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Development and Implementation of a Homeless Mobile Medical/Mental Veteran Intervention
Research has consistently identified remarkably high rates of addiction, mental illness, and health problems in the homeless population.1-9 Yet in spite of extensive service needs for these problems, abundant evidence exists of consistent underuse of health care services by homeless populations.10-12 Most of the homeless population reside in emergency shelters or in transitional or supportive housing, but many remain in places not meant for human habitation.
Homelessness is significantly overrepresented among military veterans.13 The January 2016 national point-in-time count identified 39,471 veterans experiencing homelessness.13 Iraq and Afghanistan veterans seem to have an especially high risk for homelessness.13-15 Disheartening statistics such as these prompted former VA Secretary Eric Shinseki to pledge to end veteran homelessness by December 2015.16 He argued in support of this mission that 85% of veteran homeless resources go to health care—implying that homelessness among veterans is primarily a health care issue, which is heavily burdened by substance abuse and other psychiatric and medical illnesses.17
Health care service use has been associated with improved health, mental health, and outcomes among homeless populations.12,18 Unfortunately, access to these services is limited by barriers associated with homelessness, such as transportation or lack of proper identification.19,20 Veterans experiencing homelessness also face these common barriers to health care, and unsheltered veterans especially underutilize VA health care services.21
Housing First—a successful model that places individuals into housing without prerequisites for sobriety, active participation in treatment, or other behavioral accomplishments, such as gainful employment—has not managed yet to place all the disengaged homeless veteran population into stable housing.22 However, the Housing First model, which is based on the individual’s priorities, is consistent with the approach of a new program at the VA North Texas Health Care System (VANTHCS).
The VHA, similar to other health care systems, is engaged in a cultural transformation to convert its health care approach from a traditional medical model to patient-centered care (PCC).23 In this priority area, a strategic objective is for the VHA to partner with each veteran to create a personalized, proactive strategy to optimize health and well-being and when needed provide state-of-the-art disease management. Patient-centered care is designed to address veterans’ specific needs in spiritual, environmental, physical, mental, and social domains and empower veterans to become active participants in their care. Patient-centered care differs from the traditional medical model in that patients are active participants in their treatment, partnering and collaborating with their providers on care that is quality-of-life centered instead of disease centered.23 This model is based on both respect for patients as unique individuals and on the obligation to care for them on their own terms, focused on their self-identified goals and aspirations.24
At VANTHCS, the Homeless Mobile Medical/Mental Veteran (HMMM-V) pilot program was designed to deliver effective health care services to a homeless subpopulation of veterans who historically have been the most difficult to serve—those living in unsheltered environments, such as under bridges and in encampments. The purpose of the HMMM-V program was to contact and serve veterans not currently being reached by the VA system of care, using a PCC model.
This pilot program was initially funded in January 2013 by a 2-year grant from the Office of Patient Centered Care and Cultural Transformation to apply the PCC approach to engage veteran participation. For this project, the VA Personal Health Inventory tool—originally designed for use with the general veteran population—was adapted for use with the homeless veteran population. The grant funding period covered the design, development, and implementation of the HMMM-V program; thereafter, VANTHCS provided resources through its Comprehensive Homeless Center Programs to assure its sustainability and continued use of the clinical assessment tool created for this project. 
This article describes the development and implementation of this novel program with sufficient detail to inform the development of similar programs in other sites. Descriptions of the program and staffing, creation of community partnerships, and modification of an assessment instrument are provided. It also illustrates the original implementation period of the HMMM-V program through presentation of self-reported data on the first homeless veterans it served.
Equipment and Staffing
A custom 28-foot mobile outreach vehicle was assembled according to specifications identified by the HMMM-V team as necessary to conduct the program’s interventions. The van became fully operational on April 8, 2015, after it underwent all the required reviews and inspections (eg, safety, infection control, etc) and was accredited in 2015 by the Commission on Accreditation of Rehabilitation Facilities.
The HMMM-V van has a driver compartment that is separate from its services rooms, which include a patient registration area, a fully equipped examination room, a laboratory area, and a bathroom. The vehicle is equipped with a wheelchair lift and an awning to shade outdoor areas where tables and chairs are set up for patient/staff waiting and rest areas. The vehicle is stocked with essential equipment and supplies needed to conduct work in off-street locations, vacant lots, under bridges, fields, unpaved paths, etc. It also is equipped with telemedicine capabilities to provide clinical supervision and access to attending physicians and specialists at VANTHCS. Personnel carry cell phones and laptop computers with secure Internet connections using a commercially available mobile wireless Wi-Fi hotspot to facilitate documentation of medical records and communication from the field.
This reliable type of equipment is routine for use in VA field operations; the only hurdle using these technologies for the program was acquiring funding and purchasing the equipment. The vehicle is further equipped with a refrigerator solely for secure storage of pharmaceutical supplies, a second refrigerator for specimens, and wall-mounted blood pressure and otoscope/ophthalmoscope units. The vehicle is supplied with thermometers, scales, phlebotomy supplies, and first-aid kits and is stocked with vaccines and medications, including antibiotic, hypertensive, diabetic, allergy, and over-the-counter pain medications. A more comprehensive list of supplies for the vehicle is available from the authors on request.
Medication provisions supplied to the HMMM-V mobile clinic conform to the Texas State Board of Pharmacy compliance regulations. Because the vehicle is designated as federal property and has U.S. government license plates, it is considered an extension of VANTHCS Pharmacy Service and falls under its pharmacy license. A medication formulary was created with input from HMMM-V prescribers and Dallas VAMC Pharmacy Service pharmacists. To safeguard the integrity of these pharmaceutical agents, the HMMM-V physician assistant picks up the medications before field deployment and returns the unused medications to the Dallas VAMC at the end of the day. The medications are transported in locked containers and placed either in a locked medication refrigerator or cabinet on the mobile unit.
For medication prescriptions that need laboratory testing before prescribing them, HMMM-V prescribers can check the VA electronic medical record from the field to determine whether these tests have been completed recently. If not, then HMMM-V team has an agreement with Dallas VA Pathology and Laboratory Medicine Service for testing samples obtained in the field.
The program was designed for staffing of the vehicle by 2 professional teams, each includes medical (physician’s assistant or registered nurse), mental health (psychiatrist, residents), and social work providers (licensed social workers, clinical social workers); trainees of these disciplines; a peer support specialist; and an administrative clerk. The staffing varies daily, depending on available personnel. When personnel deploy to the field, they go in pairs or groups to address potential safety issues. Cell phones are available to summon police or ambulance services in an emergency. Systematic safety training was conducted with all field personnel before their first deployment to guard against vulnerability to danger in these settings.
Once in the field, personnel engage unsheltered homeless individuals to assess eligibility for VA services. Veterans found ineligible are assisted with application for military discharge upgrade, service-connected compensation, or appeal for health care coverage. Veterans eligible for VA care receive physical examinations, vital and glucose checks, influenza and pneumonia vaccinations, first-aid skin and wound care, medication management with limited medications provided at point of care, blood and urine testing, peer support services, suicide assessments, clinical mental health evaluations, and social work services through the HMMM-V program.
Social work assistance provided includes psychosocial assessment and care coordination for psychosocial needs such as mental health, substance abuse, vision, dental, housing, employment, legal aid, transportation, food, income, hygiene, and weather-appropriate provision needs.
Community Partnerships
The HMMM-V program benefitted from a number of partnerships with community agencies. During development of the program, HMMM-V personnel accompanied the Dallas Police Department’s Crisis Intervention Unit on typical homeless crisis services deployments into the field to learn about the locations and nature of encampments and homeless peregrination patterns in the Dallas area.
To aid in the design and selection of features for the mobile outreach vehicle, team members toured Homeless Outreach Medical Service mobile clinics from 2 local county hospitals, Parkland Hospital and John Peter Smith Hospital. The staff for these mobile clinics were interviewed about their experience with various components of their programs and their recommendations for optimal design of the mobile medical clinic for service delivery.
Numerous agencies in the Dallas area that serve the homeless population assisted with locating and connecting homeless veterans to HMMM-V programs. These partnering agencies also serve homeless individuals who do not qualify for the HMMM-V program, such as veterans with other-than-honorable military discharges.
The HMMM-V mobile outreach vehicle travels to partnering agencies and provides services on a recurring basis. These agencies are the Dallas International Street Church, a church and faith-based agency aiding the recovery of people with “broken lives”; Cornerstone Ministries, a church-based ministry serving people with adverse circumstances; and City Square’s Opportunity Center, human services and community development programs for low-income city residents. The mobile clinic also travels regularly to other areas to serve homeless veterans residing in unsheltered locations, such as homeless encampments and under bridges.
Clinical Assessment
The project used a modification of the VA Personalized Health Inventory (PHI) for general veteran populations, which assesses 8 areas of self-identified needs to address the specific concerns of homeless veterans served by a mobile clinic.25 Version 19 of the PHI (revised September 18, 2012), the version of the instrument available to the team at the inception of the project, was deployed with the HMMM-V personnel into the field. It imposed a heavy interview time burden (several hours), and its content areas did not seem appropriate to address the immediate concerns of homeless populations (eg, sections pertaining to personal development through hobbies, recreation, or volunteering; healthy living spaces with plenty of lighting and color; “eating healthy, balanced meals with plenty of fruits and vegetables each day”).25
Based on HMMM-V personnel feedback, the team modified this tool and developed a patient-centered health inventory (P-CHI) for homeless veterans that was acceptable in length and applicable to the situational characteristics of homeless existence. The tool’s 10 “current and desired states” were revised to remove domains of exercise and flexibility, sleep and relaxation, and mind-body techniques. The intervention and prevention domains were combined. A material needs (clothing, furniture, transportation, financial benefits) domain was added, and a new domain on reducing alcohol/drug use was created by moving this material from the food and drink domain. 
The remaining domains were modified to fit the homeless living situation (Food and Drink = Nutrition; Personal Development = Employment/Vocation; Family, Friends, and Co-Workers = Family/Social/Legal Support; Spirit and Soul = Personal/Spiritual Fulfillment; Surroundings = Housing). Current state ratings were revised to reflect level of satisfaction, and ratings of Desired State were replaced with level of importance.
The modifications resulted in 9 domains, which were assembled into a grid for efficient rating of both satisfaction and importance for each domain (rated 1 to 10, lowest to highest, respectively), followed by an instruction to mark an X in a designated space in all the domains with which the individual would like help (Table). The intent was to reduce the burden of the instrument by having the participant complete sections providing detailed information about only the domains selected by the participant.
The details of each domain in the original VA PHI tool were captured through open-ended questions in text responses provided by the veteran. Because open-ended text responses are not conducive for summarizing characteristics of the population served or for evaluating program activities, the detailed sections covering the domains were revised completely to capture data within categoric and numeric variables. Items from the validated Homeless Supplement Interview were added to collect information not provided in the Homeless Operations Management and Evaluation System interview that is routinely administered to all veterans accessing homeless VA services.26-28
The information collected in these domains cover duration of current homeless episode, lifetime number of homeless episodes, current living arrangements and dissatisfactions with these arrangements, frequency and source of meals, employment history and current work status, sources of income, special material needs, medical and dental problems and sources of care, current medications, mental health problems and sources of care, urgent mental health concerns, current amount and frequency of alcohol and drug use, substance abuse treatment history, relationships with family and intimate partners, legal assistance needs, and self-identified needs for spiritual and personal fulfillment. This instrument is available on request to the authors.
Veterans Served
The project began with 1 team of professionals deploying with the HMMM-V vehicle while a second team was being assembled. Currently, the 2 HMMM-V teams deploy the mobile clinic 4 days per week. The mobile clinic visits agencies that serve the homeless, including emergency shelters and food ministries, as well as homeless encampments. To date, 195 homeless veterans have been served by the mobile clinic, 111 were currently enrolled with the VA, 8 were not enrolled but eligible for services, and 77 were not eligible for VA services. Of the unenrolled veterans, those eligible for services were offered VA enrollment assistance; those ineligible for VA services were offered a community referral.
For the veterans encountered in the field, the following interventions were provided: 49 housing placement referrals, 4 rental assistance referrals, 4 legal referrals, 27 medical care interventions, 13 dental referrals, 11 vision/hearing referrals, 12 mental health interventions, 9 substance abuse treatment referrals, 14 employment assistance referrals, 13 disability benefit applications, 18 transportation assists, 23 goods delivered, and 159 information assists. The HMMM-V mobile clinic also is deployed to participate in various educational and outreach events. At the time this article was written, the mobile clinic has reached nearly 2,000 veterans and community partners in at least 25 such events.
Of the veterans served to date, 73 completed the P-CHI. These veterans were predominantly male (77%), and the majority (60%) were black. The median age of the sample was 58 years, and typically they had a high school level of education (12.7; SD, 2.1 mean years of education). About half (49%) the sample were separated or divorced, and only a minority were currently married (8%). Half (50%) the sample served in the U.S. Army, with the post-Vietnam era being the era of service most represented (19%). Few (21%) veterans reported exposure to hostile or friendly fire during their service. More than three-fourths (80%) of the sample had experienced a homeless episode prior to their current one. On average, members of the sample had experienced a median of 3 lifetime homeless episodes. They had a mean 4.1 (SD, 5.8) lifetime number of years of homelessness, and 3.0 (SD, 5.2) years in their current homeless episode. Nearly one-third (31%) reported that they were currently staying in a homeless shelter, and nearly one-sixth (16%) were currently unsheltered in street settings, such as under bridges or in outdoor encampments at the time of the initial visit.
The mean number of minutes spent completing the P-CHI was 18.5 (SD, 9.4). The veterans indicated that they would like assistance with a mean 3.2 (SD, 2.2) number of domains. The domains with the highest average importance ratings were housing (mean, 9.4; SD, 1.7) and medical/dental care (mean, 8.9; SD, 2.2); the domains with the lowest average importance rating were reducing alcohol/drug use (mean, 6.4; SD, 4.1) and employment/vocation (mean, 6.3; SD, 4.2). The domains with the highest average satisfaction ratings were personal/spiritual fulfillment (mean, 7.3; SD, 2.9) and reducing substance use (mean, 5.9; SD, 4.0), and the domains with the lowest average satisfaction ratings were housing (mean, 2.9; SD, 2.9), material needs (mean, 4.2; SD, 3.3), and employment/vocation (mean, 4.2; SD, 3.2). The domain with the greatest indication of desire for help was housing, endorsed by more than four-fifths (84%) of the sample. This highly endorsed housing domain also was one of the lowest in satisfaction. The domains with the least expressed interest in obtaining help were reducing substance use (18%) and personal/spiritual fulfillment (15%).Reducing substance abuse also was one of the lowest domains of importance and the least for dissatisfaction.
Challenges and Barriers
As anticipated from its inception, this project encountered many challenges and barriers. The first was with the design, construction, and delivery of the mobile clinic unit. The vehicle took more than 2 years to be delivered. There were delays in progress necessitated by required selection of an approved vendor to build the vehicle, extensive specification of details and features, and stocking it with equipment and supplies. The weight of the unit had to be < 26,000 pounds to avoid the requirement of a commercial driver’s license, which limited the size of the vehicle to 28 feet. Stocking the unit with equipment and supplies required attention to a myriad of specifications and decisions. For example, separate refrigerators were needed for specimens, medications, and food; pharmaceutical regulations governing medications in mobile clinics required strict adherence; and difficulties were encountered in attempting to establish adequate and secure connectivity for communications devices in the field. 
Once the mobile unit was delivered and prepared for deployment, the next set of challenges pertained to learning all of the instructions required to operate and drive the vehicle and learning how to maneuver the vehicle in the field. Specific challenges for driving the vehicle encountered included unexpectedly low overpasses that prohibited passage, narrow spaces for passage, rough and uneven terrain in off-road settings, and lateral and vertical tilt of roads creating potential for sideswipes and undercarriage scrapes. Maintenance schedules needed to be developed and implemented for cleaning the unit, inspection compliance, repairs, refueling, and emptying waste materials.
Staffing the vehicle required the development of unique job specifications addressing special expertise in accessing VA databases for veteran verification and registration and for driving the mobile clinic vehicle. Schedules and deployment plans for 2 teams that shared the same vehicle had to be established and followed. Locating veterans in unsheltered settings, such as under bridges and in encampments, required community intelligence facilitated through partnerships with knowledgeable members of the Dallas police crisis unit and by gaining field experience to locate where the usual homeless gathering places are, especially those inhabited by veterans. Safety of team members and equipment/supplies in the field was paramount from the start, and additional steps beyond safety training required extra measures, such as special care in navigating known dangerous areas. Provision of services necessitated completion of everything needed in a single visit due to the likelihood of loss to follow-up and acceptance of the limited types of service that could be provided in a mobile clinic. Special procedures were needed to provide referrals to sources of available care for non-VA-qualifying veterans.
Discussion
The HMMM-V program for delivery of PCC to homeless veterans is an innovative pilot program designed to connect with difficult-to-reach homeless veterans and engage them in care. The deliverables provided by this project are (1) A mobile outreach vehicle to deliver care to homeless veterans and outreach to other veterans and community agencies in North Texas; (2) The P-CHI assessment tool for homeless veterans modified and adapted for use with this special population; and (3) pilot data on its first cohort of homeless veterans served, describing their baseline characteristics and their stated satisfaction and preferences about their goals and aspirations for their physical, emotional, and mental health and well-being.
The HMMM-V program successfully identified homeless veterans in need of services, and more than one-third of these veterans were not previously engaged in VA services. Compared with the “typical” veterans served at VANTHCS homeless programs, veterans served by the HMMM-V comprised a greater proportion of minorities and a higher proportion who had been exposed to combat.29 Age and gender characteristics were similar.29 When compared with veterans who access care at VANTHCS and have not experienced homelessness, those served by the HMMM-V were younger and more likely to belong to a minority group; however, they were similar in combat exposure and gender.1 The veterans served by the HMMM-V program also were considerably older and had more homeless chronicity than did nonveteran homeless populations, consistent with other research.4,29,30
The veterans served by the HMMM-V program not surprisingly made housing their top priority in need of help, consistent with the Housing First model.22,31 They also indicated that employment/vocation and reducing substance use were of lower importance. Need for assistance with reducing substance use and social support were the domains least often identified as areas where help was needed, which seems inconsistent with the higher established rates of substance abuse problems among homeless veterans.1
With additional fieldwork, the HMMM-V program is expected to allow refinement of procedures for identifying and serving veterans from a patient-centered care perspective. The P-CHI will be further tested and developed, and the next step will be to create and pilot intervention templates for a Patient-Centered Health Improvement Plan, based on the P-CHI results. This process parallels the original development treatment plans for the VA’s Personalized Health Plan based on the PHI.25 Once the HMMM-V program is fully established in Dallas, the plans are for an expansion that will cover a broader geographic area in North Texas that includes rural areas.
The HMMM-V program was designed to address the barriers to health care that are encountered by homeless veterans. It is unique in homeless veteran care due to its patient-centered approach that partners with homeless veterans to prioritize their needs as determined by them rather than based solely on policies or provider conceptualizations of their needs. Access to services, engagement in care, and successful utilization of needed services may lead to measurable improvements in health care outcomes among homeless populations of veterans. Desired goals include remission of illness through appropriate medical intervention, preventing morbidity, achieving healthy lifestyles, recovery from addiction, stabilization of psychiatric illness, and attainment of stable housing.
The first hurdle for implementing this type of program in other settings is the identification of resources needed for these efforts. Need of additional staffing resources, however, may be circumvented by allowing employees working in other areas to rotate in community outreach shifts in the mobile unit. Another hurdle encountered in implementation of the HMMM-V initiative was the initial difficulty finding homeless veterans in community settings, especially those in unsheltered locations. The HMMM-V program addressed this issue by partnering with other agencies serving the homeless in the community. Therefore, a general recommendation for other entities seeking to implement this type of program is to reach out to these community partners from the outset.
Conclusion
The HMMM-V has the potential to engage the most difficult-to-reach homeless veterans in need of health services by delivering care and providing resources in challenging environments. Further work is needed to validate the P-CHI for use with this program and to conduct well-designed and implemented research to demonstrate effectiveness of this intervention on veteran outcomes, especially quality of life. Once this additional work is accomplished, this innovative program can potentially be implemented by VAMCs across the nation, and potentially in more general community care settings, to more effectively reach out and deliver services to homeless members of the community.
Acknowledgments
Grant support was received from the Department of Veterans Affairs, Office of Patient Centered Care. The authors would like to acknowledge all the clinicians, trainees, and support staff who have contributed to the success of the HMMM-V program: Tara Ayala, Jose Cabrera, Tony Castillo, Rachael Lynn David, Teresa DeShazo, Sylvia Figueroa, Steven Fisher, Eric Gary, Evelyn Gibbs, Kevin Hosey, JoAnn Joseph, Taly Drimer Kagan, Miranda Kelly, Michelle King-Thompson, Sharon Marcus, Shiji Mathew, Moneeza Matin, John Moreno, Joseph Neifert, Joel Price, Tiffany Price, Natalie Qualls, Reginald Robertson, Kristine Rodrigues, Jon Saffelder, Jill Stokes, Scott Stone, and John Smith.
1. LePage JP, Bradshaw LD, Cipher DJ, Crawford AM, Hooshyar D. The effects of homelessness on veterans’ health care service use: an evaluation of independence from comorbidities. Public Health. 2014;128(11):985-992.
2. Fischer PJ, Breakey WR. The epidemiology of alcohol, drug, and mental disorders among homeless persons. Am Psychol. 1991;46(11):1115-1128.
3. Robertson MJ, Zlotnick C, Westerfelt A. Drug use disorders and treatment contact among homeless adults in Alameda County, California. Am J Public Health. 1997;87(2):221-228.
4. North CS, Eyrich KM, Pollio DE, Spitznagel EL. Are rates of psychiatric disorders in the homeless population changing? Am J Public Health. 2004;94(1):103-108.
5. Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS Med. 2008;5(12):e225.
6. Harpaz-Rotem I, Rosenheck RA, Desai R. The mental health of children exposed to maternal mental illness and homelessness. Community Ment Health J. 2006;42(5):437-448.
7. Pollio DE, Eyrich-Garg KM, North CS. The homeless. In: Johnson BA, ed. Addiction Medicine: Science and Practice. New York, NY: Springer; 2011:1487-1504.
8. Padgett D, Struening EL, Andrews H. Factors affecting the use of medical, mental health, alcohol, and drug treatment services by homeless adults. Med Care. 1990;28(9):805-821.
9. Baggett TP, Singer DE, Rao SR, O’Connell JJ, Bharel M, Rigotti NA. Food insufficiency and health services utilization in a national sample of homeless adults. J Gen Intern Med. 2011;26(6):627-634.
10. Folsom DP, Hawthorne W, Lindamer L, et al. Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. Am J Psychiatry. 2005;162(2):370-376.
11. Fuehrlein BS, Cowell AJ, Pollio D, Cupps L, Balfour ME, North CS. A prospective study of the associations among housing status and costs of services in a homeless population. Psychiatr Serv. 2015;66(1):27-32.
12. Pollio DE, North CS, Eyrich KM, Foster DA, Spitznagel E. Modeling service access in a homeless population. J Psychoactive Drugs. 2003;35(4):487-495.
13. U.S. Department of Housing and Urban Development Office of Community Planning and Development. The 2016 Annual Homeless Assessment Report (AHAR) to Congress. Part 1: point-in-time estimates of homelessness. https://www.hudexchange.info/resources/documents/2016-AHAR-Part-1.pdf. Published 2016. Accessed August 7, 2017.
14. Tsai J, Rosenheck RA. Risk factors for homelessness among U.S. veterans. Epidemiol Rev. 2015;37:177-195.
15. Williamson V, Mulhall E. Coming home: the housing crisis and homelessness threaten new veterans. Iraq and Afghanistan Veterans of America, January, 2009. http://media.iava.org/IAVA_coming_home_2009%20The%20Housing%20Crisis%20and%20Homelessness%20Threaten%20New%20Veterans.pdf. Accessed August 10, 2017
16. Shinseki EK. Remarks by Secretary Eric K. Shinseki. National Summit on Homeless Veterans; November 3, 2009; Washington, DC. https://www.va.gov/opa/speeches/2009/09_1103.asp. Updated August 8, 2016. Accessed August 7, 2017.
17. Shinseki EK. Remarks by Secretary Eric K. Shinseki. 2014 National Coalition for Homeless Veterans Annual Meeting; May 30, 2014; Arlington, VA. https://www.va.gov/opa/speeches/2014/05_30_2014.asp. Updated April 21, 2015. Accessed August 7, 2017.
18. Pollio DE, Spitznagel EL, North CS, Thompson S, Foster DA. Service use over time and achievement of stable housing in a mentally ill homeless population. Psychiatr Serv. 2000;51(12):1536-1543.
19. Page J. Barriers to transferring care of homeless people with serious mental illnesses to community mental health organizations: perspectives of street-based programs. Best Practices in Mental Health: An International Journal. 2007;3(1):26.
20. Young AS, Chinman MJ, Cradock-O’Leary JA, et al. Characteristics of individuals with severe mental illness who use emergency services. Community Ment Health J. 2005;41(2):159-168.
21. Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and low-income veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461.
22. Tsemberis S, Gulcur L, Nakae M. Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health. 2004;94(4):651-656.
23. U.S. Department of Veterans Affairs, Veterans Health Administration. VA Patient Centered Care. http://www.va.gov/patientcenteredcare. Updated July 24,2017. Accessed August 7, 2017.
24. Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100-103.
25. U.S. Department of Veterans Affairs, Office of Patient Centered Care and Cultural Transformation. My story: personal health inventory. https://www.va.gov/PATIENTCENTEREDCARE/docs/VA-OPCC-Personal-Health-Inventory-final-508.pdf. Published October 7, 2013. Accessed August 7, 2017
26. North CS, Smith EM, Pollio DE. The Homeless Supplement to the Diagnostic Interview Schedule (DIS/HS). St. Louis: Washington University, 2004.
27. North CS, Eyrich KM, Pollio DE, Foster DA, Cottler LB, Spitznagel EL. The homeless supplement to the diagnostic interview schedule: test-retest analyses. Int J Methods Psychiatr Res. 2004;13(3):184-191.
28. LaSalle JL. Homeless Operations Management and Evaluation System (HOMES) user manual-phase 1. http://www.vfwsc.org/homes.pdf. Published April 19, 2011. Accessed August 7, 2017.
29. Petrovich JC, Pollio DE, North CS. Characteristics and service use of homeless veterans and nonveterans residing in a low-demand emergency shelter. Psychiatr Serv. 2014;65(6):751-757.
30. North CS, Smith EM. A comparison of homeless men and women: different populations, different needs. Community Ment Health J. 1993;29(5):423-431.
31. Kertesz SG, Austin EL, Holmes SK, et al. Making housing first happen: organizational leadership in VA’s expansion of permanent supportive housing. J Gen Intern Med. 2014;29(suppl 4):835-844.
Research has consistently identified remarkably high rates of addiction, mental illness, and health problems in the homeless population.1-9 Yet in spite of extensive service needs for these problems, abundant evidence exists of consistent underuse of health care services by homeless populations.10-12 Most of the homeless population reside in emergency shelters or in transitional or supportive housing, but many remain in places not meant for human habitation.
Homelessness is significantly overrepresented among military veterans.13 The January 2016 national point-in-time count identified 39,471 veterans experiencing homelessness.13 Iraq and Afghanistan veterans seem to have an especially high risk for homelessness.13-15 Disheartening statistics such as these prompted former VA Secretary Eric Shinseki to pledge to end veteran homelessness by December 2015.16 He argued in support of this mission that 85% of veteran homeless resources go to health care—implying that homelessness among veterans is primarily a health care issue, which is heavily burdened by substance abuse and other psychiatric and medical illnesses.17
Health care service use has been associated with improved health, mental health, and outcomes among homeless populations.12,18 Unfortunately, access to these services is limited by barriers associated with homelessness, such as transportation or lack of proper identification.19,20 Veterans experiencing homelessness also face these common barriers to health care, and unsheltered veterans especially underutilize VA health care services.21
Housing First—a successful model that places individuals into housing without prerequisites for sobriety, active participation in treatment, or other behavioral accomplishments, such as gainful employment—has not managed yet to place all the disengaged homeless veteran population into stable housing.22 However, the Housing First model, which is based on the individual’s priorities, is consistent with the approach of a new program at the VA North Texas Health Care System (VANTHCS).
The VHA, similar to other health care systems, is engaged in a cultural transformation to convert its health care approach from a traditional medical model to patient-centered care (PCC).23 In this priority area, a strategic objective is for the VHA to partner with each veteran to create a personalized, proactive strategy to optimize health and well-being and when needed provide state-of-the-art disease management. Patient-centered care is designed to address veterans’ specific needs in spiritual, environmental, physical, mental, and social domains and empower veterans to become active participants in their care. Patient-centered care differs from the traditional medical model in that patients are active participants in their treatment, partnering and collaborating with their providers on care that is quality-of-life centered instead of disease centered.23 This model is based on both respect for patients as unique individuals and on the obligation to care for them on their own terms, focused on their self-identified goals and aspirations.24
At VANTHCS, the Homeless Mobile Medical/Mental Veteran (HMMM-V) pilot program was designed to deliver effective health care services to a homeless subpopulation of veterans who historically have been the most difficult to serve—those living in unsheltered environments, such as under bridges and in encampments. The purpose of the HMMM-V program was to contact and serve veterans not currently being reached by the VA system of care, using a PCC model.
This pilot program was initially funded in January 2013 by a 2-year grant from the Office of Patient Centered Care and Cultural Transformation to apply the PCC approach to engage veteran participation. For this project, the VA Personal Health Inventory tool—originally designed for use with the general veteran population—was adapted for use with the homeless veteran population. The grant funding period covered the design, development, and implementation of the HMMM-V program; thereafter, VANTHCS provided resources through its Comprehensive Homeless Center Programs to assure its sustainability and continued use of the clinical assessment tool created for this project.
This article describes the development and implementation of this novel program with sufficient detail to inform the development of similar programs in other sites. Descriptions of the program and staffing, creation of community partnerships, and modification of an assessment instrument are provided. It also illustrates the original implementation period of the HMMM-V program through presentation of self-reported data on the first homeless veterans it served.
Equipment and Staffing
A custom 28-foot mobile outreach vehicle was assembled according to specifications identified by the HMMM-V team as necessary to conduct the program’s interventions. The van became fully operational on April 8, 2015, after it underwent all the required reviews and inspections (eg, safety, infection control, etc) and was accredited in 2015 by the Commission on Accreditation of Rehabilitation Facilities.
The HMMM-V van has a driver compartment that is separate from its services rooms, which include a patient registration area, a fully equipped examination room, a laboratory area, and a bathroom. The vehicle is equipped with a wheelchair lift and an awning to shade outdoor areas where tables and chairs are set up for patient/staff waiting and rest areas. The vehicle is stocked with essential equipment and supplies needed to conduct work in off-street locations, vacant lots, under bridges, fields, unpaved paths, etc. It also is equipped with telemedicine capabilities to provide clinical supervision and access to attending physicians and specialists at VANTHCS. Personnel carry cell phones and laptop computers with secure Internet connections using a commercially available mobile wireless Wi-Fi hotspot to facilitate documentation of medical records and communication from the field.
This reliable type of equipment is routine for use in VA field operations; the only hurdle using these technologies for the program was acquiring funding and purchasing the equipment. The vehicle is further equipped with a refrigerator solely for secure storage of pharmaceutical supplies, a second refrigerator for specimens, and wall-mounted blood pressure and otoscope/ophthalmoscope units. The vehicle is supplied with thermometers, scales, phlebotomy supplies, and first-aid kits and is stocked with vaccines and medications, including antibiotic, hypertensive, diabetic, allergy, and over-the-counter pain medications. A more comprehensive list of supplies for the vehicle is available from the authors on request.
Medication provisions supplied to the HMMM-V mobile clinic conform to the Texas State Board of Pharmacy compliance regulations. Because the vehicle is designated as federal property and has U.S. government license plates, it is considered an extension of VANTHCS Pharmacy Service and falls under its pharmacy license. A medication formulary was created with input from HMMM-V prescribers and Dallas VAMC Pharmacy Service pharmacists. To safeguard the integrity of these pharmaceutical agents, the HMMM-V physician assistant picks up the medications before field deployment and returns the unused medications to the Dallas VAMC at the end of the day. The medications are transported in locked containers and placed either in a locked medication refrigerator or cabinet on the mobile unit.
For medication prescriptions that need laboratory testing before prescribing them, HMMM-V prescribers can check the VA electronic medical record from the field to determine whether these tests have been completed recently. If not, then HMMM-V team has an agreement with Dallas VA Pathology and Laboratory Medicine Service for testing samples obtained in the field.
The program was designed for staffing of the vehicle by 2 professional teams, each includes medical (physician’s assistant or registered nurse), mental health (psychiatrist, residents), and social work providers (licensed social workers, clinical social workers); trainees of these disciplines; a peer support specialist; and an administrative clerk. The staffing varies daily, depending on available personnel. When personnel deploy to the field, they go in pairs or groups to address potential safety issues. Cell phones are available to summon police or ambulance services in an emergency. Systematic safety training was conducted with all field personnel before their first deployment to guard against vulnerability to danger in these settings.
Once in the field, personnel engage unsheltered homeless individuals to assess eligibility for VA services. Veterans found ineligible are assisted with application for military discharge upgrade, service-connected compensation, or appeal for health care coverage. Veterans eligible for VA care receive physical examinations, vital and glucose checks, influenza and pneumonia vaccinations, first-aid skin and wound care, medication management with limited medications provided at point of care, blood and urine testing, peer support services, suicide assessments, clinical mental health evaluations, and social work services through the HMMM-V program.
Social work assistance provided includes psychosocial assessment and care coordination for psychosocial needs such as mental health, substance abuse, vision, dental, housing, employment, legal aid, transportation, food, income, hygiene, and weather-appropriate provision needs.
Community Partnerships
The HMMM-V program benefitted from a number of partnerships with community agencies. During development of the program, HMMM-V personnel accompanied the Dallas Police Department’s Crisis Intervention Unit on typical homeless crisis services deployments into the field to learn about the locations and nature of encampments and homeless peregrination patterns in the Dallas area.
To aid in the design and selection of features for the mobile outreach vehicle, team members toured Homeless Outreach Medical Service mobile clinics from 2 local county hospitals, Parkland Hospital and John Peter Smith Hospital. The staff for these mobile clinics were interviewed about their experience with various components of their programs and their recommendations for optimal design of the mobile medical clinic for service delivery.
Numerous agencies in the Dallas area that serve the homeless population assisted with locating and connecting homeless veterans to HMMM-V programs. These partnering agencies also serve homeless individuals who do not qualify for the HMMM-V program, such as veterans with other-than-honorable military discharges.
The HMMM-V mobile outreach vehicle travels to partnering agencies and provides services on a recurring basis. These agencies are the Dallas International Street Church, a church and faith-based agency aiding the recovery of people with “broken lives”; Cornerstone Ministries, a church-based ministry serving people with adverse circumstances; and City Square’s Opportunity Center, human services and community development programs for low-income city residents. The mobile clinic also travels regularly to other areas to serve homeless veterans residing in unsheltered locations, such as homeless encampments and under bridges.
Clinical Assessment
The project used a modification of the VA Personalized Health Inventory (PHI) for general veteran populations, which assesses 8 areas of self-identified needs to address the specific concerns of homeless veterans served by a mobile clinic.25 Version 19 of the PHI (revised September 18, 2012), the version of the instrument available to the team at the inception of the project, was deployed with the HMMM-V personnel into the field. It imposed a heavy interview time burden (several hours), and its content areas did not seem appropriate to address the immediate concerns of homeless populations (eg, sections pertaining to personal development through hobbies, recreation, or volunteering; healthy living spaces with plenty of lighting and color; “eating healthy, balanced meals with plenty of fruits and vegetables each day”).25
Based on HMMM-V personnel feedback, the team modified this tool and developed a patient-centered health inventory (P-CHI) for homeless veterans that was acceptable in length and applicable to the situational characteristics of homeless existence. The tool’s 10 “current and desired states” were revised to remove domains of exercise and flexibility, sleep and relaxation, and mind-body techniques. The intervention and prevention domains were combined. A material needs (clothing, furniture, transportation, financial benefits) domain was added, and a new domain on reducing alcohol/drug use was created by moving this material from the food and drink domain.
The remaining domains were modified to fit the homeless living situation (Food and Drink = Nutrition; Personal Development = Employment/Vocation; Family, Friends, and Co-Workers = Family/Social/Legal Support; Spirit and Soul = Personal/Spiritual Fulfillment; Surroundings = Housing). Current state ratings were revised to reflect level of satisfaction, and ratings of Desired State were replaced with level of importance.
The modifications resulted in 9 domains, which were assembled into a grid for efficient rating of both satisfaction and importance for each domain (rated 1 to 10, lowest to highest, respectively), followed by an instruction to mark an X in a designated space in all the domains with which the individual would like help (Table). The intent was to reduce the burden of the instrument by having the participant complete sections providing detailed information about only the domains selected by the participant.
The details of each domain in the original VA PHI tool were captured through open-ended questions in text responses provided by the veteran. Because open-ended text responses are not conducive for summarizing characteristics of the population served or for evaluating program activities, the detailed sections covering the domains were revised completely to capture data within categoric and numeric variables. Items from the validated Homeless Supplement Interview were added to collect information not provided in the Homeless Operations Management and Evaluation System interview that is routinely administered to all veterans accessing homeless VA services.26-28
The information collected in these domains cover duration of current homeless episode, lifetime number of homeless episodes, current living arrangements and dissatisfactions with these arrangements, frequency and source of meals, employment history and current work status, sources of income, special material needs, medical and dental problems and sources of care, current medications, mental health problems and sources of care, urgent mental health concerns, current amount and frequency of alcohol and drug use, substance abuse treatment history, relationships with family and intimate partners, legal assistance needs, and self-identified needs for spiritual and personal fulfillment. This instrument is available on request to the authors.
Veterans Served
The project began with 1 team of professionals deploying with the HMMM-V vehicle while a second team was being assembled. Currently, the 2 HMMM-V teams deploy the mobile clinic 4 days per week. The mobile clinic visits agencies that serve the homeless, including emergency shelters and food ministries, as well as homeless encampments. To date, 195 homeless veterans have been served by the mobile clinic, 111 were currently enrolled with the VA, 8 were not enrolled but eligible for services, and 77 were not eligible for VA services. Of the unenrolled veterans, those eligible for services were offered VA enrollment assistance; those ineligible for VA services were offered a community referral.
For the veterans encountered in the field, the following interventions were provided: 49 housing placement referrals, 4 rental assistance referrals, 4 legal referrals, 27 medical care interventions, 13 dental referrals, 11 vision/hearing referrals, 12 mental health interventions, 9 substance abuse treatment referrals, 14 employment assistance referrals, 13 disability benefit applications, 18 transportation assists, 23 goods delivered, and 159 information assists. The HMMM-V mobile clinic also is deployed to participate in various educational and outreach events. At the time this article was written, the mobile clinic has reached nearly 2,000 veterans and community partners in at least 25 such events.
Of the veterans served to date, 73 completed the P-CHI. These veterans were predominantly male (77%), and the majority (60%) were black. The median age of the sample was 58 years, and typically they had a high school level of education (12.7; SD, 2.1 mean years of education). About half (49%) the sample were separated or divorced, and only a minority were currently married (8%). Half (50%) the sample served in the U.S. Army, with the post-Vietnam era being the era of service most represented (19%). Few (21%) veterans reported exposure to hostile or friendly fire during their service. More than three-fourths (80%) of the sample had experienced a homeless episode prior to their current one. On average, members of the sample had experienced a median of 3 lifetime homeless episodes. They had a mean 4.1 (SD, 5.8) lifetime number of years of homelessness, and 3.0 (SD, 5.2) years in their current homeless episode. Nearly one-third (31%) reported that they were currently staying in a homeless shelter, and nearly one-sixth (16%) were currently unsheltered in street settings, such as under bridges or in outdoor encampments at the time of the initial visit.
The mean number of minutes spent completing the P-CHI was 18.5 (SD, 9.4). The veterans indicated that they would like assistance with a mean 3.2 (SD, 2.2) number of domains. The domains with the highest average importance ratings were housing (mean, 9.4; SD, 1.7) and medical/dental care (mean, 8.9; SD, 2.2); the domains with the lowest average importance rating were reducing alcohol/drug use (mean, 6.4; SD, 4.1) and employment/vocation (mean, 6.3; SD, 4.2). The domains with the highest average satisfaction ratings were personal/spiritual fulfillment (mean, 7.3; SD, 2.9) and reducing substance use (mean, 5.9; SD, 4.0), and the domains with the lowest average satisfaction ratings were housing (mean, 2.9; SD, 2.9), material needs (mean, 4.2; SD, 3.3), and employment/vocation (mean, 4.2; SD, 3.2). The domain with the greatest indication of desire for help was housing, endorsed by more than four-fifths (84%) of the sample. This highly endorsed housing domain also was one of the lowest in satisfaction. The domains with the least expressed interest in obtaining help were reducing substance use (18%) and personal/spiritual fulfillment (15%).Reducing substance abuse also was one of the lowest domains of importance and the least for dissatisfaction.
Challenges and Barriers
As anticipated from its inception, this project encountered many challenges and barriers. The first was with the design, construction, and delivery of the mobile clinic unit. The vehicle took more than 2 years to be delivered. There were delays in progress necessitated by required selection of an approved vendor to build the vehicle, extensive specification of details and features, and stocking it with equipment and supplies. The weight of the unit had to be < 26,000 pounds to avoid the requirement of a commercial driver’s license, which limited the size of the vehicle to 28 feet. Stocking the unit with equipment and supplies required attention to a myriad of specifications and decisions. For example, separate refrigerators were needed for specimens, medications, and food; pharmaceutical regulations governing medications in mobile clinics required strict adherence; and difficulties were encountered in attempting to establish adequate and secure connectivity for communications devices in the field.
Once the mobile unit was delivered and prepared for deployment, the next set of challenges pertained to learning all of the instructions required to operate and drive the vehicle and learning how to maneuver the vehicle in the field. Specific challenges for driving the vehicle encountered included unexpectedly low overpasses that prohibited passage, narrow spaces for passage, rough and uneven terrain in off-road settings, and lateral and vertical tilt of roads creating potential for sideswipes and undercarriage scrapes. Maintenance schedules needed to be developed and implemented for cleaning the unit, inspection compliance, repairs, refueling, and emptying waste materials.
Staffing the vehicle required the development of unique job specifications addressing special expertise in accessing VA databases for veteran verification and registration and for driving the mobile clinic vehicle. Schedules and deployment plans for 2 teams that shared the same vehicle had to be established and followed. Locating veterans in unsheltered settings, such as under bridges and in encampments, required community intelligence facilitated through partnerships with knowledgeable members of the Dallas police crisis unit and by gaining field experience to locate where the usual homeless gathering places are, especially those inhabited by veterans. Safety of team members and equipment/supplies in the field was paramount from the start, and additional steps beyond safety training required extra measures, such as special care in navigating known dangerous areas. Provision of services necessitated completion of everything needed in a single visit due to the likelihood of loss to follow-up and acceptance of the limited types of service that could be provided in a mobile clinic. Special procedures were needed to provide referrals to sources of available care for non-VA-qualifying veterans.
Discussion
The HMMM-V program for delivery of PCC to homeless veterans is an innovative pilot program designed to connect with difficult-to-reach homeless veterans and engage them in care. The deliverables provided by this project are (1) A mobile outreach vehicle to deliver care to homeless veterans and outreach to other veterans and community agencies in North Texas; (2) The P-CHI assessment tool for homeless veterans modified and adapted for use with this special population; and (3) pilot data on its first cohort of homeless veterans served, describing their baseline characteristics and their stated satisfaction and preferences about their goals and aspirations for their physical, emotional, and mental health and well-being.
The HMMM-V program successfully identified homeless veterans in need of services, and more than one-third of these veterans were not previously engaged in VA services. Compared with the “typical” veterans served at VANTHCS homeless programs, veterans served by the HMMM-V comprised a greater proportion of minorities and a higher proportion who had been exposed to combat.29 Age and gender characteristics were similar.29 When compared with veterans who access care at VANTHCS and have not experienced homelessness, those served by the HMMM-V were younger and more likely to belong to a minority group; however, they were similar in combat exposure and gender.1 The veterans served by the HMMM-V program also were considerably older and had more homeless chronicity than did nonveteran homeless populations, consistent with other research.4,29,30
The veterans served by the HMMM-V program not surprisingly made housing their top priority in need of help, consistent with the Housing First model.22,31 They also indicated that employment/vocation and reducing substance use were of lower importance. Need for assistance with reducing substance use and social support were the domains least often identified as areas where help was needed, which seems inconsistent with the higher established rates of substance abuse problems among homeless veterans.1
With additional fieldwork, the HMMM-V program is expected to allow refinement of procedures for identifying and serving veterans from a patient-centered care perspective. The P-CHI will be further tested and developed, and the next step will be to create and pilot intervention templates for a Patient-Centered Health Improvement Plan, based on the P-CHI results. This process parallels the original development treatment plans for the VA’s Personalized Health Plan based on the PHI.25 Once the HMMM-V program is fully established in Dallas, the plans are for an expansion that will cover a broader geographic area in North Texas that includes rural areas.
The HMMM-V program was designed to address the barriers to health care that are encountered by homeless veterans. It is unique in homeless veteran care due to its patient-centered approach that partners with homeless veterans to prioritize their needs as determined by them rather than based solely on policies or provider conceptualizations of their needs. Access to services, engagement in care, and successful utilization of needed services may lead to measurable improvements in health care outcomes among homeless populations of veterans. Desired goals include remission of illness through appropriate medical intervention, preventing morbidity, achieving healthy lifestyles, recovery from addiction, stabilization of psychiatric illness, and attainment of stable housing.
The first hurdle for implementing this type of program in other settings is the identification of resources needed for these efforts. Need of additional staffing resources, however, may be circumvented by allowing employees working in other areas to rotate in community outreach shifts in the mobile unit. Another hurdle encountered in implementation of the HMMM-V initiative was the initial difficulty finding homeless veterans in community settings, especially those in unsheltered locations. The HMMM-V program addressed this issue by partnering with other agencies serving the homeless in the community. Therefore, a general recommendation for other entities seeking to implement this type of program is to reach out to these community partners from the outset.
Conclusion
The HMMM-V has the potential to engage the most difficult-to-reach homeless veterans in need of health services by delivering care and providing resources in challenging environments. Further work is needed to validate the P-CHI for use with this program and to conduct well-designed and implemented research to demonstrate effectiveness of this intervention on veteran outcomes, especially quality of life. Once this additional work is accomplished, this innovative program can potentially be implemented by VAMCs across the nation, and potentially in more general community care settings, to more effectively reach out and deliver services to homeless members of the community.
Acknowledgments
Grant support was received from the Department of Veterans Affairs, Office of Patient Centered Care. The authors would like to acknowledge all the clinicians, trainees, and support staff who have contributed to the success of the HMMM-V program: Tara Ayala, Jose Cabrera, Tony Castillo, Rachael Lynn David, Teresa DeShazo, Sylvia Figueroa, Steven Fisher, Eric Gary, Evelyn Gibbs, Kevin Hosey, JoAnn Joseph, Taly Drimer Kagan, Miranda Kelly, Michelle King-Thompson, Sharon Marcus, Shiji Mathew, Moneeza Matin, John Moreno, Joseph Neifert, Joel Price, Tiffany Price, Natalie Qualls, Reginald Robertson, Kristine Rodrigues, Jon Saffelder, Jill Stokes, Scott Stone, and John Smith.
Research has consistently identified remarkably high rates of addiction, mental illness, and health problems in the homeless population.1-9 Yet in spite of extensive service needs for these problems, abundant evidence exists of consistent underuse of health care services by homeless populations.10-12 Most of the homeless population reside in emergency shelters or in transitional or supportive housing, but many remain in places not meant for human habitation.
Homelessness is significantly overrepresented among military veterans.13 The January 2016 national point-in-time count identified 39,471 veterans experiencing homelessness.13 Iraq and Afghanistan veterans seem to have an especially high risk for homelessness.13-15 Disheartening statistics such as these prompted former VA Secretary Eric Shinseki to pledge to end veteran homelessness by December 2015.16 He argued in support of this mission that 85% of veteran homeless resources go to health care—implying that homelessness among veterans is primarily a health care issue, which is heavily burdened by substance abuse and other psychiatric and medical illnesses.17
Health care service use has been associated with improved health, mental health, and outcomes among homeless populations.12,18 Unfortunately, access to these services is limited by barriers associated with homelessness, such as transportation or lack of proper identification.19,20 Veterans experiencing homelessness also face these common barriers to health care, and unsheltered veterans especially underutilize VA health care services.21
Housing First—a successful model that places individuals into housing without prerequisites for sobriety, active participation in treatment, or other behavioral accomplishments, such as gainful employment—has not managed yet to place all the disengaged homeless veteran population into stable housing.22 However, the Housing First model, which is based on the individual’s priorities, is consistent with the approach of a new program at the VA North Texas Health Care System (VANTHCS).
The VHA, similar to other health care systems, is engaged in a cultural transformation to convert its health care approach from a traditional medical model to patient-centered care (PCC).23 In this priority area, a strategic objective is for the VHA to partner with each veteran to create a personalized, proactive strategy to optimize health and well-being and when needed provide state-of-the-art disease management. Patient-centered care is designed to address veterans’ specific needs in spiritual, environmental, physical, mental, and social domains and empower veterans to become active participants in their care. Patient-centered care differs from the traditional medical model in that patients are active participants in their treatment, partnering and collaborating with their providers on care that is quality-of-life centered instead of disease centered.23 This model is based on both respect for patients as unique individuals and on the obligation to care for them on their own terms, focused on their self-identified goals and aspirations.24
At VANTHCS, the Homeless Mobile Medical/Mental Veteran (HMMM-V) pilot program was designed to deliver effective health care services to a homeless subpopulation of veterans who historically have been the most difficult to serve—those living in unsheltered environments, such as under bridges and in encampments. The purpose of the HMMM-V program was to contact and serve veterans not currently being reached by the VA system of care, using a PCC model.
This pilot program was initially funded in January 2013 by a 2-year grant from the Office of Patient Centered Care and Cultural Transformation to apply the PCC approach to engage veteran participation. For this project, the VA Personal Health Inventory tool—originally designed for use with the general veteran population—was adapted for use with the homeless veteran population. The grant funding period covered the design, development, and implementation of the HMMM-V program; thereafter, VANTHCS provided resources through its Comprehensive Homeless Center Programs to assure its sustainability and continued use of the clinical assessment tool created for this project.
This article describes the development and implementation of this novel program with sufficient detail to inform the development of similar programs in other sites. Descriptions of the program and staffing, creation of community partnerships, and modification of an assessment instrument are provided. It also illustrates the original implementation period of the HMMM-V program through presentation of self-reported data on the first homeless veterans it served.
Equipment and Staffing
A custom 28-foot mobile outreach vehicle was assembled according to specifications identified by the HMMM-V team as necessary to conduct the program’s interventions. The van became fully operational on April 8, 2015, after it underwent all the required reviews and inspections (eg, safety, infection control, etc) and was accredited in 2015 by the Commission on Accreditation of Rehabilitation Facilities.
The HMMM-V van has a driver compartment that is separate from its services rooms, which include a patient registration area, a fully equipped examination room, a laboratory area, and a bathroom. The vehicle is equipped with a wheelchair lift and an awning to shade outdoor areas where tables and chairs are set up for patient/staff waiting and rest areas. The vehicle is stocked with essential equipment and supplies needed to conduct work in off-street locations, vacant lots, under bridges, fields, unpaved paths, etc. It also is equipped with telemedicine capabilities to provide clinical supervision and access to attending physicians and specialists at VANTHCS. Personnel carry cell phones and laptop computers with secure Internet connections using a commercially available mobile wireless Wi-Fi hotspot to facilitate documentation of medical records and communication from the field.
This reliable type of equipment is routine for use in VA field operations; the only hurdle using these technologies for the program was acquiring funding and purchasing the equipment. The vehicle is further equipped with a refrigerator solely for secure storage of pharmaceutical supplies, a second refrigerator for specimens, and wall-mounted blood pressure and otoscope/ophthalmoscope units. The vehicle is supplied with thermometers, scales, phlebotomy supplies, and first-aid kits and is stocked with vaccines and medications, including antibiotic, hypertensive, diabetic, allergy, and over-the-counter pain medications. A more comprehensive list of supplies for the vehicle is available from the authors on request.
Medication provisions supplied to the HMMM-V mobile clinic conform to the Texas State Board of Pharmacy compliance regulations. Because the vehicle is designated as federal property and has U.S. government license plates, it is considered an extension of VANTHCS Pharmacy Service and falls under its pharmacy license. A medication formulary was created with input from HMMM-V prescribers and Dallas VAMC Pharmacy Service pharmacists. To safeguard the integrity of these pharmaceutical agents, the HMMM-V physician assistant picks up the medications before field deployment and returns the unused medications to the Dallas VAMC at the end of the day. The medications are transported in locked containers and placed either in a locked medication refrigerator or cabinet on the mobile unit.
For medication prescriptions that need laboratory testing before prescribing them, HMMM-V prescribers can check the VA electronic medical record from the field to determine whether these tests have been completed recently. If not, then HMMM-V team has an agreement with Dallas VA Pathology and Laboratory Medicine Service for testing samples obtained in the field.
The program was designed for staffing of the vehicle by 2 professional teams, each includes medical (physician’s assistant or registered nurse), mental health (psychiatrist, residents), and social work providers (licensed social workers, clinical social workers); trainees of these disciplines; a peer support specialist; and an administrative clerk. The staffing varies daily, depending on available personnel. When personnel deploy to the field, they go in pairs or groups to address potential safety issues. Cell phones are available to summon police or ambulance services in an emergency. Systematic safety training was conducted with all field personnel before their first deployment to guard against vulnerability to danger in these settings.
Once in the field, personnel engage unsheltered homeless individuals to assess eligibility for VA services. Veterans found ineligible are assisted with application for military discharge upgrade, service-connected compensation, or appeal for health care coverage. Veterans eligible for VA care receive physical examinations, vital and glucose checks, influenza and pneumonia vaccinations, first-aid skin and wound care, medication management with limited medications provided at point of care, blood and urine testing, peer support services, suicide assessments, clinical mental health evaluations, and social work services through the HMMM-V program.
Social work assistance provided includes psychosocial assessment and care coordination for psychosocial needs such as mental health, substance abuse, vision, dental, housing, employment, legal aid, transportation, food, income, hygiene, and weather-appropriate provision needs.
Community Partnerships
The HMMM-V program benefitted from a number of partnerships with community agencies. During development of the program, HMMM-V personnel accompanied the Dallas Police Department’s Crisis Intervention Unit on typical homeless crisis services deployments into the field to learn about the locations and nature of encampments and homeless peregrination patterns in the Dallas area.
To aid in the design and selection of features for the mobile outreach vehicle, team members toured Homeless Outreach Medical Service mobile clinics from 2 local county hospitals, Parkland Hospital and John Peter Smith Hospital. The staff for these mobile clinics were interviewed about their experience with various components of their programs and their recommendations for optimal design of the mobile medical clinic for service delivery.
Numerous agencies in the Dallas area that serve the homeless population assisted with locating and connecting homeless veterans to HMMM-V programs. These partnering agencies also serve homeless individuals who do not qualify for the HMMM-V program, such as veterans with other-than-honorable military discharges.
The HMMM-V mobile outreach vehicle travels to partnering agencies and provides services on a recurring basis. These agencies are the Dallas International Street Church, a church and faith-based agency aiding the recovery of people with “broken lives”; Cornerstone Ministries, a church-based ministry serving people with adverse circumstances; and City Square’s Opportunity Center, human services and community development programs for low-income city residents. The mobile clinic also travels regularly to other areas to serve homeless veterans residing in unsheltered locations, such as homeless encampments and under bridges.
Clinical Assessment
The project used a modification of the VA Personalized Health Inventory (PHI) for general veteran populations, which assesses 8 areas of self-identified needs to address the specific concerns of homeless veterans served by a mobile clinic.25 Version 19 of the PHI (revised September 18, 2012), the version of the instrument available to the team at the inception of the project, was deployed with the HMMM-V personnel into the field. It imposed a heavy interview time burden (several hours), and its content areas did not seem appropriate to address the immediate concerns of homeless populations (eg, sections pertaining to personal development through hobbies, recreation, or volunteering; healthy living spaces with plenty of lighting and color; “eating healthy, balanced meals with plenty of fruits and vegetables each day”).25
Based on HMMM-V personnel feedback, the team modified this tool and developed a patient-centered health inventory (P-CHI) for homeless veterans that was acceptable in length and applicable to the situational characteristics of homeless existence. The tool’s 10 “current and desired states” were revised to remove domains of exercise and flexibility, sleep and relaxation, and mind-body techniques. The intervention and prevention domains were combined. A material needs (clothing, furniture, transportation, financial benefits) domain was added, and a new domain on reducing alcohol/drug use was created by moving this material from the food and drink domain.
The remaining domains were modified to fit the homeless living situation (Food and Drink = Nutrition; Personal Development = Employment/Vocation; Family, Friends, and Co-Workers = Family/Social/Legal Support; Spirit and Soul = Personal/Spiritual Fulfillment; Surroundings = Housing). Current state ratings were revised to reflect level of satisfaction, and ratings of Desired State were replaced with level of importance.
The modifications resulted in 9 domains, which were assembled into a grid for efficient rating of both satisfaction and importance for each domain (rated 1 to 10, lowest to highest, respectively), followed by an instruction to mark an X in a designated space in all the domains with which the individual would like help (Table). The intent was to reduce the burden of the instrument by having the participant complete sections providing detailed information about only the domains selected by the participant.
The details of each domain in the original VA PHI tool were captured through open-ended questions in text responses provided by the veteran. Because open-ended text responses are not conducive for summarizing characteristics of the population served or for evaluating program activities, the detailed sections covering the domains were revised completely to capture data within categoric and numeric variables. Items from the validated Homeless Supplement Interview were added to collect information not provided in the Homeless Operations Management and Evaluation System interview that is routinely administered to all veterans accessing homeless VA services.26-28
The information collected in these domains cover duration of current homeless episode, lifetime number of homeless episodes, current living arrangements and dissatisfactions with these arrangements, frequency and source of meals, employment history and current work status, sources of income, special material needs, medical and dental problems and sources of care, current medications, mental health problems and sources of care, urgent mental health concerns, current amount and frequency of alcohol and drug use, substance abuse treatment history, relationships with family and intimate partners, legal assistance needs, and self-identified needs for spiritual and personal fulfillment. This instrument is available on request to the authors.
Veterans Served
The project began with 1 team of professionals deploying with the HMMM-V vehicle while a second team was being assembled. Currently, the 2 HMMM-V teams deploy the mobile clinic 4 days per week. The mobile clinic visits agencies that serve the homeless, including emergency shelters and food ministries, as well as homeless encampments. To date, 195 homeless veterans have been served by the mobile clinic, 111 were currently enrolled with the VA, 8 were not enrolled but eligible for services, and 77 were not eligible for VA services. Of the unenrolled veterans, those eligible for services were offered VA enrollment assistance; those ineligible for VA services were offered a community referral.
For the veterans encountered in the field, the following interventions were provided: 49 housing placement referrals, 4 rental assistance referrals, 4 legal referrals, 27 medical care interventions, 13 dental referrals, 11 vision/hearing referrals, 12 mental health interventions, 9 substance abuse treatment referrals, 14 employment assistance referrals, 13 disability benefit applications, 18 transportation assists, 23 goods delivered, and 159 information assists. The HMMM-V mobile clinic also is deployed to participate in various educational and outreach events. At the time this article was written, the mobile clinic has reached nearly 2,000 veterans and community partners in at least 25 such events.
Of the veterans served to date, 73 completed the P-CHI. These veterans were predominantly male (77%), and the majority (60%) were black. The median age of the sample was 58 years, and typically they had a high school level of education (12.7; SD, 2.1 mean years of education). About half (49%) the sample were separated or divorced, and only a minority were currently married (8%). Half (50%) the sample served in the U.S. Army, with the post-Vietnam era being the era of service most represented (19%). Few (21%) veterans reported exposure to hostile or friendly fire during their service. More than three-fourths (80%) of the sample had experienced a homeless episode prior to their current one. On average, members of the sample had experienced a median of 3 lifetime homeless episodes. They had a mean 4.1 (SD, 5.8) lifetime number of years of homelessness, and 3.0 (SD, 5.2) years in their current homeless episode. Nearly one-third (31%) reported that they were currently staying in a homeless shelter, and nearly one-sixth (16%) were currently unsheltered in street settings, such as under bridges or in outdoor encampments at the time of the initial visit.
The mean number of minutes spent completing the P-CHI was 18.5 (SD, 9.4). The veterans indicated that they would like assistance with a mean 3.2 (SD, 2.2) number of domains. The domains with the highest average importance ratings were housing (mean, 9.4; SD, 1.7) and medical/dental care (mean, 8.9; SD, 2.2); the domains with the lowest average importance rating were reducing alcohol/drug use (mean, 6.4; SD, 4.1) and employment/vocation (mean, 6.3; SD, 4.2). The domains with the highest average satisfaction ratings were personal/spiritual fulfillment (mean, 7.3; SD, 2.9) and reducing substance use (mean, 5.9; SD, 4.0), and the domains with the lowest average satisfaction ratings were housing (mean, 2.9; SD, 2.9), material needs (mean, 4.2; SD, 3.3), and employment/vocation (mean, 4.2; SD, 3.2). The domain with the greatest indication of desire for help was housing, endorsed by more than four-fifths (84%) of the sample. This highly endorsed housing domain also was one of the lowest in satisfaction. The domains with the least expressed interest in obtaining help were reducing substance use (18%) and personal/spiritual fulfillment (15%).Reducing substance abuse also was one of the lowest domains of importance and the least for dissatisfaction.
Challenges and Barriers
As anticipated from its inception, this project encountered many challenges and barriers. The first was with the design, construction, and delivery of the mobile clinic unit. The vehicle took more than 2 years to be delivered. There were delays in progress necessitated by required selection of an approved vendor to build the vehicle, extensive specification of details and features, and stocking it with equipment and supplies. The weight of the unit had to be < 26,000 pounds to avoid the requirement of a commercial driver’s license, which limited the size of the vehicle to 28 feet. Stocking the unit with equipment and supplies required attention to a myriad of specifications and decisions. For example, separate refrigerators were needed for specimens, medications, and food; pharmaceutical regulations governing medications in mobile clinics required strict adherence; and difficulties were encountered in attempting to establish adequate and secure connectivity for communications devices in the field.
Once the mobile unit was delivered and prepared for deployment, the next set of challenges pertained to learning all of the instructions required to operate and drive the vehicle and learning how to maneuver the vehicle in the field. Specific challenges for driving the vehicle encountered included unexpectedly low overpasses that prohibited passage, narrow spaces for passage, rough and uneven terrain in off-road settings, and lateral and vertical tilt of roads creating potential for sideswipes and undercarriage scrapes. Maintenance schedules needed to be developed and implemented for cleaning the unit, inspection compliance, repairs, refueling, and emptying waste materials.
Staffing the vehicle required the development of unique job specifications addressing special expertise in accessing VA databases for veteran verification and registration and for driving the mobile clinic vehicle. Schedules and deployment plans for 2 teams that shared the same vehicle had to be established and followed. Locating veterans in unsheltered settings, such as under bridges and in encampments, required community intelligence facilitated through partnerships with knowledgeable members of the Dallas police crisis unit and by gaining field experience to locate where the usual homeless gathering places are, especially those inhabited by veterans. Safety of team members and equipment/supplies in the field was paramount from the start, and additional steps beyond safety training required extra measures, such as special care in navigating known dangerous areas. Provision of services necessitated completion of everything needed in a single visit due to the likelihood of loss to follow-up and acceptance of the limited types of service that could be provided in a mobile clinic. Special procedures were needed to provide referrals to sources of available care for non-VA-qualifying veterans.
Discussion
The HMMM-V program for delivery of PCC to homeless veterans is an innovative pilot program designed to connect with difficult-to-reach homeless veterans and engage them in care. The deliverables provided by this project are (1) A mobile outreach vehicle to deliver care to homeless veterans and outreach to other veterans and community agencies in North Texas; (2) The P-CHI assessment tool for homeless veterans modified and adapted for use with this special population; and (3) pilot data on its first cohort of homeless veterans served, describing their baseline characteristics and their stated satisfaction and preferences about their goals and aspirations for their physical, emotional, and mental health and well-being.
The HMMM-V program successfully identified homeless veterans in need of services, and more than one-third of these veterans were not previously engaged in VA services. Compared with the “typical” veterans served at VANTHCS homeless programs, veterans served by the HMMM-V comprised a greater proportion of minorities and a higher proportion who had been exposed to combat.29 Age and gender characteristics were similar.29 When compared with veterans who access care at VANTHCS and have not experienced homelessness, those served by the HMMM-V were younger and more likely to belong to a minority group; however, they were similar in combat exposure and gender.1 The veterans served by the HMMM-V program also were considerably older and had more homeless chronicity than did nonveteran homeless populations, consistent with other research.4,29,30
The veterans served by the HMMM-V program not surprisingly made housing their top priority in need of help, consistent with the Housing First model.22,31 They also indicated that employment/vocation and reducing substance use were of lower importance. Need for assistance with reducing substance use and social support were the domains least often identified as areas where help was needed, which seems inconsistent with the higher established rates of substance abuse problems among homeless veterans.1
With additional fieldwork, the HMMM-V program is expected to allow refinement of procedures for identifying and serving veterans from a patient-centered care perspective. The P-CHI will be further tested and developed, and the next step will be to create and pilot intervention templates for a Patient-Centered Health Improvement Plan, based on the P-CHI results. This process parallels the original development treatment plans for the VA’s Personalized Health Plan based on the PHI.25 Once the HMMM-V program is fully established in Dallas, the plans are for an expansion that will cover a broader geographic area in North Texas that includes rural areas.
The HMMM-V program was designed to address the barriers to health care that are encountered by homeless veterans. It is unique in homeless veteran care due to its patient-centered approach that partners with homeless veterans to prioritize their needs as determined by them rather than based solely on policies or provider conceptualizations of their needs. Access to services, engagement in care, and successful utilization of needed services may lead to measurable improvements in health care outcomes among homeless populations of veterans. Desired goals include remission of illness through appropriate medical intervention, preventing morbidity, achieving healthy lifestyles, recovery from addiction, stabilization of psychiatric illness, and attainment of stable housing.
The first hurdle for implementing this type of program in other settings is the identification of resources needed for these efforts. Need of additional staffing resources, however, may be circumvented by allowing employees working in other areas to rotate in community outreach shifts in the mobile unit. Another hurdle encountered in implementation of the HMMM-V initiative was the initial difficulty finding homeless veterans in community settings, especially those in unsheltered locations. The HMMM-V program addressed this issue by partnering with other agencies serving the homeless in the community. Therefore, a general recommendation for other entities seeking to implement this type of program is to reach out to these community partners from the outset.
Conclusion
The HMMM-V has the potential to engage the most difficult-to-reach homeless veterans in need of health services by delivering care and providing resources in challenging environments. Further work is needed to validate the P-CHI for use with this program and to conduct well-designed and implemented research to demonstrate effectiveness of this intervention on veteran outcomes, especially quality of life. Once this additional work is accomplished, this innovative program can potentially be implemented by VAMCs across the nation, and potentially in more general community care settings, to more effectively reach out and deliver services to homeless members of the community.
Acknowledgments
Grant support was received from the Department of Veterans Affairs, Office of Patient Centered Care. The authors would like to acknowledge all the clinicians, trainees, and support staff who have contributed to the success of the HMMM-V program: Tara Ayala, Jose Cabrera, Tony Castillo, Rachael Lynn David, Teresa DeShazo, Sylvia Figueroa, Steven Fisher, Eric Gary, Evelyn Gibbs, Kevin Hosey, JoAnn Joseph, Taly Drimer Kagan, Miranda Kelly, Michelle King-Thompson, Sharon Marcus, Shiji Mathew, Moneeza Matin, John Moreno, Joseph Neifert, Joel Price, Tiffany Price, Natalie Qualls, Reginald Robertson, Kristine Rodrigues, Jon Saffelder, Jill Stokes, Scott Stone, and John Smith.
1. LePage JP, Bradshaw LD, Cipher DJ, Crawford AM, Hooshyar D. The effects of homelessness on veterans’ health care service use: an evaluation of independence from comorbidities. Public Health. 2014;128(11):985-992.
2. Fischer PJ, Breakey WR. The epidemiology of alcohol, drug, and mental disorders among homeless persons. Am Psychol. 1991;46(11):1115-1128.
3. Robertson MJ, Zlotnick C, Westerfelt A. Drug use disorders and treatment contact among homeless adults in Alameda County, California. Am J Public Health. 1997;87(2):221-228.
4. North CS, Eyrich KM, Pollio DE, Spitznagel EL. Are rates of psychiatric disorders in the homeless population changing? Am J Public Health. 2004;94(1):103-108.
5. Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS Med. 2008;5(12):e225.
6. Harpaz-Rotem I, Rosenheck RA, Desai R. The mental health of children exposed to maternal mental illness and homelessness. Community Ment Health J. 2006;42(5):437-448.
7. Pollio DE, Eyrich-Garg KM, North CS. The homeless. In: Johnson BA, ed. Addiction Medicine: Science and Practice. New York, NY: Springer; 2011:1487-1504.
8. Padgett D, Struening EL, Andrews H. Factors affecting the use of medical, mental health, alcohol, and drug treatment services by homeless adults. Med Care. 1990;28(9):805-821.
9. Baggett TP, Singer DE, Rao SR, O’Connell JJ, Bharel M, Rigotti NA. Food insufficiency and health services utilization in a national sample of homeless adults. J Gen Intern Med. 2011;26(6):627-634.
10. Folsom DP, Hawthorne W, Lindamer L, et al. Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. Am J Psychiatry. 2005;162(2):370-376.
11. Fuehrlein BS, Cowell AJ, Pollio D, Cupps L, Balfour ME, North CS. A prospective study of the associations among housing status and costs of services in a homeless population. Psychiatr Serv. 2015;66(1):27-32.
12. Pollio DE, North CS, Eyrich KM, Foster DA, Spitznagel E. Modeling service access in a homeless population. J Psychoactive Drugs. 2003;35(4):487-495.
13. U.S. Department of Housing and Urban Development Office of Community Planning and Development. The 2016 Annual Homeless Assessment Report (AHAR) to Congress. Part 1: point-in-time estimates of homelessness. https://www.hudexchange.info/resources/documents/2016-AHAR-Part-1.pdf. Published 2016. Accessed August 7, 2017.
14. Tsai J, Rosenheck RA. Risk factors for homelessness among U.S. veterans. Epidemiol Rev. 2015;37:177-195.
15. Williamson V, Mulhall E. Coming home: the housing crisis and homelessness threaten new veterans. Iraq and Afghanistan Veterans of America, January, 2009. http://media.iava.org/IAVA_coming_home_2009%20The%20Housing%20Crisis%20and%20Homelessness%20Threaten%20New%20Veterans.pdf. Accessed August 10, 2017
16. Shinseki EK. Remarks by Secretary Eric K. Shinseki. National Summit on Homeless Veterans; November 3, 2009; Washington, DC. https://www.va.gov/opa/speeches/2009/09_1103.asp. Updated August 8, 2016. Accessed August 7, 2017.
17. Shinseki EK. Remarks by Secretary Eric K. Shinseki. 2014 National Coalition for Homeless Veterans Annual Meeting; May 30, 2014; Arlington, VA. https://www.va.gov/opa/speeches/2014/05_30_2014.asp. Updated April 21, 2015. Accessed August 7, 2017.
18. Pollio DE, Spitznagel EL, North CS, Thompson S, Foster DA. Service use over time and achievement of stable housing in a mentally ill homeless population. Psychiatr Serv. 2000;51(12):1536-1543.
19. Page J. Barriers to transferring care of homeless people with serious mental illnesses to community mental health organizations: perspectives of street-based programs. Best Practices in Mental Health: An International Journal. 2007;3(1):26.
20. Young AS, Chinman MJ, Cradock-O’Leary JA, et al. Characteristics of individuals with severe mental illness who use emergency services. Community Ment Health J. 2005;41(2):159-168.
21. Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and low-income veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461.
22. Tsemberis S, Gulcur L, Nakae M. Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health. 2004;94(4):651-656.
23. U.S. Department of Veterans Affairs, Veterans Health Administration. VA Patient Centered Care. http://www.va.gov/patientcenteredcare. Updated July 24,2017. Accessed August 7, 2017.
24. Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100-103.
25. U.S. Department of Veterans Affairs, Office of Patient Centered Care and Cultural Transformation. My story: personal health inventory. https://www.va.gov/PATIENTCENTEREDCARE/docs/VA-OPCC-Personal-Health-Inventory-final-508.pdf. Published October 7, 2013. Accessed August 7, 2017
26. North CS, Smith EM, Pollio DE. The Homeless Supplement to the Diagnostic Interview Schedule (DIS/HS). St. Louis: Washington University, 2004.
27. North CS, Eyrich KM, Pollio DE, Foster DA, Cottler LB, Spitznagel EL. The homeless supplement to the diagnostic interview schedule: test-retest analyses. Int J Methods Psychiatr Res. 2004;13(3):184-191.
28. LaSalle JL. Homeless Operations Management and Evaluation System (HOMES) user manual-phase 1. http://www.vfwsc.org/homes.pdf. Published April 19, 2011. Accessed August 7, 2017.
29. Petrovich JC, Pollio DE, North CS. Characteristics and service use of homeless veterans and nonveterans residing in a low-demand emergency shelter. Psychiatr Serv. 2014;65(6):751-757.
30. North CS, Smith EM. A comparison of homeless men and women: different populations, different needs. Community Ment Health J. 1993;29(5):423-431.
31. Kertesz SG, Austin EL, Holmes SK, et al. Making housing first happen: organizational leadership in VA’s expansion of permanent supportive housing. J Gen Intern Med. 2014;29(suppl 4):835-844.
1. LePage JP, Bradshaw LD, Cipher DJ, Crawford AM, Hooshyar D. The effects of homelessness on veterans’ health care service use: an evaluation of independence from comorbidities. Public Health. 2014;128(11):985-992.
2. Fischer PJ, Breakey WR. The epidemiology of alcohol, drug, and mental disorders among homeless persons. Am Psychol. 1991;46(11):1115-1128.
3. Robertson MJ, Zlotnick C, Westerfelt A. Drug use disorders and treatment contact among homeless adults in Alameda County, California. Am J Public Health. 1997;87(2):221-228.
4. North CS, Eyrich KM, Pollio DE, Spitznagel EL. Are rates of psychiatric disorders in the homeless population changing? Am J Public Health. 2004;94(1):103-108.
5. Fazel S, Khosla V, Doll H, Geddes J. The prevalence of mental disorders among the homeless in western countries: systematic review and meta-regression analysis. PLoS Med. 2008;5(12):e225.
6. Harpaz-Rotem I, Rosenheck RA, Desai R. The mental health of children exposed to maternal mental illness and homelessness. Community Ment Health J. 2006;42(5):437-448.
7. Pollio DE, Eyrich-Garg KM, North CS. The homeless. In: Johnson BA, ed. Addiction Medicine: Science and Practice. New York, NY: Springer; 2011:1487-1504.
8. Padgett D, Struening EL, Andrews H. Factors affecting the use of medical, mental health, alcohol, and drug treatment services by homeless adults. Med Care. 1990;28(9):805-821.
9. Baggett TP, Singer DE, Rao SR, O’Connell JJ, Bharel M, Rigotti NA. Food insufficiency and health services utilization in a national sample of homeless adults. J Gen Intern Med. 2011;26(6):627-634.
10. Folsom DP, Hawthorne W, Lindamer L, et al. Prevalence and risk factors for homelessness and utilization of mental health services among 10,340 patients with serious mental illness in a large public mental health system. Am J Psychiatry. 2005;162(2):370-376.
11. Fuehrlein BS, Cowell AJ, Pollio D, Cupps L, Balfour ME, North CS. A prospective study of the associations among housing status and costs of services in a homeless population. Psychiatr Serv. 2015;66(1):27-32.
12. Pollio DE, North CS, Eyrich KM, Foster DA, Spitznagel E. Modeling service access in a homeless population. J Psychoactive Drugs. 2003;35(4):487-495.
13. U.S. Department of Housing and Urban Development Office of Community Planning and Development. The 2016 Annual Homeless Assessment Report (AHAR) to Congress. Part 1: point-in-time estimates of homelessness. https://www.hudexchange.info/resources/documents/2016-AHAR-Part-1.pdf. Published 2016. Accessed August 7, 2017.
14. Tsai J, Rosenheck RA. Risk factors for homelessness among U.S. veterans. Epidemiol Rev. 2015;37:177-195.
15. Williamson V, Mulhall E. Coming home: the housing crisis and homelessness threaten new veterans. Iraq and Afghanistan Veterans of America, January, 2009. http://media.iava.org/IAVA_coming_home_2009%20The%20Housing%20Crisis%20and%20Homelessness%20Threaten%20New%20Veterans.pdf. Accessed August 10, 2017
16. Shinseki EK. Remarks by Secretary Eric K. Shinseki. National Summit on Homeless Veterans; November 3, 2009; Washington, DC. https://www.va.gov/opa/speeches/2009/09_1103.asp. Updated August 8, 2016. Accessed August 7, 2017.
17. Shinseki EK. Remarks by Secretary Eric K. Shinseki. 2014 National Coalition for Homeless Veterans Annual Meeting; May 30, 2014; Arlington, VA. https://www.va.gov/opa/speeches/2014/05_30_2014.asp. Updated April 21, 2015. Accessed August 7, 2017.
18. Pollio DE, Spitznagel EL, North CS, Thompson S, Foster DA. Service use over time and achievement of stable housing in a mentally ill homeless population. Psychiatr Serv. 2000;51(12):1536-1543.
19. Page J. Barriers to transferring care of homeless people with serious mental illnesses to community mental health organizations: perspectives of street-based programs. Best Practices in Mental Health: An International Journal. 2007;3(1):26.
20. Young AS, Chinman MJ, Cradock-O’Leary JA, et al. Characteristics of individuals with severe mental illness who use emergency services. Community Ment Health J. 2005;41(2):159-168.
21. Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and low-income veterans: a spotlight on the VA Supportive Housing (VASH) program in greater Los Angeles. Med Care. 2014;52(5):454-461.
22. Tsemberis S, Gulcur L, Nakae M. Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. Am J Public Health. 2004;94(4):651-656.
23. U.S. Department of Veterans Affairs, Veterans Health Administration. VA Patient Centered Care. http://www.va.gov/patientcenteredcare. Updated July 24,2017. Accessed August 7, 2017.
24. Epstein RM, Street RL Jr. The values and value of patient-centered care. Ann Fam Med. 2011;9(2):100-103.
25. U.S. Department of Veterans Affairs, Office of Patient Centered Care and Cultural Transformation. My story: personal health inventory. https://www.va.gov/PATIENTCENTEREDCARE/docs/VA-OPCC-Personal-Health-Inventory-final-508.pdf. Published October 7, 2013. Accessed August 7, 2017
26. North CS, Smith EM, Pollio DE. The Homeless Supplement to the Diagnostic Interview Schedule (DIS/HS). St. Louis: Washington University, 2004.
27. North CS, Eyrich KM, Pollio DE, Foster DA, Cottler LB, Spitznagel EL. The homeless supplement to the diagnostic interview schedule: test-retest analyses. Int J Methods Psychiatr Res. 2004;13(3):184-191.
28. LaSalle JL. Homeless Operations Management and Evaluation System (HOMES) user manual-phase 1. http://www.vfwsc.org/homes.pdf. Published April 19, 2011. Accessed August 7, 2017.
29. Petrovich JC, Pollio DE, North CS. Characteristics and service use of homeless veterans and nonveterans residing in a low-demand emergency shelter. Psychiatr Serv. 2014;65(6):751-757.
30. North CS, Smith EM. A comparison of homeless men and women: different populations, different needs. Community Ment Health J. 1993;29(5):423-431.
31. Kertesz SG, Austin EL, Holmes SK, et al. Making housing first happen: organizational leadership in VA’s expansion of permanent supportive housing. J Gen Intern Med. 2014;29(suppl 4):835-844.
Military Sexual Trauma and Sexual Health: Practice and Future Research for Mental Health Professionals
About 24% of women and 1% of men will experience military sexual trauma (MST) during their service.1 Despite the higher percentage of women reporting MST, the estimated number of men (55,491) and women (72,497) who endorse MST is relatively similar. Military sexual trauma is associated with negative psychosocial (eg, decreased quality of life) and psychiatric (eg, posttraumatic stress disorder [PTSD], depression) sequelae. Surís and colleagues provided a full review of sequelae, with PTSD being the most discussed consequence of MST.2 However, sexually transmitted infections (STIs) during or after MST are a consequence of growing concern.
Sexually Transmitted Infections
The link between sexual trauma and increased incidence of STIs is well established. Survivors of rape are at a higher risk of exposure to STIs due to unprotected sexual contact that may occur during the assault(s).3 Numerous studies have demonstrated that sexual trauma is directly related to greater engagement in risky sexual behaviors (eg, more sexual partners, unprotected sex, and “sex trading”).2,4
This relationship is particularly concerning given that individuals in the military tend to report sexual trauma with greater propensity than that reported in civilian populations.4 Additionally, military personnel and veteran populations tend to engage in high-risk behaviors (eg, alcohol and drug use) more often than their civilian counterparts, increasing their potential susceptibility to predatory sexual trauma(s) and victimization.2,5 Taken in aggregate, military personnel and veterans may be at increased risk for STIs compared with the civilian population due to the increased incidence of risky sexual behavior and sexual traumatization during military service.
Sexually transmitted infections potentially lead to immediate-term (eg, physical discomfort, sexual dysfunction) and long-term (eg, cancer, infertility) adverse health consequences.6 Early detection is crucial in the treatment of STIs because it can aid in preventing STI transmission and allow for early intervention. See Table for a list of common STIs and their prevalence, testing method, method of sexual transmission, and treatment. Early detection is also important because many STIs may be asymptomatic (eg, HIV, human papillomavirus [HPV]), which decreases the likelihood of seeking testing or treatment as well as increases the likelihood of transmission.7
Current Research
To date, only 1 study has explicitly examined the relationship between MST and STIs. In 2011, researchers analyzed a large national database of 420,725 male and female Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans.6 In the study, both male and female OEF/OIF veterans who endorsed MST were significantly more likely than those who did not endorse MST to have a STI diagnosis. The researchers noted that this finding underscored the necessity for sexual health assessment in survivors of MST, to facilitate early detection and treatment.
STI Risk Assessment
Because military personnel and veterans often initially disclose their MST to a mental health provider (MHP), these providers operate in a unique circumstance where they may be the individual’s first point of contact for determining STI risk. In these circumstances, the MHP should consider the utility of briefly assessing the patient’s sexual health and making subsequent medical referrals as necessary.
To accurately assess a patient’s STI risk, the MHP should gather information regarding both current/acute risk (eg, “Have you had unprotected sexual contact, for instance, genital contact without a condom or oral sex without a dental dam, in the past month?”) as well as longer standing (eg, “Have you had unprotected sexual contact... in the past year?”) STI risk. Providers also should consider oral, anal, and genital modes of sexual contact as well as common STI symptoms (eg, warts, sores, genital discharge, and/or pain or burning sensation when peeing or during sex). Additionally, psychoeducation should be provided, especially information regarding the asymptomatic nature of certain STIs, such as HIV and HPV, and the risk of transmission in all forms of sexual contact, including nongenital anal contact. Appropriate referrals to sexual health education, including safe sex practices, also should be considered in order to minimize risk of future STI transmission.
Mental health providers also should determine the date of patient’s most recent STI test. Not all STIs can be detected via a blood test or routine yearly Papanicolaou (Pap test) physicals. Additionally, MHPs should be aware that risky practices, including substance misuse, are more common in survivors of MST and that there is an association between substance misuse and STIs.2,6 If testing has not occurred recently, MHPs should strongly encourage the individual to access STI testing and provide resources as necessary, such as access to low-cost STI testing. Further, if the MHP has reason to suspect the presence of an STI after the brief assessment (eg, individual endorses unprotected sexual contact or risky behaviors, including substance misuse, sex trading, and STI symptomatology; a positive STI test but the patient has not accessed treatment), an appropriate sexual health referral should be made.
During the assessment and psychoeducation processes, terminology and language plays an integral role. If a MHP assumes an individual has sexual contact only with opposite sex partners (eg, asking a male “How many women have you had sexual contact with in the past 30 days?” vs “How many partners have you had sexual contact with in the past 30 days?”), the MHP will not accurately assess the individual’s level of current risk. Additionally, it is important to remember that sexual behavior does not always align with sexual identity: A man who identifies as heterosexual may still have sexual contact with men. Due to the sensitive nature of sexual health, MHPs should be careful to use nonjudgmental language, such as using the term sex work rather than the more pejorative term prostitution, to avoid offending patients and to increase their likelihood to disclose sexual health information.
Nonjudgmental language is especially relevant when working with gender-minority veterans (eg, transgender, gender nonconforming, gender transitioning), because this clinical population has a higher risk of victimization and lower rates of help-seeking health behavior.7 In particular, a sizable portion of individuals who identify as transgender do not seek services out of fear that they will be discriminated against, humiliated, or misunderstood.7 To assuage these concerns, MHPs should ensure they refer to the veteran with the veteran’s preferred pronouns. For example, a MHP could ask “I would like to be respectful, how would you like to be addressed?” or “What name and pronoun would you like me/us to use?” Providers also should consider nonbinary pronouns when appropriate (eg, singular: ze/hir/hirs; plural: they/them/theirs). Providers also should recognize that making a mistake is not uncommon, and they should apologize to maintain rapport and maximize the patient’s comfort during this distressing process. Further, MHPs should consider additional training, education, and/or consultation if they feel uncomfortable or ill prepared when working with gender-minority veterans.
Future Research
Research has attempted to understand the consequences of MST on sexual health; however, despite these efforts, more research is necessary. The majority of published studies have focused on females even though a similar number of males have reported MST.2 This dearth of published studies likely is due to hesitation by male active-duty personnel and veterans to disclose or seek treatment for MST and because the percentage of females reporting MST is much higher. Males are less likely to report or seek treatment for MST because of stigma-based concerns (eg, shame, self-blame, privacy concerns).8,9 Therefore, it is difficult to acquire a sizable research sample to study. As previously noted, a single study has specifically examined MST and STI risk. Although this study included a sizable population of male OEF/OIF veterans, results have yet to be replicated in other clinical populations of interest, such as male military personnel and male veterans of other service eras.
Research is even more limited regarding lesbian, gay, bisexual, transgender, and other gender-minority military personnel and veterans. Although researchers propose that these populations may experience a similar, or even heightened, likelihood of MST during their service, no empirical research yet exists to fully examine this hypothesis.10,11 It is important to note that the paucity of research attention may be related to the Don’t Ask, Don’t Tell (DADT) policy, which obstructed the open discussion and empirical examination of sexual and gender minorities within military populations.11 The DADT policy led to limited awareness and greater stigmatization among sexual- and gender-minority personnel, resulting in poorer sexual health outcomes in these populations.10,11 With the end of DADT in 2011, it is now imperative for future research to examine the prevalence and associated consequences of MST in sexual- and gender-minority military personnel and veterans.
Conclusion
The DoD and VA should be commended for their continued focus on understanding the health consequences of MST. These efforts have yielded substantial information regarding the negative effects of MST on sexual health; in particular, increased risk for STIs. These findings suggest that MHPs may, at times, be the first point of contact for MST-related sexual health concerns. These providers should be aware of their ability to assess for STI risk and make appropriate referrals to facilitate early detection and access to treatment. Despite the presence of MST-related sexual health research, continued research remains necessary. In particular, a broader focus that includes other genders (eg, male, transgender) and sexual minorities would further inform research and clinical practice.
1. Military Sexual Trauma Support Team. Military sexual trauma (MST) screening report fiscal year 2012. Washington DC: U.S. Department of Veterans Affairs, Office of Patient Care Services, Mental Health Services; 2013.
2. Surís A, Holliday R, Weitlauf JC, North CS; the Veteran Safety Initiative Writing Collaborative. Military sexual trauma in the context of veterans’ life experiences. Fed Pract. 2013;30(suppl 3):16S-20S.
3. Jenny C, Hooton TM, Bowers A, et al. Sexually transmitted diseases in victims of rape. N Eng J Med. 1990;322(11):713-716.
4. Senn TE, Carey MP, Vanable PA, Coury-Doniger P, Urban MA. Childhood sexual abuse and sexual risk behavior among men and women attending a sexually transmitted disease clinic. J Consult Clin Psychol. 2006;74(4):720-731.
5. Schultz JR, Bell KM, Naugle AE, Polusny MA. Child sexual abuse and adult sexual assault among military veteran and civilian women. Mil Med. 2006;171(8):723-728.
6. Turchik JA, Pavao J, Nazarian D, Iqbal S, McLean C, Kimerling R. Sexually transmitted infections and sexual dysfunctions among newly returned veterans with and without military sexual trauma. Int J Sex Health. 2012;24(1):45-59.
7. National LGBT Health Education Center. Affirmative care for transgender and gender non-conforming people: best practices for front-line health care staff. https://www.lgbthealth education.org/wp-content/uploads/2016/12/Affirmative-Care-for-Transgender -and-Gender-Non-conforming-People-Best-Practices -for-Frontline-Health-Care-Staff.pdf. Published 2016. Accessed February 16, 2017.
8. Morris EE, Smith JC, Farooqui SY, Surís AM. Unseen battles: the recognition, assessment, and treatment issues of men with military sexual trauma (MST). Trauma Violence Abuse. 2014;15(2):94-101.
9. Turchik JA, Edwards KM. Myths about male rape: a literature review. Psychol Men Masc. 2012;13(2):211-226.
10. Mattocks KM, Kauth MR, Sandfort T, Matza AR, Sullivan JC, Shipherd J. Understanding health-care needs of sexual and gender minority veterans: how targeted research and policy can improve health. LGBT Health. 2014;1(1):50-57.
11. Burks DJ. Lesbian, gay, and bisexual victimization in the military: an unintended consequence of “Don’t Ask, Don’t Tell”? Am Psychol. 2011;66(7):604-613.
About 24% of women and 1% of men will experience military sexual trauma (MST) during their service.1 Despite the higher percentage of women reporting MST, the estimated number of men (55,491) and women (72,497) who endorse MST is relatively similar. Military sexual trauma is associated with negative psychosocial (eg, decreased quality of life) and psychiatric (eg, posttraumatic stress disorder [PTSD], depression) sequelae. Surís and colleagues provided a full review of sequelae, with PTSD being the most discussed consequence of MST.2 However, sexually transmitted infections (STIs) during or after MST are a consequence of growing concern.
Sexually Transmitted Infections
The link between sexual trauma and increased incidence of STIs is well established. Survivors of rape are at a higher risk of exposure to STIs due to unprotected sexual contact that may occur during the assault(s).3 Numerous studies have demonstrated that sexual trauma is directly related to greater engagement in risky sexual behaviors (eg, more sexual partners, unprotected sex, and “sex trading”).2,4
This relationship is particularly concerning given that individuals in the military tend to report sexual trauma with greater propensity than that reported in civilian populations.4 Additionally, military personnel and veteran populations tend to engage in high-risk behaviors (eg, alcohol and drug use) more often than their civilian counterparts, increasing their potential susceptibility to predatory sexual trauma(s) and victimization.2,5 Taken in aggregate, military personnel and veterans may be at increased risk for STIs compared with the civilian population due to the increased incidence of risky sexual behavior and sexual traumatization during military service.
Sexually transmitted infections potentially lead to immediate-term (eg, physical discomfort, sexual dysfunction) and long-term (eg, cancer, infertility) adverse health consequences.6 Early detection is crucial in the treatment of STIs because it can aid in preventing STI transmission and allow for early intervention. See Table for a list of common STIs and their prevalence, testing method, method of sexual transmission, and treatment. Early detection is also important because many STIs may be asymptomatic (eg, HIV, human papillomavirus [HPV]), which decreases the likelihood of seeking testing or treatment as well as increases the likelihood of transmission.7
Current Research
To date, only 1 study has explicitly examined the relationship between MST and STIs. In 2011, researchers analyzed a large national database of 420,725 male and female Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans.6 In the study, both male and female OEF/OIF veterans who endorsed MST were significantly more likely than those who did not endorse MST to have a STI diagnosis. The researchers noted that this finding underscored the necessity for sexual health assessment in survivors of MST, to facilitate early detection and treatment.
STI Risk Assessment
Because military personnel and veterans often initially disclose their MST to a mental health provider (MHP), these providers operate in a unique circumstance where they may be the individual’s first point of contact for determining STI risk. In these circumstances, the MHP should consider the utility of briefly assessing the patient’s sexual health and making subsequent medical referrals as necessary.
To accurately assess a patient’s STI risk, the MHP should gather information regarding both current/acute risk (eg, “Have you had unprotected sexual contact, for instance, genital contact without a condom or oral sex without a dental dam, in the past month?”) as well as longer standing (eg, “Have you had unprotected sexual contact... in the past year?”) STI risk. Providers also should consider oral, anal, and genital modes of sexual contact as well as common STI symptoms (eg, warts, sores, genital discharge, and/or pain or burning sensation when peeing or during sex). Additionally, psychoeducation should be provided, especially information regarding the asymptomatic nature of certain STIs, such as HIV and HPV, and the risk of transmission in all forms of sexual contact, including nongenital anal contact. Appropriate referrals to sexual health education, including safe sex practices, also should be considered in order to minimize risk of future STI transmission.
Mental health providers also should determine the date of patient’s most recent STI test. Not all STIs can be detected via a blood test or routine yearly Papanicolaou (Pap test) physicals. Additionally, MHPs should be aware that risky practices, including substance misuse, are more common in survivors of MST and that there is an association between substance misuse and STIs.2,6 If testing has not occurred recently, MHPs should strongly encourage the individual to access STI testing and provide resources as necessary, such as access to low-cost STI testing. Further, if the MHP has reason to suspect the presence of an STI after the brief assessment (eg, individual endorses unprotected sexual contact or risky behaviors, including substance misuse, sex trading, and STI symptomatology; a positive STI test but the patient has not accessed treatment), an appropriate sexual health referral should be made.
During the assessment and psychoeducation processes, terminology and language plays an integral role. If a MHP assumes an individual has sexual contact only with opposite sex partners (eg, asking a male “How many women have you had sexual contact with in the past 30 days?” vs “How many partners have you had sexual contact with in the past 30 days?”), the MHP will not accurately assess the individual’s level of current risk. Additionally, it is important to remember that sexual behavior does not always align with sexual identity: A man who identifies as heterosexual may still have sexual contact with men. Due to the sensitive nature of sexual health, MHPs should be careful to use nonjudgmental language, such as using the term sex work rather than the more pejorative term prostitution, to avoid offending patients and to increase their likelihood to disclose sexual health information.
Nonjudgmental language is especially relevant when working with gender-minority veterans (eg, transgender, gender nonconforming, gender transitioning), because this clinical population has a higher risk of victimization and lower rates of help-seeking health behavior.7 In particular, a sizable portion of individuals who identify as transgender do not seek services out of fear that they will be discriminated against, humiliated, or misunderstood.7 To assuage these concerns, MHPs should ensure they refer to the veteran with the veteran’s preferred pronouns. For example, a MHP could ask “I would like to be respectful, how would you like to be addressed?” or “What name and pronoun would you like me/us to use?” Providers also should consider nonbinary pronouns when appropriate (eg, singular: ze/hir/hirs; plural: they/them/theirs). Providers also should recognize that making a mistake is not uncommon, and they should apologize to maintain rapport and maximize the patient’s comfort during this distressing process. Further, MHPs should consider additional training, education, and/or consultation if they feel uncomfortable or ill prepared when working with gender-minority veterans.
Future Research
Research has attempted to understand the consequences of MST on sexual health; however, despite these efforts, more research is necessary. The majority of published studies have focused on females even though a similar number of males have reported MST.2 This dearth of published studies likely is due to hesitation by male active-duty personnel and veterans to disclose or seek treatment for MST and because the percentage of females reporting MST is much higher. Males are less likely to report or seek treatment for MST because of stigma-based concerns (eg, shame, self-blame, privacy concerns).8,9 Therefore, it is difficult to acquire a sizable research sample to study. As previously noted, a single study has specifically examined MST and STI risk. Although this study included a sizable population of male OEF/OIF veterans, results have yet to be replicated in other clinical populations of interest, such as male military personnel and male veterans of other service eras.
Research is even more limited regarding lesbian, gay, bisexual, transgender, and other gender-minority military personnel and veterans. Although researchers propose that these populations may experience a similar, or even heightened, likelihood of MST during their service, no empirical research yet exists to fully examine this hypothesis.10,11 It is important to note that the paucity of research attention may be related to the Don’t Ask, Don’t Tell (DADT) policy, which obstructed the open discussion and empirical examination of sexual and gender minorities within military populations.11 The DADT policy led to limited awareness and greater stigmatization among sexual- and gender-minority personnel, resulting in poorer sexual health outcomes in these populations.10,11 With the end of DADT in 2011, it is now imperative for future research to examine the prevalence and associated consequences of MST in sexual- and gender-minority military personnel and veterans.
Conclusion
The DoD and VA should be commended for their continued focus on understanding the health consequences of MST. These efforts have yielded substantial information regarding the negative effects of MST on sexual health; in particular, increased risk for STIs. These findings suggest that MHPs may, at times, be the first point of contact for MST-related sexual health concerns. These providers should be aware of their ability to assess for STI risk and make appropriate referrals to facilitate early detection and access to treatment. Despite the presence of MST-related sexual health research, continued research remains necessary. In particular, a broader focus that includes other genders (eg, male, transgender) and sexual minorities would further inform research and clinical practice.
About 24% of women and 1% of men will experience military sexual trauma (MST) during their service.1 Despite the higher percentage of women reporting MST, the estimated number of men (55,491) and women (72,497) who endorse MST is relatively similar. Military sexual trauma is associated with negative psychosocial (eg, decreased quality of life) and psychiatric (eg, posttraumatic stress disorder [PTSD], depression) sequelae. Surís and colleagues provided a full review of sequelae, with PTSD being the most discussed consequence of MST.2 However, sexually transmitted infections (STIs) during or after MST are a consequence of growing concern.
Sexually Transmitted Infections
The link between sexual trauma and increased incidence of STIs is well established. Survivors of rape are at a higher risk of exposure to STIs due to unprotected sexual contact that may occur during the assault(s).3 Numerous studies have demonstrated that sexual trauma is directly related to greater engagement in risky sexual behaviors (eg, more sexual partners, unprotected sex, and “sex trading”).2,4
This relationship is particularly concerning given that individuals in the military tend to report sexual trauma with greater propensity than that reported in civilian populations.4 Additionally, military personnel and veteran populations tend to engage in high-risk behaviors (eg, alcohol and drug use) more often than their civilian counterparts, increasing their potential susceptibility to predatory sexual trauma(s) and victimization.2,5 Taken in aggregate, military personnel and veterans may be at increased risk for STIs compared with the civilian population due to the increased incidence of risky sexual behavior and sexual traumatization during military service.
Sexually transmitted infections potentially lead to immediate-term (eg, physical discomfort, sexual dysfunction) and long-term (eg, cancer, infertility) adverse health consequences.6 Early detection is crucial in the treatment of STIs because it can aid in preventing STI transmission and allow for early intervention. See Table for a list of common STIs and their prevalence, testing method, method of sexual transmission, and treatment. Early detection is also important because many STIs may be asymptomatic (eg, HIV, human papillomavirus [HPV]), which decreases the likelihood of seeking testing or treatment as well as increases the likelihood of transmission.7
Current Research
To date, only 1 study has explicitly examined the relationship between MST and STIs. In 2011, researchers analyzed a large national database of 420,725 male and female Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans.6 In the study, both male and female OEF/OIF veterans who endorsed MST were significantly more likely than those who did not endorse MST to have a STI diagnosis. The researchers noted that this finding underscored the necessity for sexual health assessment in survivors of MST, to facilitate early detection and treatment.
STI Risk Assessment
Because military personnel and veterans often initially disclose their MST to a mental health provider (MHP), these providers operate in a unique circumstance where they may be the individual’s first point of contact for determining STI risk. In these circumstances, the MHP should consider the utility of briefly assessing the patient’s sexual health and making subsequent medical referrals as necessary.
To accurately assess a patient’s STI risk, the MHP should gather information regarding both current/acute risk (eg, “Have you had unprotected sexual contact, for instance, genital contact without a condom or oral sex without a dental dam, in the past month?”) as well as longer standing (eg, “Have you had unprotected sexual contact... in the past year?”) STI risk. Providers also should consider oral, anal, and genital modes of sexual contact as well as common STI symptoms (eg, warts, sores, genital discharge, and/or pain or burning sensation when peeing or during sex). Additionally, psychoeducation should be provided, especially information regarding the asymptomatic nature of certain STIs, such as HIV and HPV, and the risk of transmission in all forms of sexual contact, including nongenital anal contact. Appropriate referrals to sexual health education, including safe sex practices, also should be considered in order to minimize risk of future STI transmission.
Mental health providers also should determine the date of patient’s most recent STI test. Not all STIs can be detected via a blood test or routine yearly Papanicolaou (Pap test) physicals. Additionally, MHPs should be aware that risky practices, including substance misuse, are more common in survivors of MST and that there is an association between substance misuse and STIs.2,6 If testing has not occurred recently, MHPs should strongly encourage the individual to access STI testing and provide resources as necessary, such as access to low-cost STI testing. Further, if the MHP has reason to suspect the presence of an STI after the brief assessment (eg, individual endorses unprotected sexual contact or risky behaviors, including substance misuse, sex trading, and STI symptomatology; a positive STI test but the patient has not accessed treatment), an appropriate sexual health referral should be made.
During the assessment and psychoeducation processes, terminology and language plays an integral role. If a MHP assumes an individual has sexual contact only with opposite sex partners (eg, asking a male “How many women have you had sexual contact with in the past 30 days?” vs “How many partners have you had sexual contact with in the past 30 days?”), the MHP will not accurately assess the individual’s level of current risk. Additionally, it is important to remember that sexual behavior does not always align with sexual identity: A man who identifies as heterosexual may still have sexual contact with men. Due to the sensitive nature of sexual health, MHPs should be careful to use nonjudgmental language, such as using the term sex work rather than the more pejorative term prostitution, to avoid offending patients and to increase their likelihood to disclose sexual health information.
Nonjudgmental language is especially relevant when working with gender-minority veterans (eg, transgender, gender nonconforming, gender transitioning), because this clinical population has a higher risk of victimization and lower rates of help-seeking health behavior.7 In particular, a sizable portion of individuals who identify as transgender do not seek services out of fear that they will be discriminated against, humiliated, or misunderstood.7 To assuage these concerns, MHPs should ensure they refer to the veteran with the veteran’s preferred pronouns. For example, a MHP could ask “I would like to be respectful, how would you like to be addressed?” or “What name and pronoun would you like me/us to use?” Providers also should consider nonbinary pronouns when appropriate (eg, singular: ze/hir/hirs; plural: they/them/theirs). Providers also should recognize that making a mistake is not uncommon, and they should apologize to maintain rapport and maximize the patient’s comfort during this distressing process. Further, MHPs should consider additional training, education, and/or consultation if they feel uncomfortable or ill prepared when working with gender-minority veterans.
Future Research
Research has attempted to understand the consequences of MST on sexual health; however, despite these efforts, more research is necessary. The majority of published studies have focused on females even though a similar number of males have reported MST.2 This dearth of published studies likely is due to hesitation by male active-duty personnel and veterans to disclose or seek treatment for MST and because the percentage of females reporting MST is much higher. Males are less likely to report or seek treatment for MST because of stigma-based concerns (eg, shame, self-blame, privacy concerns).8,9 Therefore, it is difficult to acquire a sizable research sample to study. As previously noted, a single study has specifically examined MST and STI risk. Although this study included a sizable population of male OEF/OIF veterans, results have yet to be replicated in other clinical populations of interest, such as male military personnel and male veterans of other service eras.
Research is even more limited regarding lesbian, gay, bisexual, transgender, and other gender-minority military personnel and veterans. Although researchers propose that these populations may experience a similar, or even heightened, likelihood of MST during their service, no empirical research yet exists to fully examine this hypothesis.10,11 It is important to note that the paucity of research attention may be related to the Don’t Ask, Don’t Tell (DADT) policy, which obstructed the open discussion and empirical examination of sexual and gender minorities within military populations.11 The DADT policy led to limited awareness and greater stigmatization among sexual- and gender-minority personnel, resulting in poorer sexual health outcomes in these populations.10,11 With the end of DADT in 2011, it is now imperative for future research to examine the prevalence and associated consequences of MST in sexual- and gender-minority military personnel and veterans.
Conclusion
The DoD and VA should be commended for their continued focus on understanding the health consequences of MST. These efforts have yielded substantial information regarding the negative effects of MST on sexual health; in particular, increased risk for STIs. These findings suggest that MHPs may, at times, be the first point of contact for MST-related sexual health concerns. These providers should be aware of their ability to assess for STI risk and make appropriate referrals to facilitate early detection and access to treatment. Despite the presence of MST-related sexual health research, continued research remains necessary. In particular, a broader focus that includes other genders (eg, male, transgender) and sexual minorities would further inform research and clinical practice.
1. Military Sexual Trauma Support Team. Military sexual trauma (MST) screening report fiscal year 2012. Washington DC: U.S. Department of Veterans Affairs, Office of Patient Care Services, Mental Health Services; 2013.
2. Surís A, Holliday R, Weitlauf JC, North CS; the Veteran Safety Initiative Writing Collaborative. Military sexual trauma in the context of veterans’ life experiences. Fed Pract. 2013;30(suppl 3):16S-20S.
3. Jenny C, Hooton TM, Bowers A, et al. Sexually transmitted diseases in victims of rape. N Eng J Med. 1990;322(11):713-716.
4. Senn TE, Carey MP, Vanable PA, Coury-Doniger P, Urban MA. Childhood sexual abuse and sexual risk behavior among men and women attending a sexually transmitted disease clinic. J Consult Clin Psychol. 2006;74(4):720-731.
5. Schultz JR, Bell KM, Naugle AE, Polusny MA. Child sexual abuse and adult sexual assault among military veteran and civilian women. Mil Med. 2006;171(8):723-728.
6. Turchik JA, Pavao J, Nazarian D, Iqbal S, McLean C, Kimerling R. Sexually transmitted infections and sexual dysfunctions among newly returned veterans with and without military sexual trauma. Int J Sex Health. 2012;24(1):45-59.
7. National LGBT Health Education Center. Affirmative care for transgender and gender non-conforming people: best practices for front-line health care staff. https://www.lgbthealth education.org/wp-content/uploads/2016/12/Affirmative-Care-for-Transgender -and-Gender-Non-conforming-People-Best-Practices -for-Frontline-Health-Care-Staff.pdf. Published 2016. Accessed February 16, 2017.
8. Morris EE, Smith JC, Farooqui SY, Surís AM. Unseen battles: the recognition, assessment, and treatment issues of men with military sexual trauma (MST). Trauma Violence Abuse. 2014;15(2):94-101.
9. Turchik JA, Edwards KM. Myths about male rape: a literature review. Psychol Men Masc. 2012;13(2):211-226.
10. Mattocks KM, Kauth MR, Sandfort T, Matza AR, Sullivan JC, Shipherd J. Understanding health-care needs of sexual and gender minority veterans: how targeted research and policy can improve health. LGBT Health. 2014;1(1):50-57.
11. Burks DJ. Lesbian, gay, and bisexual victimization in the military: an unintended consequence of “Don’t Ask, Don’t Tell”? Am Psychol. 2011;66(7):604-613.
1. Military Sexual Trauma Support Team. Military sexual trauma (MST) screening report fiscal year 2012. Washington DC: U.S. Department of Veterans Affairs, Office of Patient Care Services, Mental Health Services; 2013.
2. Surís A, Holliday R, Weitlauf JC, North CS; the Veteran Safety Initiative Writing Collaborative. Military sexual trauma in the context of veterans’ life experiences. Fed Pract. 2013;30(suppl 3):16S-20S.
3. Jenny C, Hooton TM, Bowers A, et al. Sexually transmitted diseases in victims of rape. N Eng J Med. 1990;322(11):713-716.
4. Senn TE, Carey MP, Vanable PA, Coury-Doniger P, Urban MA. Childhood sexual abuse and sexual risk behavior among men and women attending a sexually transmitted disease clinic. J Consult Clin Psychol. 2006;74(4):720-731.
5. Schultz JR, Bell KM, Naugle AE, Polusny MA. Child sexual abuse and adult sexual assault among military veteran and civilian women. Mil Med. 2006;171(8):723-728.
6. Turchik JA, Pavao J, Nazarian D, Iqbal S, McLean C, Kimerling R. Sexually transmitted infections and sexual dysfunctions among newly returned veterans with and without military sexual trauma. Int J Sex Health. 2012;24(1):45-59.
7. National LGBT Health Education Center. Affirmative care for transgender and gender non-conforming people: best practices for front-line health care staff. https://www.lgbthealth education.org/wp-content/uploads/2016/12/Affirmative-Care-for-Transgender -and-Gender-Non-conforming-People-Best-Practices -for-Frontline-Health-Care-Staff.pdf. Published 2016. Accessed February 16, 2017.
8. Morris EE, Smith JC, Farooqui SY, Surís AM. Unseen battles: the recognition, assessment, and treatment issues of men with military sexual trauma (MST). Trauma Violence Abuse. 2014;15(2):94-101.
9. Turchik JA, Edwards KM. Myths about male rape: a literature review. Psychol Men Masc. 2012;13(2):211-226.
10. Mattocks KM, Kauth MR, Sandfort T, Matza AR, Sullivan JC, Shipherd J. Understanding health-care needs of sexual and gender minority veterans: how targeted research and policy can improve health. LGBT Health. 2014;1(1):50-57.
11. Burks DJ. Lesbian, gay, and bisexual victimization in the military: an unintended consequence of “Don’t Ask, Don’t Tell”? Am Psychol. 2011;66(7):604-613.