Predictors of VA and Non-VA Health Care Service Use by Homeless Veterans Residing in a Low-Demand Emergency Shelter
Conclusions
These findings suggest, in large part, the validity of the Andersen and Gelberg models of health care service use. Consistent with prior studies, need-based factors predicted the use of any psychiatric and substance-related sector services as well as the use of non-VA subcomponent services for both sectors. Also consistent with prior studies, enabling factors (medical sector service use) predicted service use, with the exception of VA or non-VA substance-abuse services. Unlike prior studies, however, predisposing factors (eg, age, race, marital status, and income) were not associated with service use.
This study could not determine why veterans underutilized substance-abuse services, even those available locally to them in Fort Worth. One possible barrier to care is that the services are designed or delivered in a manner that does not engage these veterans (eg, expectations regarding abstinence or service involvement). Another barrier could be that referral pathways between VA outpatient medical and psychiatric service providers and VA substance-related services are not sufficiently facilitative. Future investigations could build upon the findings of this study by collecting data that could help assess these potential barriers.
The data from this study suggest 3 opportunities to improve the utilization of services most needed by this population. The first opportunity would be to accurately differentiate between substance abuse and psychiatric problems in clinical assessment and identify the most appropriate type of care. Another opportunity, linked closely to the first, would be to facilitate more effective and efficient referral pathways among VA service sectors, especially from medical and psychiatric services to substance-abuse services. Another strategy to improve referral pathways would be for VA service networks to systematically examine local service systems for factors or processes that may disrupt integrated care and implement program improvements.28 For homeless veterans navigating an inherently complex VA health care system, peer-to-peer and patient navigator programs have helped improve service efficiency and service outcomes.29 The third opportunity to improve utilization of services would be to ensure geographic availability and accessibility by strategic placement of these services.
The results from this study, while informative, point directly to needed areas for further inquiry to inform public health response. Although the low-demand shelter users are a particularly challenging subgroup of veterans experiencing chronic homelessness, other equally challenging populations warrant additional study. For example, veterans outside of both VA and community services (eg, unsheltered populations) are likely to require different approaches to engage in appropriate services. Additionally, changes to the homeless policy implemented in the period after this sample was recruited suggest the need to revisit the service-using behaviors of this population. Finally, interventions developed as part of the national response need to be assessed for their ability to engage these difficult-to-reach veterans.
Acknowledgements
This study was funded by a U.S. Department of Veterans Affairs Office of Academic Affiliations Pre-Doctoral Social Work Research Fellowship award.
