DESCRIPTION (provided by applicant): Background: Veterans are overrepresented within the homeless population-comprising approximately 12% of homeless adults-and are at a particularly high risk of homelessness compared to the general population of individuals living in poverty. To prevent and end homelessness among veterans, the U.S. Department of Veterans Affairs (VA) has refined its programming and policies to focus on ending chronic homelessness and preventing new episodes of homelessness. To support the latter, VA has allocated close to $1 billion toward homelessness prevention services since Federal Fiscal Year (FFY) 2011 through the Supportive Services for Veteran Families (SSVF) program. To assist in the identification of veterans in need of homelessness prevention, the National Center on Homelessness Among Veterans developed the Homelessness Screening Clinical Reminder (HSCR), a two-question universal screener that assesses housing instability and risk among veterans who present for outpatient care and are not already engaged with VA Homeless Programs. During FFY 2013, more than 4 million veterans accessing outpatient health services through the Veterans Health Administration (VHA) responded to the HSCR. Among those screened, 0.8% reported current homelessness and 1.0% reported imminent risk. Veterans who screen positive are offered a referral for further assessment and intervention; of note is the community-based SSVF program, which provides supportive services and temporary financial assistance to quickly end or prevent episodes of homelessness. Objectives: The proposed study will evaluate VA's efforts at identifying veterans at risk of homelessness and linking them with services of their choosing that are both efficient and effective. The objectives are: 1. To validate the HSCR and assess prevalence and risk factors for homelessness and imminent risk among veteran users of VHA healthcare services. 2. To assess the effectiveness of the HSCR at linking veterans who screen positive for homelessness or risk with subsequent services. 3. To evaluate the psychometric properties and efficacy of an existing instrument (SSVF Instrument) used by the SSVF program to quantify risk of homelessness among veterans. Methods: The proposed study will employ a mixed methods approach, using a combination of data from existing VA data sources and primary data collection. The evaluation and validation of the two instruments identified here-the HSCR and SSVF Instrument-will use secondary data collected during regular VA operations. To assess the effectiveness of the HSCR at linking veterans to needed services, the study team will use a mixed methods explanatory sequential design whereby initial analysis of secondary quantitative data will be followed by primary qualitative data collection. Anticipated Impact on Veteran's Healthcare: The existing body of research related to homelessness prevention is limited in terms of its practical application to policies and programs; the primary contribution of this study will be the examination and refinement of the current set of policies and practices to identify, refer, and intervene with veterans who are experiencing homelessness or are at risk. This study will have an immediate impact on the system of care by informing and guiding more efficient and effective use of homelessness prevention resources. CRITIQUE 1 1. Significance. This project evaluates the Homelessness Screening Clinical Reminder (HSCR), a two-question universal screener that assesses housing instability and risk among veterans who present for outpatient care and are not already engaged with VA Homeless Programs. For patients that screen positive through the HSCR, they are referred as an option to the Supportive Services for Veteran Families (SSVF) program. The SSVF provides supportive services and temporary financial assistance to quickly end or prevent episodes of Homelessness may use its well-funded resources (approaching $1B), for further assessment and intervention. This project addresses a high priority area of the VA. The main objectives are: 1. To validate the Homelessness Screening Clinical Reminder (HSCR) and assess risk factors for current homelessness and imminent risk of homelessness among Veteran users of Veterans Health Administration. 2. To assess the effectiveness of the HSCR at linking Veterans who screen positive for homelessness or risk with subsequent services. 3. To evaluate the psychometric properties and efficacy of an existing instrument used by the Supportive Services for Veteran Families (SSVF) program to quantify risk of homelessness among Veterans. 2. Approach (including Feasibility). As stated in the grant summary, the proposed study will use a mixed methods approach and a combination of data from existing VA data sources and primary data collection. The evaluation and validation of the two instruments identified here-the HSCR and SSVF Instrument-will use secondary data collected during regular VA operations. To assess the effectiveness of the HSCR at linking veterans to needed services, the study team will use a mixed methods explanatory sequential design whereby initial analysis of secondary quantitative data will be followed by primary qualitative data collection. AIM 1 For Aim 1, the research team will collect secondary data from VA data sources. will use a prospective cohort design and data from CDW and Homeless registry to model (statically) screened participants administratively for up to 24 months prior to and following the date of their initial screening to determine homelessness status and services utilization (Dependent VARS (TABLE 3): Current housing instability, Risk of homelessness, Recurrent housing instability/risk, Resolved housing instability/risk, Recent housing instability/risk, Use of VA Homeless Programs) (Independent VARS (TABLE 4): demographics, OEF/OIF, VBA Pension, use of VHA homeless programs 18 mo. pre-screen, etc.). AIM 2 uses a mixed methods explanatory sequential design: initial analysis of secondary quantitative data, followed by primary, qualitative data collection to explain how screening links Veterans to services. Qualitative data will be collected from two key stakeholder groups-veterans and VA social workers-will explicate and expand upon quantitative findings, etc. By conducting interviews with social workers from PVAMC and CVAMC will complement interviews with veterans. AIM 3 will use secondary quantitative data collected by VA social workers using the SSVF Instrument as part of regular operations. The evaluation of the SSVF Instrument will use administrative data collected during ongoing operations at 4 VAMCs: Philadelphia, PA; Bay Pines, FL; Bedford, MA; and Los Angeles, CA (TABLE 7). 3. Impact and Innovation. This project seems rather logical and I believe will be impactful. That is given the amount of financial resources aimed at homelessness ($450M+) it seem rather logical to have an evaluation to determine if they are being appropriately used to the correct individuals by evaluating the screening through HSCR and SSVF. Again as stated by reviewer #1 - one limitation is that there is no cost effectiveness of the various interventions that SSVF may provide. Instead the study will refine the SSVF instrument which assesses veterans' homelessness risk. What is done subsequently compared to alternatives with SSVF financial resources and related outcomes is as worthy an AIM as the preceding validation of instruments, etc. but is unfortunately not part of this study but should be evaluated in subsequent study. 4. Investigator Qualifications, and Facilities and Resources. Improved team based on response to previous review 5. Multiple PI Leadership Plan. (if applicable) 6. Adequacy of Response to Previous Feedback Provided by HSR&D Regarding the Proposed Study. The application responded well and appropriately to the previous critique. The previous critique echoed the first critique that this is still a very ambitious project-and it remains so in this revision. However, this revision of the proposal has made the case well that this ambition is appropriate, needed for the complete investigation of the topic of the proposal, and feasible. Despite the last critique's comment about the project's ambition, it recommended the addition of cost-effectiveness analysis and expansion of the study to include Veterans who do not use VA services. These suggestions were credibly dismissed by the revised proposal as beyond the scope of this study and not feasible. The application was responsive to the need identified by the critique to include variables that were lacking for substance abuse and mental health service use that may be important for outcomes. Importantly, the proposal added expertise in informatics (Dr. Gundlapalli and supporting staff) that was noted in the prior critique as needed for obtaining and managing large, complex VHA data sources. 7. Protection of Human Subjects from Research Risk. No concerns. 8. Inclusion of Women and Minorities in Research. No concerns. 9. Budget. No concerns. 10. Overall Impression. This very well-written application has been very responsive to two previous rounds of critiques. The application addresses a high-priority area for the VA-Veteran homelessness-and it proposes to investigate the VA's current procedures for identifying Veterans needing homeless services and linking them to those services. It remains an ambitious study, but the application convincingly makes the case that it can be done and that the proposed research plan is a cohesive and feasible research project. A minor point is that there was little to no description o how quantitative and qualitative data in Aim 2 will contribute to results in a manner that is greater than the sum of the findings of each alone, in a mixed methods strategy. 11. Key Strengths. 1. Aims are straightforward and their purpose is strong and clear; well-written application. 2. Significance is high for VA priority areas (Veteran homelessness and VA's ability to identify Veterans with needs and link them to homeless services). 3. The mixed methods aim elegantly describes the use of qualitative and quantitative investigation of the topic of the study. 12. Key Weaknesses. 1. More description of the combination of findings from the qualitative and quantitative studies to yield mixed model findings that are greater for both combined than for either alone for Aim 2 would be informative. 2. More detail on how statistically significant findings from analyses of giant datasets will be handled in terms of clinical or theoretical significance and meaningfulness would be useful.

This study will use a mixed methods approach to examine and refine VA's policies and practices to identify, refer, and intervene with veterans experiencing homelessness or risk. This study will impact the system of care by informing and guiding more efficient and effective use of homelessness prevention resources. Specifically, using responses to VA's Homelessness Screening Clinical Reminder (HSCR)—a universal screener of homelessness and imminent risk among veterans—this study will assess prevalence and risk for homelessness among veterans. In addition, the study will evaluate the effectiveness of the HSCR at linking veterans who screen positive for homelessness or risk with services and explore factors related to veterans' positive screens and reasons they accept or refuse referrals. The study will also evaluate an existing instrument used by the Supportive Services for Veteran Families (SSVF) program—a VA-funded, community- based, nation-wide homelessness prevention program—to quantify risk of homelessness among veterans.