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Authors

Audience for this brief:

National Homeless Program staff, non-VA partners and grantees, program managers, and researchers.

Funding

This project was funded by an Intramural Grant from the National Center on Homelessness Among Veterans (NCHAV).

What do We Know?

Veterans experiencing homelessness (VEH) tend to have poorer health outcomes and higher rates of inpatient and emergency department care than housed veterans.^1,2 The Veterans Access, Choice, and Accountability Act (Choice Act) of 2014 expanded access to non-VA care for enrollees of VA health care, including VEH.³ Around the same time, the Affordable Care Act expanded Medicaid eligibility to low-income adults in participating states. Gaps in the literature exist for health outcomes following both VA and non-VA hospitalizations for VEH with and without Medicare.⁵ Examining mortality, readmission, and length of stay outcomes between VA and non-VA hospitals is important to identifying knowledge gaps in efforts to provide the best care outcomes for VEH.

New Information Provided by this Study

This retrospective observational study utilized longitudinal comprehensive VA and non-VA administrative data collected from the VA Homeless Registry, VA Corporate Data Warehouse (CDW), VA enrollment files, VA Observational Medical Outcomes Partnership files, and the VA Vital Status Files to compare 30-day mortality, readmission, and length of hospital stay data for VEH who were hospitalized in 11 states (AZ, CA, CT, FL, IL, LA, MA, MO NY, PA, SC). VA hospitalization data were obtained from the CDW Inpatient files. Non-VA hospitalization data were obtained from state all-payer claims data from each state individually. The timeframe of interest was 2012 -2017, which is the time prior and post expansion of the Choice Act. Observation care was not included due to lack of complete data.

The cohort of VEH was younger and more likely to be low-income or Medicaid eligible than their housed Veterans. Both VEH and other veterans had decreased VA hospitalizations associated with the Choice Act for both medical/surgical and psychiatric care, and the decrease was larger for VEH. VA hospitalizations of VEH had 0.02% significantly lower probability of 30-day mortality (equivalent to 54 fewer deaths per year) and 5% significantly lower probability of 30-day readmission (equivalent to 2549 fewer total readmissions per year) but a 0.84 day significantly longer mean length of stay when compared to non-VA hospitalizations among 161,584 medical/surgical hospitalizations. For psychiatric hospitalizations, VA hospitalizations had 7% lower probability of readmissions and 2 days longer length of stay than non-VA hospitalizations.

A. Medical/Surgical Hospitalizations, B. Psychiatric Hospitalizations Before and After the Veterans’ Choice Act by Patients’ Homeless Status

Summary / Implications

Policies expanding Veterans’ access to non-VA providers had greater impacts on VEH than other Veterans. VEH had larger decreases in VA hospitalizations than other Veterans, yet VEH had larger increases in hospitalizations, specifically psychiatric care, covered by VA-purchased care and Medicaid, associated with the Choice Act and Medicaid expansion. VEH had worse outcomes such as higher mortality and readmissions in non-VA hospitalizations compared to VA hospitalizations. Policies to increase access for the most at-risk veterans should balance access with quality of care.

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References

1. Doran KM, Ragins KT, Iacomacci AL, et al: The revolving hospital door: hospital readmissions among patients who are homeless. Med Care 2013; 51:767–773
2. Wadhera RK, Khatana SAM, Choi E, et al: Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions. JAMA Intern Med 2020; 180:357–366
3. Gellad WF: The Veterans Choice Act and dual health system use. J Gen Intern Med 2016; 31:153–154
4. Trivedi AN, Jiang L, Johnson EE, et al: Dual use and hospital admissions among veterans enrolled in the VA’s Homeless Patient Aligned Care Team. Health Serv Res 2018; 53:5219–5237
5. Nelson RE, Suo Y, Pettey W, et al: Costs associated with health care services accessed through VA and in the community through Medicare for veterans experiencing homelessness. Health Serv Res 2018; 53:5352–5374