veterans are just as likely to become
  homeless after leaving military service as men
• This suggests a higher level of risk

12
Homeless women compared to men

• Women use VA homelessness services (8) at a rate
  similar to their representation in the VA user
  population (7)
• Women are less likely to be literally homeless
  (54) than men (57)
• Women are younger and more likely to have
  dependent children
• Women are more likely to have non-military
  related PTSD
• Women are referred to supported housing more than
  men

13
Possible Reasons for homelessness

• Women who enter the military may be more likely
  than other women to have risk factors that put
  them at risk for later homelessness
• Unstable families, child abuse and neglect,
  poverty, lack of educational opportunities,
  family histories of mental illness and/or
  substance use
• The disruptions caused by the current conflict,
  especially those serving in Reserve and National
  Guard Units, may be disproportionately worse for
  women

14
Possible Reasons (cont.)

• After leaving military service, female veterans
  may have fewer resources than their civilian
  counterparts to prevent the onset of homelessness
• They were less likely to be married and have
  children
• They may have disrupted social ties to family or
  other social supports
• Their military training may not have prepared
  them for well-paying civilian jobs
• Preclusion from serving in combat roles (on
  paper) discriminated against them for promotions
  and medals
• Disability, unemployment, and worse physical and
  mental health increase risk for homelessness

15
Possible Reasons (cont.)

• There may be some particular aspects of military
  service that put female veterans at increased
  risk of homelessness
• Increased risk of stress-related illness
• Increased risk of mental illness and/or substance
  abuse
• Gender discrimination
• Sexual harassment and sexual assault

16
Military Sexual Trauma (MST)

• MST refers to sexual harassment and/or sexual
  assault perpetrated upon an active duty soldier
  of any gender, and by any gender
• A history of MST is grounds for VA treatment,
  even if a veteran would otherwise not be eligible
  for VA services
• There are mandatory screening requirements of all
  VA patients to identify those with MST

17
Rates of MST

• There are no stable estimates for how many female
  veterans have experienced MST
• There have been very few good studies of MST in
  veteran populations
• Rates differ widely based upon the population
  being studied and the methods of assessing MST
• Highest rates in those requesting VA disability
  and veterans of more recent conflicts (about
  40-70)
• Lowest in population samples of female veterans
  and VA primary care patients (3-30)
• Screening rates in VHA female patients are about
  20

18
Why Is MST Particularly Problematic?

• It is an interpersonal trauma
• It is perpetrated by someone who presumably is
  supposed to be protecting your life
• It may not be possible to report the crime, for a
  variety of reasons
• It may be coupled, in recent veterans, with
  combat exposure as well

19
Homelessness Services Available to Women in VA

• MHRRTPs and Domiciliaries
• Health Care for Homeless Veterans
• Grant and Per Diem programs
• HUD-VASH programs
• VJO and Re-Entry Programs
• Specialized Homeless Womens Programs
• Homeless Veterans Supported Employment Programs

20
Mental Health Residential Rehabilitation and
Treatment (MH RRTP)

• The MH RRTP mission is to provide
  state-of-the-art, high-quality residential
  rehabilitation and treatment services for
  Veterans with multiple and severe medical
  conditions, mental illness, addiction, or
  psychosocial deficits. The MH RRTP identifies
  and addresses goals of rehabilitation, recovery,
  health maintenance, improved quality of life, and
  community integration in addition to specific
  treatment of medical conditions, mental
  illnesses, addictive disorders, and homelessness.

21
MH RRTP Stays Among Female Veterans, 2005
2012

• The total number of MH RRTP stays among Female
  Veterans increased by 74.8 between 2005 and 2012.

22
Female Veterans as a Proportion of MH RRTP Stays,
2005 2012
Fiscal Year Number of Female Veterans Female Vets as a of MH RRTP Stays
2012 2,213 6.1
2011 2,199 5.8
2010 2,122 5.4
2009 1,789 5.2
2008 1,738 5.2
2007 1,482 4.6
2006 1,375 4.5
2005 1,266 4.0

• The proportion of MH RRTP stays that are female
  Veterans has been steadily increasing since 2005.

23
Differences Between Female and Male Veterans in
MH RRTPs, 2012
Female Male Female Male Female Male
Mean Age (years) 45.0 yrs 49.3 yrs
OEF/OIF/OND 16.7 14.5
Homeless 62.6 65.9
Substance Use Diagnosis 70.9 85.6
PTSD 47.9 32.6
Major Affective Disorder 19.0 11.2
Mental Health OPV 7 Days Post-DC 61.6 57.1

• Female Veterans are younger and less likely to be
  homeless. They are also less likely to be
  diagnosed with substance abuse problems, however
  more likely to have a serious mental illness, in
  particular, PTSD and depression. LOS are similar
  to male Veterans, however, female Veterans are
  more likely to follow-up with post-discharge
  outpatient treatment services.

24
Number and Proportion of Stays Among Female
Veterans by MH RRTP Category, 2012
In 2012 the proportion of stays among female
Veterans was 6.1 (n2,213). The greatest
proportion of women Veterans was within the PTSD
MH RRTPs (8.9), however, the greatest number of
stays among female Veterans was in the SUD MH
RRTPs (n745).
25
MH RRTPs Entirely Dedicated to Female Veterans,
2012
Program Location MH RRTP Bed Category Number of Beds
Boston MA CWT/TR 7 beds
Brockton MA PTSD RRTP 8 beds
Batavia NY PTSD RRTP 6 beds
Lyons NJ PTSD RRTP 10 beds
Temple TX PTSD RRTP 8 beds
Palo Alto CA PTSD RRTP 10 beds
Total 6 programs 49 beds
During 2012 there were 6 MH RRTPs (n49 beds)
totally dedicated to women.
26
MH RRTPs Providing Specialized Tracks for
Females, 2012
MH RRTP Type Number of Programs Total Number of Beds
DCHV 2 as needed
SUD 2 as needed
PTSD 3 20 (plus as needed)
General 3 as needed
Total 10 20 (plus as needed)
In addition to the 6 programs entirely dedicated
to the treatment of female Veterans, there were
10 MH RRTPs that provided a specialized track for
female Veterans.
A Track is defined as treatment provided to a
subset of Veterans within the residential program
who receive the same or similar specialized
treatment and rehabilitative services. Tracks do
not reflect populations served, but rather
targeted programming directed towards a subset of
Veterans served by the program. To be considered
as having a female track, a program just have had
at least 2 hours/day of gender specific care.
27
MH RRTP Access for Female Veterans, 2012

• 206 (86.9) programs admitted female Veterans
  in 2012
• 102 (49.5) programs had beds for female
  Veterans located in a separate, secure wing
• 1,703 (20.3) beds met safety and security
  requirements
• for female Veterans
• 683 (8.1) beds were designated solely for
  the treatment of female Veterans

28
MH RRTP Access for Female Veterans, 2012

• 31 (13.1) programs did not admit any female
  Veterans during 2012
• The residential treatment needs of female
  Veterans at these MH RRTPs were addressed by
• 16 programs referred to another MH RRTP at
  their VAMC
• 12 programs referred to another MH RRTP at
  another VAMC
• 3 referred to local community providers

29
Percent of Beds Designated Solely for Female
Veterans and Percent of Female MH RRTP Stays by
MH RRTP Bed Category, 2012
Overall, 6.1 (n2,213) of MH RRTP stays are
among female Veterans and 8.1 (n683) of MH RRTP
beds are designated solely for the treatment of
female Veterans. PTSD MH RRTPs have the greatest
capacity for treating female Veterans but
proportionally have fewer MH RRTP stays. PTSD
programs have the capacity to admit 50 more
female Veterans.
30
Propensity to Admit to MH RRTPs, Male to Female
Ratio by VISN, 2012
Overall , the national propensity to admit to
residential treatment male to female ratio
1.68. The ideal score would be a value of 1.00
indicating that male and female Veterans have
equal access to VA residential care. Female
Veterans in VISNs 1, 8, 10 and 21 generally have
similar access to residential treatment as their
male Veteran counterparts. Numerator The
percentage of Veterans in the denominator who
have at least one bed day in residential care .
Denominator Number of men (or women) who are in
one of the following groups 1. Total number of
unique Veterans at the facility who are thought
to be homeless. 2. Total number of unique
Veterans who have at least one bed day in a
psychiatric or substance abuse bed section (not
including residential) and a primary or secondary
diagnosis of PTSD 3. Total number of unique
Veterans who have at least one bed day in a
psychiatric or substance abuse bed section (not
including residential) and a primary or secondary
diagnosis of substance use disorder 4. Total
number of Veterans on the National Psychosis
Registry. Second stage is the ratio of male to
female rates from above. Home facilities were
assigned for this measure and thus referrals were
counted. Data were extracted from the MH
Information System dashboard.
31
Services Offered by the HCHV Program

• The central goal of the HCHV program is to reduce
  homelessness among Veterans by conducting
  outreach to those who are not currently receiving
  services and engage them in treatment and
  rehabilitative programs. While the approach taken
  at each medical center is designed to fit into
  the particular community setting and to integrate
  with local services, the central activities of
  HCHV teams include
• Outreach to identify Veterans among homeless
  persons encountered in shelters, soup kitchens,
  and other community locations
• Clinical assessments, to determine the needs of
  each Veteran seen by the team and to give
  priority to those who are most vulnerable
• Referral to medical and psychiatric inpatient and
  outpatient treatment and to social services and
  entitlement programs
• Rehabilitation in community-based residential
  treatment facilities or other community housing,
  through any of the HCHV components and
• Follow-up case management, to help Veterans
  identify resources which will facilitate their
  community re-entry.

32
Female Veterans Served by HCHV
Veterans FY06 FY07 FY08 FY09 FY10
(N38,819) (N39,364) (N40,422) (N40,216) (N42,858)
Male 96 95.7 95.6 95.4 94.3
Female 4 4.3 4.4 4.6 5.7

• While male Veterans comprise the vast majority of
  those served by HCHV, the number of female
  Veterans being served by HCHV has been steadily
  increasing since 2006.

33
Grant and Per Diem Services

• For the majority of Grant and Per Diem (GPD)
  programs, the principal mission is to provide
  time-limited housing with supportive services as
  an aid to the transition to permanent housing.
• Veterans may receive relatively intensive
  residential treatment in a GPD facility.
• However, programs with alternate missions have
  been funded. For example, programs have been
  funded to specifically serve women and their
  families.
• Yet other programs are intended to provide stable
  housing, but offer minimal supportive services.
• Thus, the GPD represents a heterogeneous group of
  programs that have the common goal of providing
  flexible housing and support services.

34
Women in Grant and Per Diem Programs

• Nationally, 4.5 of Veterans placed into GPD
  programs are female
• Many programs do not have the capacity to handle
  women due to structural or physical limitations
• Many programs also cannot handle families, which
  restricts access for women

35
Women in HUD-VASH Programs

• In 1992, VA and the Department of Housing and
  Urban Development (HUD) established the HUD-VASH
  Program.
• VA provides case management services to Veterans
  experiencing homelessness, while HUD provides
  permanent housing subsidies to Veteran
  participants and their immediate families through
  its Housing Choice voucher program.
• The primary goal of HUD-VASH is to assist
  Veterans and their families exit homelessness and
  fully reintegrate back into the community of
  their choosing. A key component of the program
  is VAs case management services.
• Case management services are designed to support
  the Veterans recovery process through enhancing
  housing stability in safe, decent and affordable
  permanent housing and through engagement of the
  Veteran to address physical and mental health
  and/or substance use disorder concerns.

36
Outcomes of women in transitional housing programs

• Women in transitional housing were younger, had
  higher psychiatric symptoms, fewer days homeless,
  fewer days drinking alcohol and less alcohol
  dependence, and were more likely to have been
  recently hospitalized
• Women and men had similar 12 month outcomes on
  housing, work activity, substance use, overall
  physical and mental health, or quality of life
• Women were similar to men for 6 months, but then
  worse, on employment income and psychiatric
  symptoms

37
Veterans Justice Outreach and Re-entry Programs

• The purpose of the Veteran Justice Outreach (VJO)
  Initiative is to avoid the unnecessary
  criminalization of mental illness and extended
  incarceration among Veterans by ensuring that
  eligible justice-involved Veterans have timely
  access to VHA mental health and substance use
  services when clinically indicated, and other VA
  services and benefits as appropriate.
• VA is requiring justice-focused activity at the
  medical center level. VA Medical Centers have
  been strongly encouraged to develop working
  relationships with the court system and local law
  enforcement and must now provide outreach to
  justice-involved Veterans in the communities they
  serve.
• Each VA medical center has been asked to
  designate a facility-based Veterans' Justice
  Outreach Specialist, responsible for direct
  outreach, assessment, and case management for
  justice-involved Veterans in local courts and
  jails, and liaison with local justice system
  partners.

38
Women in Veterans Justice Outreach Programs

• There were 542 women served by VJO programs in
  FY12
• 55 are between 31 and 50 years old, 54 served
  in the Army, and 30 served in Iraq or
  Afghanistan
• 24 had been in combat (hostile or friendly fire)
  
• 45 have an alcohol use disorder, 35 drug
• 8 have schizophrenia or other psychotic
  disorder, 21 are bipolar
• 33 have military-related PTSD, 14 non-military
  related PTSD
• 46 depression, 29 anxiety

39
Specialized Homeless Womens Programs

• Very few specialized womens homeless programs in
  the country (about 10), funded in large urban
  areas
• Established through special needs funding for
  women and families through the GPD program
• Community providers reserve beds for homeless
  women Veterans
• Women are served largely in alternate settings