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2023 HSR&D/QUERI National Conference Abstract

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1193 — Using Ethnography to Identify Transitions in the Lives of Veterans Experiencing Homelessness

Lead/Presenter: Shawn Dunlap,  COIN - Bedford/Boston
All Authors: Dunlap S (Center for Healthcare Organization and Implementation Research), Roncarati J (Center for Healthcare Organization and Implementation Research) Conti J (Center for Healthcare Organization and Implementation Research) Foster M (Center for Healthcare Organization and Implementation Research, Boston University School of Medicine, Section of General Internal Medicine, VA Boston Healthcare System, Department of Quality Management) Hyde J (Center for Healthcare Organization and Implementation Research, Boston University School of Medicine, Section of General Internal Medicine) Fix G (Center for Healthcare Organization and Implementation Research, Boston University School of Medicine, Section of General Internal Medicine McInnes DK (Center for Healthcare Organization and Implementation Research, Department of Health Law, Policy, and Management, Boston University School of Public Health)

Objectives:
A dearth of literature exists to document real-time lived experience of homeless Veterans, including day-to-day activities, interactions with health and social services, and residential transitions. These fluctuations can influence a homeless Veterans success in finding and maintain housing. We used a formative ethnographic approach to identify important daily and weekly events in homeless Veterans’ lives.

Methods:
Our longitudinal ethnographic data collection involved approximately four qualitative interviews each week completed over a course of 4–6-weeks. Three shorter interviews inquired about day-to-day experiences and routines, and one large and small disruptions that might lead to serious housing and health events. Longer interviews each focused on a specific area: healthcare, services, and technology. Interviews were conducted in-person when possible with a majority being conducted by telephone. We used convenience sampling to recruit Veterans with a range of experience with homelessness and categorized on having experienced chronic homelessness, experiencing a recent onset of homelessness, or those at-risk for homelessness.

Results:
We conducted a total of 111 interviews. With our 10 participants this averaged 11 interviews per participant over the 4 week period. Participants were Veterans at risk for or experiencing homelessness. Participants were mostly male, were 30-70 years old, and represented racial/ethnic diversity. Housing situations included transitional housing program, a VA domiciliary program, and unsheltered status. We found that almost all reportedly had used or were actively using drugs and/or alcohol, most expressed feelings of loneliness or lack of social support, and a majority reported a perceived lack of control over life circumstances. Participants detailed a wide range of physical, behavioral, and mental health needs, though success in seeking care for these inside and outside the VA was often sporadic.

Implications:
In veterans experiencing or at risk for homelessness we observed dynamic, everyday events that influenced participants’ housing stability and health. Our ethnographic data collection was effective at identifying health and social factors such as decreasing homelessness, understanding the root causes of substance use disorders, and improving social support services.

Impacts:
Longitudinal ethnography generated data from Veterans experiencing homelessness, data that informs providers and staff about transition points and how Veterans navigate such transitions. Our analysis also suggests how knowledge about transitions can lead to program and service changes to improve homeless Veteran health and service outcomes.