Journal of Urban Health

, Volume 94, Issue 1, pp 54–63 | Cite as

Comparing the Utilization and Cost of Health Services between Veterans Experiencing Brief and Ongoing Episodes of Housing Instability

  • Thomas Byrne
  • Richard E. Nelson
  • Ann Elizabeth Montgomery
  • Emily Brignone
  • Adi V. Gundlapalli
  • Jamison D. Fargo


Housing instability is associated with costly patterns of health and behavioral health service use. However, little prior research has examined patterns of service use associated with higher costs among those experiencing ongoing housing instability. To address this gap, we compared inpatient and outpatient medical and behavioral health service utilization and costs between veterans experiencing brief and ongoing episodes of housing instability. We used data from a brief screening instrument for homelessness and housing instability that has been implemented throughout the US Department of Veterans Affairs (VA) health care system to identify a national sample of veterans experiencing housing instability. Veterans were classified as experiencing either brief or ongoing housing instability, based on two consecutive responses to the instrument, and we used a series of two-part regression models to conduct adjusted comparisons of costs between veterans experiencing brief and ongoing episodes of housing instability. Among 5794 veterans screening positive for housing instability, 4934 (85%) were experiencing brief and 860 (15%) ongoing instability. The average total annual incremental cost associated with ongoing versus brief episodes of housing instability was estimated at $7573, with the bulk of this difference found in inpatient services. Cost differences resulted more from a higher probability of service use among those experiencing ongoing episodes of housing instability than from higher costs among service users. Our findings suggest that VA programmatic efforts aimed at preventing extended episodes of housing instability could potentially result in substantial cost offsets for the VA health care system.


Housing Homelessness Veterans Health service use 



This study was supported by funding from the U.S. Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) grant number IIR 13-334 "Identifying and Measuring Risk for Homelessness Among Veterans" and from the VA National Center on Homelessness Among Veterans. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. None of the authors have any conflicts of interest to disclose.


  1. 1.
    Kushel MB, Gupta R, Gee L, Haas JS. Housing instability and food insecurity as barriers to health care among low-income Americans. J Gen Intern Med. 2006; 21(1): 71–77. doi: 10.1111/j.1525-1497.2005.00278.x.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Reid KW, Vittinghoff E, Kushel MB. Association between the level of housing instability, economic standing and health care access: a meta-regression. J Health Care Poor Underserved. 2008; 19(4): 1212–1228. doi: 10.1353/hpu.0.0068.CrossRefPubMedGoogle Scholar
  3. 3.
    Duchon LM, Weitzman BC, Shinn M. The relationship of residential instability to medical care utilization among poor mothers in New York City. Med Care. 1999; 37(12): 1282–1293.CrossRefPubMedGoogle Scholar
  4. 4.
    Hwang SW, Weaver J, Aubry T, Hoch JS. Hospital costs and length of stay among homeless patients admitted to medical, surgical, and psychiatric services. Med Care. 2011; 49(4): 350–354. doi: 10.1097/MLR.0b013e318206c50d.CrossRefPubMedGoogle Scholar
  5. 5.
    Kushel MB, Perry S, Bangsberg D, Clark R, Moss AR. Emergency department use among the homeless and marginally housed: results from a community-based study. Am J Public Health. 2002; 92(5): 778–784. doi: 10.2105/AJPH.92.5.778.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Salit S, Kuhn E, Hartz A. Hospitalization costs associated with homelessness in New York City. N Engl J Med. 1998; 338(24): 1734–1740.CrossRefPubMedGoogle Scholar
  7. 7.
    Doran KM, Ragins KT, Iacomacci AL, Cunningham A, Jubanyik KJ, Jenq GY. The revolving hospital door: hospital readmissions among patients who are homeless. Med Care. 2013; 51(9): 767–773. doi: 10.1097/MLR.0b013e31829fafbb.CrossRefPubMedGoogle Scholar
  8. 8.
    Mandelberg JH, Kuhn RE, Kohn MA. Epidemiologic analysis of an urban, public emergency department’s frequent users. Acad Emerg Med. 2000; 7(6): 637–646. doi: 10.1111/j.1553-2712.2000.tb02037.x.CrossRefPubMedGoogle Scholar
  9. 9.
    O’Toole TP, Pollini R, Gray P, Jones T, Bigelow G, Ford DE. Factors identifying high-frequency and low-frequency health service utilization among substance-using adults. J Subst Abuse Treat. 2007; 33(1): 51–59. doi: 10.1016/j.jsat.2006.12.002.CrossRefPubMedGoogle Scholar
  10. 10.
    Lim YW, Andersen R, Leake B, Cunningham W, Gelberg L. How accessible is medical care for homeless women? Med Care. 2002; 40(6): 510–520.CrossRefPubMedGoogle Scholar
  11. 11.
    Buck DS, Brown CA, Mortensen K, Riggs JW, Franzini L. Comparing homeless and domiciled patients’ utilization of the Harris County, Texas public hospital system. J Health Care Poor Underserved. 2012; 23(4): 1660–1670. doi: 10.1353/hpu.2012.0171.CrossRefPubMedGoogle Scholar
  12. 12.
    Doran KM, Raven MC, Rosenheck RA. What drives frequent emergency department use in an integrated health system? National data from the Veterans Health Administration. Ann Emerg Med. 2013; 62(2): 151–159. doi: 10.1016/j.annemergmed.2013.02.016.CrossRefPubMedGoogle Scholar
  13. 13.
    Tsai J, Rosenheck RA. Risk factors for ED use among homeless veterans. Am J Emerg Med. 2013; 31(5): 855–858. doi: 10.1016/j.ajem.2013.02.046.CrossRefPubMedGoogle Scholar
  14. 14.
    Flaming D, Burns P, Matsunaga M. Where we sleep: costs when homeless and housed in Los Angeles. Economic Roundtable: Los Angeles, CA; 2009.Google Scholar
  15. 15.
    Kuhn R, Culhane DP. Applying cluster analysis to test a typology of homelessness by pattern of shelter utilization: results from the analysis of administrative data. Am J Community Psychol. 1998; 26(2): 207–232. doi: 10.1023/A:1022176402357.CrossRefPubMedGoogle Scholar
  16. 16.
    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. doi: 10.1176/ Scholar
  17. 17.
    Spellman B, Khadduri J, Sokol B, Leopold J. Costs associated with first-time homelessness for families and individuals. Washington, DC: U.S. Department of Housing and Urban Develpment; 2010.Google Scholar
  18. 18.
    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. doi: 10.1176/ Scholar
  19. 19.
    Tsai J, Mares AS, Rosenheck RA. Do homeless veterans have the same needs and outcomes as non-veterans? Mil Med. 2012; 177(1): 27–31.CrossRefPubMedGoogle Scholar
  20. 20.
    Montgomery AE, Hill LL, Kane V, Culhane DP. Housing chronically homeless veterans: evaluation the efficacy of a housing first approach to HUD-VASH. J Community Psychol. 2013; 41(4): 505–514. doi: 10.1002/jcop.21554.CrossRefGoogle Scholar
  21. 21.
    Drummond MF, Sculpher MJ, Torrance GW, O’Brien BJ, Stoddart GL. Methods for the economic evaluation of health care programmes. 3rd ed. Oxford, UK: Oxford University Press; 2005.Google Scholar
  22. 22.
    U.S. Department of Commerce Bureau of Economic Analysis. Consumer spending. Published 2016. Accessed June 29, 2016.
  23. 23.
    U.S. Census Bureau. Geographic terms and concepts—census divisions and census regions. Published 2013. Accessed 31 Oct 2016.
  24. 24.
    Diehr P, Yanez D, Ash A, Hornbrook M, Lin DY. Methods for analyzing health care utilization and costs. Annu Rev Public Health. 1999; 20: 125–144. doi: 10.1146/annurev.publhealth.20.1.125.CrossRefPubMedGoogle Scholar
  25. 25.
    Efron B, Tibshirani R. An introduction to the bootstrap. New York, NY: Chapman & Hall; 1993.CrossRefGoogle Scholar
  26. 26.
    O’Toole TP, Buckel L, Bourgault C, et al. Applying the chronic care model to homeless veterans: effect of a population approach to primary care on utilization and clinical outcomes. Am J Public Health. 2010; 100(12): 2493–2499. doi: 10.2105/AJPH.2009.179416.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    U.S. Department of Veterans Affairs. Supportive services for veteran families (SSVF): FY 2014 Annual Report. 2014. Published 2015. Accessed 31 Oct 2016
  28. 28.
    Ly A, Latimer E. Housing first impact on costs and associated cost offsets: a review of the literature. Can J Psychiatry. 2015; 60(11): 475–487.PubMedPubMedCentralGoogle Scholar
  29. 29.
    McGuire J, Mares A. Hoptel equalizes length of stay for homeless and domiciled inpatients. Med Care. 2000; 38(10): 1003–1010. doi: 10.1097/00005650-200010000-00004.CrossRefPubMedGoogle Scholar
  30. 30.
    Buchanan D, Doblin B, Sai T, Garcia P. The effects of respite care for homeless patients: a cohort study. Am J Public Health. 2006; 96(7): 1278–1281. doi: 10.2105/AJPH.2005.067850.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Borowsky SJ, Cowper DC. Dual use of VA and non-VA primary care. J Gen Intern Med. 1999; 14(5): 274–280. doi: 10.1046/j.1525-1497.1999.00335.x.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Ross JS, Keyhani S, Keenan PS, et al. Dual use of veterans affairs services and use of recommended ambulatory care. Med Care. 2008; 46(3): 309–316. doi: 10.1097/MLR.0b013e31815b9db3.CrossRefPubMedGoogle Scholar

Copyright information

© The New York Academy of Medicine (outside the USA) 2017

Authors and Affiliations

  1. 1.Boston University School of Social WorkBostonUSA

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