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Response to Commentary (HSR Leadership Letter)VA's Health Systems Research (HSR): Working Toward Evidence-Based Solutions to End Veteran HomelessnessHealth Systems Research (HSR) has been committed to meeting the overall VA goals of preventing and ending homelessness. This complex issue requires prioritizing research that creates an evidence base for the services needed to help Veterans overcome the socio-economic, demographic, and institutional challenges they face. Recently, the updated 2022 VA healthcare priorities reaffirmed HSR’s 2010 commitment to ending homelessness. VA Cross-agency Priority Goals Strategic Objective 2.1: Underserved, Marginalized, and At-risk Veterans emphasizes the delivery of benefits, healthcare, and other services to prevent both Veteran suicide and homelessness; fulfilling this objective has the potential to improve Veteran economic security, health, resilience, and quality of life, as well as ensuring equity in health service delivery. VA’s focus on ending homelessness is complemented by the White House’s 2023 renewed commitment to reduce unsheltered homelessness by 25 percent by 2025 through the “ALL INside” initiative led by the U.S. Interagency Council on Homelessness (USICH) and 19 federal partner agencies, including the Department of Veterans Affairs.1 Currently, the Office of Research and Development (ORD) is reorganizing to align its research funding more closely with the issues most salient to Veterans. Similarly, HSR has updated its research priorities to reflect the VA Strategic Plan & Agency Priority Goals while simultaneously embracing the focus of learning health systems (LHS) as informed by the National Academy of Medicine (NAM) Quintuple Aim goal (improve access, outcomes, equity, experience, and value). While these steps are expected to help bring broad, positive change in population health, they also should ultimately answer the question of whether Veteran health is improving, even under conditions like homelessness.2 The steps needed to achieve them are seen as integral to ending Veteran housing insecurity and homelessness within the context of the VA LHS. An LHS uses common data and infrastructure to support continuous research and quality improvement initiatives that address and inform identified health priority goals.3 These research and quality improvement efforts in turn support VA requirements under the Foundations for Evidence-based Policymaking Act of 2018 (Evidence Act, US Public Law 115-435), which requires that federal agency budgets be supported by research evidence and evaluation. Embedded within HSR, the Quality Enhancement Research Initiative (QUERI) leverages the LHS model by accelerating the adoption of evidence-based practices within routine VA practice, such as using program and policy evaluations to inform VA efforts to end Veteran homelessness. While notable progress has been made towards ending homelessness via the “Housing First” approach, additional avenues to success are needed. Identifying new evidence-based approaches could be the key to further improvement in the housing security of Veterans. To fulfill Evidence Act requirements, VA published a Homelessness Learning Agenda supplement in 2022 that expands the FY2022-28 Learning Agenda to focus on public advocacy efforts in this area. The supplement targets building strong foundational relationships across organizational boundaries to foster a “whole person/whole life” longitudinal, Veteran-centric approach to understanding the “life journey” of individual Veterans who are or are at risk of experiencing housing or economic insecurity and/or homelessness. The supplement addresses challenges in coordination and obtaining evidence and raises essential questions in the effort to understand and to mitigate housing and economic insecurity. Subsequently, the Homelessness Integrated Process Team, with representation spanning VHA, VBA, and staff offices such as the Office of Enterprise Integration and the Veterans Experience Office, is leading the development of this comprehensive analytical model to address the questions raised in the Learning Agenda supplement. Under this approach, the Homelessness Integrated Process Team recognizes that some Veterans have significant predispositions that increase their risk for homelessness. These Veterans experience complex social determinants for homelessness risk, including the circumstances and location of their pre-military years, their family’s financial, social, and housing situations, and their societal and community connections. While in military service this risk may be suppressed, upon returning to civilian life, these predispositions along with service-related experiences may surface to put them at risk again. Analyzing a Veteran’s life journey could generate the information necessary to mitigate risk for homelessness as early as practical, thereby minimizing adversity for Veterans and their families while likely reducing societal costs. Capturing the life journey of Veterans will help identify gaps in evidence and address Homelessness Learning Agenda supplement questions by processing data on Veteran housing and economic insecurity risk. Understanding a Veteran’s life journey will have additional benefits, including helping to inform the design, testing, and implementation of evidence-based practices as well as the optimization of VA programs and policies for ending Veteran homelessness. This analysis also could present an opportunity for funding new research and evaluation (quality improvement) initiatives. As such, QUERI funded an LHS led by Drs. Rich Nelson and Jack Tsai to create a homelessness learning community to build capacity for evidence, evaluation, and quality improvement activities. Such a community would develop a second-level common data infrastructure (VA and non-VA data) and standard operating procedures (SOPs) to overcome the challenges noted in the VA LA supplement. Future initiatives through HSR and QUERI seek to continue leveraging research and operations funding to launch novel research and quality improvement initiatives to better serve Veterans at risk of housing and economic insecurity, to ultimately prevent and end homelessness. HSR Portfolio of Veteran Homelessness StudiesSince the start of 2023, HSR has supported a dozen studies with Veteran homelessness as either the primary or a secondary outcome of the project, and all HSR-funded projects have yielded over 25 papers on the topic of homelessness during the last year. Over the last decade, HSR has supported over 65 merit and pilot studies, along with six career development awards and one research career scientist award, all of which have addressed Veteran homelessness as either a primary or a key secondary outcome. Further information on the broad range of HSR supported, investigator initiated work on Veteran homelessness is available at Homelessness (va.gov). A review of recent and current HSR work on homelessness shows our investigators are already working on answers to the critical questions raised by Ms. Diaz in her commentary article. With respect to homeless and criminal justice prevention, HSR researchers have been studying health services for justice-involved Veterans, adapting and testing an intervention for justice-involved homeless Veterans with co- occurring substance use and mental health disorders, and helping justice-involved Veterans access help via the National Call Center for Homeless Veterans. Some researchers are looking at employment services for Veterans by studying strategies to facilitate long-term financial and housing stability for at-risk Veterans and improving healthcare utilization by Veterans receiving supported employment. One study focusing on collaborative case management services is evaluating the impact of COVID-19 on case management, healthcare utilization, and housing outcomes for HUD-VASH Veterans while another is targeting addiction housing case management. Finally, expanding VA Peer support workforce capacity to facilitate increased access to VHA mental health services and continuity of care for Veterans with mental illness during the COVID-19 pandemic is our first focus on specialty healthcare services. HSR investigators also are collaborating with DoD investigators to leverage data collected from the ongoing Army Study to Assess Risk and Resilience in Servicemembers (STARRS) longitudinal study. This represents an initial effort to better understand precursors to Veteran homelessness by integrating data from their time before enlistment, time as a service member, and time as a transitioning Veteran. This collaboration has resulted in papers that suggest models to help predict risk for homelessness, understand how risk is impacted by stressful life events, and how different types of military discharges may impact risk for both homelessness and suicide. We are optimistic about reaching a time when no Veteran experiences the tragedy and indignity of homelessness but fully understand that it will take great effort to reach that goal. Our collaboration with the Homeless Program Office, through both HSR and QUERI, will help providers get the critical information they need to ensure that every Veteran has a safe, stable, accessible, and affordable home. References
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