Addiction Housing Case Management for Homeless Veterans

Background: Homelessness, substance use, and co-occurring psychiatric disorders form a
mutually perpetuating, downwardly spiraling triad that maintains a state of homelessness,
increases morbidity and mortality and thereby escalates health care utilization and costs.
Addiction treatment is one portal of health care entry accessed by many Veterans with this
devastating triad, yet addiction treatment fails to address homelessness directly. Homeless
Veterans entering addiction treatment have worse treatment outcomes and incur more costs
than housed Veterans entering such treatment. Further, many homeless Veterans never obtain
housing after treatment entry and substantial proportion of those who do may subsequently
return to homelessness. Assertive community treatment / intensive case management shows
promise in improving housing status, as well as substance use and mental health outcomes in
this population. Life Skills Training, which has been shown to improve the likelihood of
maintaining housing, may increase the effectiveness of this method of treatment. An approach
to homelessness incorporating assertive community treatment / intensive case management and
Life Skills Training has never previously been integrated into VA addiction specialty care.

Objectives: The proposed study will examine intensive case management for homeless Veterans
in addiction treatment by integrating addiction/housing case managers (AHCM), operating from
a Life Skills Training perspective, into an addiction specialty program. The primary aim is
to determine whether the AHCM intervention increases number of days housed during the year
following treatment entry. Secondary aims are to compare costs and cost-effectiveness of
AHCM vs. time and attention control, determine if AHCM improves addiction outcomes and
functional status, and examine treatment process variables associated with improved
outcomes.

Methods: The proposed study is a, parallel design, intention to treat, randomized clinical
trial comparing the AHCM intervention to a time and attention control (weekly housing group)
among homeless Veterans (N=400) newly entering addiction treatment. Following baseline
assessment, Veterans will be randomly assigned, stratified by gender and primary substance
problem, to one of the two treatment conditions and followed for 12 months. All Veterans
will receive addiction treatment as usual. Veterans assigned to the AHCM condition will have
a case manager who is integrated with the interdisciplinary treatment team. The AHCM will
meet with the Veteran weekly, assist the Veteran with potential housing options, support the
Veteran in continuing addiction treatment and psychiatric care, visit the Veteran in the
community when appropriate, and obtain point of care urine toxicology testing to assess
abstinence with the goal of addressing substance use issues proactively. The AHCM will
educate the Veteran on needed basic life skills using existing manuals. Veterans assigned to
the control condition will attend a weekly housing group where housing options are
discussed. Participants will complete research assessments every 3 months through one year
and then every 6 months for up to 2 years post-randomization to assess housing status and
other outcomes. The Northwest Regional Data Warehouse and Decision Support System data
sources will be used to determine outpatient and inpatient VA health care services and costs
for the 1 year before and 2 years after study enrollment.

Impact: If the AHCM model interrupts the mutually perpetuating triad of homelessness,
substance use, and co-occurring psychiatric disorders by increasing days stably housed,
reducing costs and excessive health care utilization, and improving functional status, the
model could be feasibly and rapidly replicated in VA addiction programs nationwide thereby
decreasing homelessness among Veterans and preserving precious health care resources.

Inclusion Criteria:

- Veterans newly presenting or returning to specialty treatment for substance
dependence at VA Puget Sound Seattle Division who, after an initial evaluation, are
scheduled for a treatment appointment in the Addiction Treatment Center

- Currently homeless (unsheltered, staying in temporary emergency shelter, or doubled
up with friends/family)

Exclusion Criteria:

- Not planning to stay in the Puget Sound area during the next 12 months

- Unable to provide informed consent