Improving access to disability benefits among homeless persons with mental illness: an agency-specific approach to services integration

OBJECTIVES

This study evaluated a joint initiative of the Social Security Administration (SSA) and the Department of Veterans Affairs (VA) to improve access to Social Security disability benefits among homeless veterans with mental illness.

METHODS

Social Security personnel were colocated with VA clinical staff at 4 of the VA's Health Care for Homeless Veterans (HCHV) programs. Intake assessment data were merged with SSA administrative data to determine the proportion of veterans who filed applications and who received disability awards at the 4 SSA-VA Joint Outreach Initiative sites (n = 6709) and at 34 comparison HCHV sites (n = 27 722) during the 2 years before and after implementation of the program.

RESULTS

During the 2 years after the initiative began, higher proportions of veterans applied for disability (18.9% vs 11.1%; P < .001) and were awarded benefits (11.4% vs 7.2%, P < .001) at SSA-VA Joint Initiative sites.

CONCLUSION

A colocation approach to service system integration can improve access to disability entitlements among homeless persons with mental illness. Almost twice as many veterans were eligible for this entitlement as received it through a standard outreach program.

Inpatient treatment of comorbid psychiatric and substance abuse disorders: comparison of public sector and privately insured populations

Public health delivery systems are increasingly compared to private systems as policymakers continue to focus on reducing the costs of care. However, there are very few studies comparing trends in utilization and cost between public and private providers. This study examines discharge abstract records for VA patients and insurance claims data for a national sample of privately insured individuals to investigate trends in inpatient utilization and costs for dually diagnosed individuals in these two systems. Although the substantial differences in the populations treated could account for the differences in these measures across systems, this study is useful in illustrating the possibilities and limitations of system comparisons.

Assessing quality of care: administrative indicators and clinical outcomes in posttraumatic stress disorder

BACKGROUND

Although the use of quality of care indicators based on data collected for administrative purposes has become widespread, the relationship between those measures and clinical outcomes has yet to be evaluated.

RESEARCH DESIGN

This study used hierarchical linear modeling to examine the relationship between 12 performance indicators derived from administrative data sets and 6 clinical outcome measures addressing symptoms, substance abuse, and social functions.

SUBJECTS

Patient interviews were conducted with 4,165 veterans 4 months after their discharge from 62 specialized VA inpatient programs for treatment of Posttraumatic Stress disorder.

RESULTS

Five of twelve administrative measures were significantly associated with at least one of the clinical outcome measures, which was all in the expected directions. The number of hospital readmissions during the 6 months after the index discharge was significantly related to poor outcomes on all 5 of 6 measures. Measures of readmission and post-discharge hospital use were more strongly and consistently related to outcome than to measures of access, intensity, or continuity of outpatient care.

CONCLUSION

Administrative data, especially measures of hospital readmission, are significantly related to clinical outcomes. Correlations, however, are small to modest in magnitude indicating that these 2 types of performance measures assess different aspects of quality and can not be substituted for one another.

Comparison of outcome between homogeneous and heterogeneous treatment environments in combat-related posttraumatic stress disorder

This study compared treatment outcome at discharge, and 4, 8, and 12 month follow-up between an inpatient program consisting of a mixture of Vietnam combat veterans with posttraumatic stress disorder (PTSD) and general psychiatric patients (N = 42), and the same program at a later period, consisting of only Vietnam combat veterans with PTSD (N = 33). Veterans rated the homogeneous environment higher in satisfaction, support, order, clarity, and amount of discussion of combat, and lower in hostility, than the heterogeneous condition. However, veterans showed no improvement in condition at 12 month follow-up, with the exception of decreased violence, replicating earlier studies. No differences in outcome were found between homogeneous or heterogeneous treatment environments. This study underscores the enduring nature of chronic posttraumatic stress disorder in the veteran population.

Impact of clozapine on negative symptoms and on the deficit syndrome in refractory schizophrenia. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia

OBJECTIVE

This study compared the effect of clozapine and haloperidol on positive and negative symptoms of schizophrenia and in patients with high levels of negative symptoms or the deficit syndrome.

METHOD

Patients were participants in a 15-site double-blind, random-assignment Veterans Administration trial comparing clozapine (N=205) and haloperidol (N=217) in hospitalized patients with refractory schizophrenia. Analysis of covariance examining change at 6 weeks, 3 months, and 1 year evaluated 1) clozapine's effect on positive and negative syndromes; 2) clozapine's effect on each syndrome, statistically controlling for the other; and 3) the interaction of clozapine treatment and the presence or absence of high levels of negative symptoms at baseline and the deficit syndrome.

RESULTS

Patients treated with clozapine showed significantly greater improvement than control subjects on positive symptoms at all time points and on negative symptoms at 3 months. Clozapine had no independent effect on negative symptoms at any time after control for positive symptoms, but its effects on positive symptoms persisted after control for negative symptoms at 6 weeks only. There were no significant differences in response to clozapine between patients with high and low levels of negative symptoms at baseline or between patients with and without the deficit syndrome.

CONCLUSIONS

The greater effectiveness of clozapine as compared to conventional medications in refractory schizophrenia is not specific to either negative clinical symptoms or clinical subtypes defined by prominent negative symptoms or evidence of the deficit syndrome.

Social support and service use among homeless persons with serious mental illness

It has been widely hypothesized that persons with greater social support use fewer health care services, although previous studies have shown variable results. This study examines the relationship between levels of social support and formal service use among clients entering 18 community treatment programs for homeless persons with serious mental illness as part of the ACCESS demonstration project of the U.S. Center for Mental Health Services. Baseline and follow-up data on 1,828 clients entering the ACCESS program were used to evaluate the relationship between individual client socio-demographic and clinical characteristics, seven measures of social support, and levels of formal service use in this population. Three measures of social support were positively related to the use of outpatient medical services and one each to the use of substance abuse services and the total days of service use. Six out of seven measures of social support were positively related to the receipt of multiple services. It appears that social support is most strongly associated with improved access to an array of different services--a very important need among this population.

A model of war zone stressors and posttraumatic stress disorder

We present a theoretical model of field placement, war zone stressors (fighting, death and injury of others, threat of death or injury to oneself, killing others, participating in atrocities, harsh physical conditions and insufficiency of resources in the environment) and posttraumatic stress disorder (PTSD). Theater veterans from the National Vietnam Veterans Readjustment Study were divided randomly into two subsamples of 599 each. The model was developed on the first subsample and cross-validated on the second using structural equation modeling. The model provides a theoretically and empirically satisfactory description of the anatomy of war zone stressors and their role in the etiology of PTSD, but it leaves unanswered important questions regarding the etiological role of insufficiency of resources in the environment.

Substance use and assignment of representative payees

Recent legislation prohibiting the awarding of Social Security Disability Insurance benefits to people whose disability is based on drug and alcohol abuse has effectively eliminated the Social Security Administration's practice of assigning representative payees to such persons. Currently no regulations exist for assigning representative payees to substance users who receive benefits based on non-substance-use disabilities. The authors suggest guidelines for determining when recipients with comorbid substance use disorders are incapable of managing their benefit funds. Representative payeeship is recommended for recipients who meet three criteria within the last 12 months: a maladaptive pattern of substance use; mismanagement of funds due to substance use, causing substantial harm to the recipient, unavailability of sufficient funds to meet basic needs, or victimization of the recipient; and availability of a representative payee whose efforts would increase the likelihood that the beneficiary's mismanagement of funds will be curtailed.

Consensus criteria for traumatic grief. A preliminary empirical test

BACKGROUND

Studies suggest that symptoms of traumatic grief constitute a distinct syndrome worthy of diagnosis.

AIMS

A consensus conference aimed to develop and test a criteria set for traumatic grief.

METHOD

The expert panel proposed consensus criteria for traumatic grief. Receiver operator characteristic (ROC) analyses tested the performance of the proposed criteria on 306 widowed respondents at seven months post loss.

RESULTS

ROC analyses indicated that three of four separation distress symptoms (e.g. yearning, searching, loneliness) had to be endorsed as at least 'sometimes true' and four of the final eight traumatic distress symptoms (e.g. numbness, disbelief, distrust, anger, sense of futility about the future) had to be endorsed as at least 'mostly true' to yield a sensitivity of 0.93 and a specificity of 0.93 for a diagnosis of traumatic grief.

CONCLUSIONS

Preliminary analyses suggest the consensus criteria for traumatic grief have satisfactory operating characteristics, and point to directions for further refinement of the criteria set.

Multiple outcome assessment in a study of the cost-effectiveness of clozapine in the treatment of refractory schizophrenia. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia

OBJECTIVE

To develop new methods for combining results from multiple outcome domains and to demonstrate their application in a study of the cost-effectiveness of clozapine in treating hospitalized patients with refractory schizophrenia.

DATA SOURCES/STUDY SETTING

Interview assessments, and administrative utilization and cost data, concerning 423 patients with refractory schizophrenia who had been hospitalized for 30-364 days during the year before study entry, at 15 VA medical centers.

STUDY DESIGN

A 12-month double-blind trial compared clozapine (n = 205) and haloperidol (n = 218) in the treatment of refractory schizophrenia.

DATA COLLECTION/EXTRACTION METHODS

Data from standard assessment instruments, gathered at baseline and at 6 weeks, and at 3, 6, 9, and 12 months, were used to develop a Composite Health Index for Schizophrenia, a measure that addresses outcome in six domains, weighted by patient or provider preferences. Cumulative improvement was estimated by computing the area under the improvement curve. This measure was then combined with cost data, reflecting consumption of societal resources to estimate incremental cost-effectiveness ratios.

PRINCIPAL FINDINGS

Clozapine was significantly more effective than haloperidol on measures of symptoms (p = .02) and side effects (p < .0001), with nonsignificant trends in the positive direction on community role functioning (p = .06), family relationships (p = .23), social relationships (p = .30), and daily activities (p = .20). Clozapine was also more effective than haloperidol on the one-year cumulative Composite Health Index for Schizophrenia (p < .0001 for all weighting schemes). After converting this measure to a 0-1 Worst Health-Good Health Scale analogous to Quality Adjusted Life Years, clozapine was found to yield a small improvement of .049 Worst Health-Good Health Units as compared to an improvement of only .027 Units for haloperidol (p < .0001). Average annual costs were $2,733 lower for clozapine (95% C.I. = -$9,220 to $3,754). Although clozapine was significantly more effective than haloperidol, the summary cost-effectiveness ratio had a wide 95 percent confidence interval ranging from -$431,585 to $177,352.

CONCLUSIONS

Methods demonstrate an approach to using conventional disease-specific measures to evaluate the cumulative effectiveness of novel treatments for psychotic disorders and for expressing their economic effect as cost-effectiveness ratios. Among high hospital users with refractory schizophrenia, clozapine is more cost-effective than standard treatment, although the magnitude of its effect is small and there is considerable uncertainty about the cost estimates.

Service system integration, access to services, and housing outcomes in a program for homeless persons with severe mental illness

OBJECTIVES

This study evaluated the hypothesis that greater integration and coordination between agencies within service systems is associated with greater accessibility of services and improved client housing outcomes.

METHODS

As part of the Access to Community Care and Effective Services and Supports program, data were obtained on baseline client characteristics, service use, and 3-month and 12-month outcomes from 1832 clients seen at 18 sites during the first year of program operation. Data on interorganizational relationships were obtained from structured interviews with key informants from relevant organizations in each community (n = 32-82 at each site).

RESULTS

Complete follow-up data were obtained from 1340 clients (73%). After control for baseline characteristics, service system integration was associated with superior housing outcomes at 12 months, and this relationship was mediated through greater access to housing agencies.

CONCLUSIONS

Service system integration is related to improved access to housing services and better housing outcomes among homeless people with mental illness.

Transgenerational effects of abusive violence on the children of Vietnam combat veterans

This study examined the relationship between participation in abusive violence in Vietnam and behavioral disturbances among children aged 6-16 in the next generation. As part of the National Vietnam Veterans Readjustment Study (NVVRS) detailed data were obtained on a national sample of male veterans who were living in households with children aged 6-16 (N = 257). Interviews with spouses/partners were used to evaluate current family relationships and child behavior. Children of veterans who participated in abusive violence showed more behavioral disturbance than children of other Vietnam veterans even after multivariate analysis was used to adjust for other factors such as PTSD symptoms, combat exposure, and postmilitary family relationships. Participation in abusive violence appears to affect parent-child relationships in a way that adversely influences children living at home.

Predictors of differential response to clozapine and haloperidol. Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia

BACKGROUND

We sought to identify baseline predictors of response to clozapine.

METHODS

Data were from a 15-site randomized clinical trial comparing clozapine and haloperidol in hospitalized patients with refractory schizophrenia (n = 423). Three-month outcomes were analyzed with the full sample (n = 368 due to attrition). Because of crossovers, analyses of 12-month outcomes were conducted with crossovers excluded (n = 291). Clinical predictors included age, race, diagnosis (current substance abuse, paranoid subtype of schizophrenia, or depressive syndrome), severity of symptoms, quality of life, age at onset of schizophrenia, extrapyramidal symptoms, and VA compensation payment. Multiple regression analysis was used to examine the interaction of treatment condition and each of these variables in predicting outcomes for symptoms, quality of life, side effects, and days hospitalized.

RESULTS

Patients with higher quality of life at baseline (p = .04) and higher symptoms (p = .02) had relatively smaller declines in hospital days at 6 months. In the 12-month sample patients with higher levels of symptoms had greater symptom reductions at 12 months (p = .03) and greater improvement in quality of life (p = .004).

CONCLUSIONS

Although high levels of symptoms were associated with greater improvement on clozapine, these findings are not robust enough to suggest that any specific, clinically defined subgroup of refractory patients should be preferentially targeted for clozapine treatment.

Homelessness: health service use and related costs

OBJECTIVES

This study examines health service use and costs for homeless and domiciled veterans hospitalized in psychiatric and substance abuse units at Department of Veterans Affairs (VA) medical centers, nationwide.

METHODS

A national survey of residential status at the time of admission was conducted on all VA inpatients hospitalized in acute mental health care units on September 30, 1995. Survey data were merged with computerized workload data bases to assess service use and cost during the 6 months before and after the date of discharge from the index hospitalization.

RESULTS

Of 9,108 veterans with complete survey data, 1,797 (20%) had been literally homeless at the time of admission, and 1,380 (15%) were doubled up temporarily, for a total homelessness rate of 35%. Combining patients from general psychiatry and substance abuse programs, the average annual cost of care for homeless veterans, after adjusting for other factors, was $27,206; $3,196 (13.3%) higher than the cost of care for domiciled veterans (P < 0.0001). Approximately 26% of annual inpatient VA mental health expenditures ($404 million) are spent on the care of homeless persons.

CONCLUSIONS

Homelessness adds substantially to the cost of health care services for persons with mental illness in VA, and most likely, in other "safety net" systems that serve the poor. These high costs, along with the prospect of declining public funding for health and social welfare programs, and an anticipated increase in the numbers of homeless mentally ill persons, portend a difficult time ahead for both homeless patients and the organizations that care for them.

Participation and outcome in a residential treatment and work therapy program for addictive disorders: the effects of race

OBJECTIVE

The authors examined differences in program participation and outcome between black and white veterans with addictive disorders who participated in an intensive Department of Veterans Affairs (VA) residential work therapy program.

METHOD

Data on 962 veterans treated in the VA Compensated Work Therapy/Transitional Residence Program were gathered. Multivariate analyses were used to compare black and white veterans on admission characteristics, program participation, and 3-month outcome.

RESULTS

The black subjects were younger than the white veterans and had more severe drug abuse problems, less severe alcohol and psychiatric problems, and more extensive social support networks. There were no differences between groups in 11 of 13 measures of program participation, although the blacks felt more positively about the therapeutic milieu and worked more hours per month in the work therapy program than the whites. The black veterans also showed more improvement in alcohol use and housing. The proportion of black participants at the site level had no impact on measures of program participation or outcome among black participants with one exception: blacks were more likely to achieve sobriety at 3 months when treated in programs with higher proportions of black participants.

CONCLUSIONS

Detailed data on program participation and outcome in a large study group showed no evidence of less program participation or worse outcome among black patients.

Psychological benefits and liabilities of traumatic exposure in the war zone

Data from the National Vietnam Veterans Readjustment Study on 1,198 Vietnam theater veterans were used to examine the psychological benefits and liabilities of traumatic exposure in the war zone. Psychological benefits and liabilities were found to be largely independent of one another and to be related positively to the dose of traumatic exposure. Additionally, there was a curvilinear trend in the form of an inverted U, such that psychological benefits, most notably solidarity with others, were stronger at intermediate compared to high and low levels of exposure. Psychological benefits counteracted and psychological liabilities passed through the effects of traumatic exposure on posttraumatic stress disorder (PTSD). The psychological benefit of self-improvement moderated the effects of the psychological liability of self-impoverishment on PTSD.

Does participation in psychosocial treatment augment the benefit of clozapine? Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia

BACKGROUND

This study examines the role of participation in psychosocial treatment as a mediator of the clinical effectiveness of clozapine.

METHODS

Subjects participated in a 12-month double-blind random-assignment trial comparing clozapine and haloperidol in patients hospitalized 30 to 364 days for refractory schizophrenia at 15 Department of Veterans Affairs medical centers. A broker-advocate case management intervention was used to facilitate participation in psychosocial treatments and to document such participation.

RESULTS

Between those who continued receiving clozapine (n=122) or a conventional antipsychotic drug (n=169) for 12 months, those receiving clozapine were more likely to participate in psychosocial rehabilitation treatment. Although they were no more likely to receive clinical recommendations for such treatments, they were more likely to both verbally accept recommendations and to act on them. Structural equation modeling shows that participation in psychosocial treatment did not play a mediating role in clozapine's effect on outcomes at 6 months, but was associated with both reduced symptoms and improved quality of life at 12 months.

CONCLUSIONS

Clozapine facilitates participation in psychosocial treatment, and such enhanced participation is associated with improved quality-of-life and symptom outcomes. Psychosocial rehabilitation should be offered concomitantly with clozapine.

Duty-related and sexual stress in the etiology of PTSD among women veterans who seek treatment

OBJECTIVE

The stressful experiences of women serving in the military have been a focus of increasing concern. A model of the impact of stress related to military duty and stress related to sexual abuse and harassment on the development of posttraumatic stress disorder (PTSD) among female veterans was evaluated.

METHODS

Structural equation modeling was applied to data from 327 women treated in a VA clinical program for women with stress disorders. The model was a chronological one and included variables related to the women's premilitary experience, their military service, and their postmilitary experience.

RESULTS

Altogether 48 percent of the sample served overseas, and 12 percent were exposed to enemy fire. A total of 63 percent reported experiences of physical sexual harassment during military service, and 43 percent reported rape or attempted rape. Both duty-related and sexual stress were found to contribute separately and significantly to the development of PTSD. Sexual stress was found to be almost four times as influential in the development of PTSD as duty-related stress. Postmilitary social support played a highly significant mediational role between sexual stress during military service and development of PTSD.

CONCLUSIONS

Women's exposure to sexual stress in the military is much more prevalent than previously believed. It is particularly toxic for the development of PTSD. Correct assessment is essential to effective treatment.

The effect of victimization on clinical outcomes of homeless persons with serious mental illness

OBJECTIVE

The study examined the prevalence and correlates of criminal victimization and the relationship between victimization and client outcomes for homeless clients with mental illness.

METHODS

Subjects were clients in community treatment programs participating in the Access to Community Care and Effective Services and Supports (ACCESS) program of the Center for Mental Health Services. Data were obtained through interviews conducted at program entry and at three and 12 months after entry with ACCESS clients in 18 sites during the first year of program operation (N = 1,839). Self-reports of victimization during the past two months as well as data on sociodemographic, health, and social adjustment indicators were obtained at each time point. Multiple regression was used to determine both the correlates of victimization among this population and the effect of recent victimization on client outcomes three and 12 months after program entry.

RESULTS

Forty-four percent of the clients were the victims of at least one crime during the two months before entering the program. Women were significantly more likely than men to have been victimized. Multivariate analysis showed that the more severe the client's psychotic symptoms, alcohol abuse, and criminal history, the more likely he or she was to have been victimized. Recent victimization had a significant impact on client outcomes in terms of increased homelessness and decreased quality of life. Victimization shortly before program entry was also the single most important predictor of victimization at both follow-up points.

CONCLUSIONS

These findings suggest the critical need for service providers who work with homeless people with serious mental illness to assess the extent to which they have been victims of crime and to address issues of victimization and safety along with psychiatric and social adjustment problems.