Temporary Financial Assistance for Housing Expenditures and Mortality and Suicide Outcomes Among US Veterans

Abstract

Introduction

It is unclear whether interventions designed to increase housing stability can also lead to improved health outcomes such as reduced risk of death and suicide morbidity. The objective of this study was to estimate the potential impact of temporary financial assistance (TFA) for housing-related expenses from the US Department of Veterans Affairs (VA) on health outcomes including all-cause mortality, suicide attempt, and suicidal ideation.

Methods

We conducted a retrospective national cohort study of Veterans who entered the VA Supportive Services for Veteran Families (SSVF) program between 10/2015 and 9/2018. We assessed the association between TFA and health outcomes using a multivariable Cox proportional hazards regression approach with inverse probability of treatment weighting. We conducted these analyses on our overall cohort as well as separately for those in the rapid re-housing (RRH) and homelessness prevention (HP) components of SSVF. Outcomes were all-cause mortality, suicide attempt, and suicidal ideation at 365 and 730 days following enrollment in SSVF.

Results

Our analysis cohort consisted of 41,969 unique Veterans with a mean (SD) duration of 87.6 (57.4) days in the SSVF program. At 365 days following SSVF enrollment, TFA was associated with a decrease in the risk of all-cause mortality (HR: 0.696, p < 0.001) and suicidal ideation (HR: 0.788, p < 0.001). We found similar results at 730 days (HR: 0.811, p = 0.007 for all-cause mortality and HR: 0.881, p = 0.037 for suicidal ideation). These results were driven primarily by individuals enrolled in the RRH component of SSVF. We found no association between TFA and suicide attempts.

Conclusion

We find that providing housing-related financial assistance to individuals facing housing instability is associated with improvements in important health outcomes such as all-cause mortality and suicidal ideation. If causal, these results suggest that programs to provide housing assistance have positive spillover effects into other important aspects of individuals’ lives.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11606-023-08337-7.

INTRODUCTION

Many studies have suggested a negative effect of homelessness on both physical and mental health, even as poor health can contribute to homelessness.^1–4 For instance, homelessness is associated with higher rates of chronic health conditions⁵ and can often exacerbate the symptoms and severity of these chronic diseases which can result in early-onset disability and costly inpatient care.^{6, 7} Individuals experiencing homelessness are also often victims of violence and exploitation⁸ and this lack of personal safety can lead to depression,⁹ chronic stress, and disrupted sleep patterns.¹⁰ Poor physical and mental health among people experiencing homelessness is often compounded by barriers to proper healthcare including overuse of emergency room, lack of preventive health services, fragmented care, and inadequate follow-up care.⁷

A recent systematic review affirms that individuals experiencing homelessness are at increased risk of early mortality.⁶ One study found that younger Veterans between the ages of 30 and 54 experiencing homelessness had a higher risk of death over the 10-year follow-up period compared to a non-homeless comparison group (HR = 2.9, 95% CI: 2.8–3.1)¹¹ while another found similar results for older Veterans age 55–59 (RR = 2.46, 95% CI: 2.23–2.66) and 60 and older (RR = 3.64, 95% CI: 3.33–3.98).¹² The most common causes of death in these studies were cardiovascular disease, neoplasms, and respiratory disease. Other studies focusing on non-Veteran populations found increased risk of deaths due to substance use disorder, accidental overdose, cancer, heart disease, assault, and HIV among homeless adults.^13–15

Despite findings that homelessness may place individuals at an increased risk of death, studies examining whether housing interventions can mitigate this risk offer mixed findings. However, some studies have shown that housing may decrease risk factors for death such as alcohol misuse,¹⁶ while others have found no effect on cardiovascular events.¹⁷ Most relevant to our current study are two recent, retrospective studies conducted among US Veterans. The first study was an examination of the US Department of Veterans Affairs (VA) homeless programs that found that enrollment in any of these programs, including Supportive Services for Veteran Families (SSVF), as well as the number of programs in which a Veteran is enrolled, was associated with a significant decrease in the risk of all-cause mortality and suicide for Veterans with evidence of housing instability.¹⁸ This important study established the notion that housing-focused social programs may have beneficial health effects for individuals facing housing instability but the programs studied cover a broad range of assistance types including inpatient residential treatment programs, permanent supportive housing, and transitional housing, and the study did not attempt to identify unique impact of specific programs. An important next step would be to identify components of specific programs that are particularly beneficial so as to better inform decisions around the targeting and funding of specific programs. The second study found no effect of social service use on suicide, suicidal ideation, and suicide attempt among three cohorts of Veterans with indicators of homelessness, unemployment, or criminal justice involvement.¹⁹ Given the inconsistent findings between these two studies, a deeper dive into the relationship between housing interventions and mortality outcomes is warranted.

Through the SSVF program, the VA partners with non-profit organizations (known as grantees) to provide housing support to Veterans facing housing instability. Veterans who are currently experiencing homeless at the time of enrollment in SSVF are provided rapid re-housing (RRH) services while those who are not currently homeless but at risk receive homelessness prevention (HP) services. In FY2019, SSVF awarded more than $350 million to 252 grantees that provided services to 72,640 Veteran households.²⁰ A key component of SSVF is temporary financial assistance (TFA), which can be used to pay rent, utility payments, security deposits, and other housing-related expenses. The average amount of TFA received over an entire SSVF episode is roughly $6000. We have found that TFA is associated with higher rates of stable housing²¹ as well as lower healthcare costs.²² In addition, in a mixed methods study, we found that a number of observable factors were associated with receiving TFA, including demographic (age, race, sex, and family composition) and socioeconomic (income, education, employment, and previous homelessness) characteristics.²³

In this paper, we extend these previous analyses which have looked generally at a wide range of VA homelessness programs by examining the potential effects of the TFA component of SSVF on health outcomes including all-cause mortality, suicide attempt, and suicidal ideation. This is the first study to examine the impact of providing short-term financial help for housing-related expenses on health outcomes for individuals facing housing insecurity.

METHODS

Setting and Population

This analysis applies a historical cohort study design with SSVF service episodes from October 2015 to September 2018. If a Veteran enrolled in SSVF multiple times during this time period, only their first episode was included in our analysis.

Data

SSVF grantees enter information for SSVF-enrolled Veterans into a system established by the US Department of Housing and Urban Development for collecting information about persons accessing homeless assistance systems, Homeless Management Information Systems (HMIS). This information includes demographic characteristics, employment and education status, receipt of TFA, and receipt of other social benefits as well as entry and exit dates into SSVF. We used HMIS data to identify episodes of SSVF services as well as Veteran characteristics. In addition, we used the SSVF grantee determinations from their HMIS data entries as to whether the enrollee was currently experiencing homelessness or was at risk for homelessness. Enrollment in VA homeless programs other than SSVF was obtained from the VA Homeless Operations Management and Evaluation System. We used data from the VA Corporate Data Warehouse and Managerial Cost Accounting system for Veterans’ comorbid conditions and VA healthcare costs, respectively. Finally, mortality was obtained from the VA Vital Status File.

Outcomes

The outcomes in this study were all-cause mortality, suicide attempt, and suicidal ideation in the 350 and 730 days following enrollment in SSVF. International Classification of Disease, 10th edition (ICD-10) codes were used to identify suicide attempt (T14.91, X71–X83) and suicidal ideation (R45.851). We also explored death by suicide as an outcome but, ultimately, did not include it in the analysis because it occurred too infrequently.

Independent Variables

Our key independent variable was an indicator for whether the Veteran received any TFA during their SSVF episode. In secondary analyses, we expanded the TFA indicator variable to be a categorical variable characterizing the total amount of TFA received ($0, $1–$2000, $2001–$4000, $4001–$6000, or more than $6000).

In multivariable regression models, we included a number of independent variables to reduce the effect of confounding on the relationship between TFA and mortality and suicide outcomes. These independent variables included demographic characteristics (such as age, sex, presence of spouse or partner, number of children < 18 years of age, rurality, and race) and socioeconomic status (including income, education, employment, and prior homelessness). We also included indicators for enrollment in other social benefit programs, health insurance from a variety of sources, VA disability benefits, and enrollment in other VA homeless programs. Finally, we included the Charlson Comorbidity Index, indicators for fiscal year of the SSVF episode and the grantee that administered the SSVF episode, and the zip code Area Deprivation Index.^{24, 25}

Statistical Analysis

We constructed separate Kaplan–Meier curves for Veterans in our sample receiving and not receiving TFA for each of the three outcomes. These curves were constructed separately for Veterans enrolling in the RRH and HP components of SSVF. Veterans in our sample who did not experience an event were censored at 730 days.

To estimate the association between TFA and mortality and suicide outcomes, we first generated a propensity score using a multivariable logistic regression model in which receipt of TFA served as the outcome and the full set of additional covariates described above served as the predictors. We then used this propensity score to perform an inverse probability of treatment weighting (IPTW) analysis using a multivariable Cox proportional hazards regression model. To reduce the influence of outliers, we truncated our weights at the 5th and 95th percentile.^{26, 27} We ran these models for all SSVF-enrolled Veterans as well as separately for Veterans enrolling in the RRH and HP components of SSVF. In addition, we ran separate versions of each model with censoring at 365 days and at 730 days.

RESULTS

Table 1 shows summary statistics comparing characteristics of the Veterans in our cohort who did (N = 29,184) and did not (N = 12,785) receive TFA during their SSVF episode. Those who received TFA were more likely to be female (13.0% vs. 12.2%, p = 0.029), have dependent children (22.2% vs. 20.5%, p < 0.001), receive healthcare through the VA (77.3% vs. 71.6%, p < 0.001), participate in the HUD-VASH program (20.9% vs. 11.2%, p < 0.001), have been homeless in the 3 years prior to SSVF entry (39.0% vs. 37.2%, p = 0.001), and have a mental health diagnosis (54.7% vs. 51.8%, p < 0.001). While these differences were statistically significant, they were small in magnitude.

Table 1.

Descriptive Statistics of National Cohort of Veterans Receiving SSVF in FY2016–2018, by TFA Receipt

	TFA		No TFA
Characteristic	Count/mean	%/SD	Count/mean	%/SD	p-value
Total	29,184		12,785
Age	50.4	12.9	50.0	13.3	0.003
< 40	7089	24.3%	3323	26.0%
40–50	4702	16.1%	2053	16.1%	0.002
50–60	9607	32.9%	4048	31.7%
60 +	7786	26.7%	3361	26.3%
Female	3788	13.0%	1556	12.2%	0.029
Spouse or partner	5436	18.6%	2211	17.3%	0.001
Children	6481	22.2%	2624	20.5%	< 0.0001
Race
White	16,033	54.9%	7256	56.8%	< 0.0001
African American	12,834	44.0%	5268	41.2%
Native American	872	3.0%	519	4.1%
Other	497	1.7%	212	1.7%
Rurality	3251	11.1%	1419	11.1%	0.903
Total monthly income
$0	8670	29.7%	4102	32.1%	< 0.0001
$0–$500	2841	9.7%	1168	9.1%
$500–$1500	12,641	43.3%	5160	40.4%
> $1500	5032	17.2%	2355	18.4%
Education
Less than HS	14,380	49.3%	6469	50.6%	0.020
Completed HS	7849	26.9%	3402	26.6%
Some college	4244	14.5%	1827	14.3%
College degree	2711	9.3%	1087	8.5%
Employment
No evidence	28,056	96.1%	12,318	96.3%	0.128
Part-time employment	336	1.2%	160	1.3%
Full-time employment	792	2.7%	307	2.4%
Income type
Earned	5145	17.6%	2208	17.3%	0.373
SSI	3652	12.5%	1587	12.4%	0.770
VA disability	9159	31.4%	3808	29.8%	0.001
Other	533	1.8%	242	1.9%	0.641
Public benefits
SNAP	10,872	37.3%	4351	34.0%	< 0.0001
Other benefits	1217	4.2%	485	3.8%	0.072
Health insurance
Medicaid	4314	14.8%	2178	17.0%	< 0.0001
Medicare	2428	8.3%	1176	9.2%	0.003
VA medical services	22,553	77.3%	9151	71.6%	< 0.0001
Employer provided	459	1.6%	204	1.6%	0.863
Other health insurance	1265	4.3%	622	4.9%	0.016
Homeless in last 3 years	11,374	39.0%	4759	37.2%	0.001
Type of SSVF benefits
Homelessness prevention	9337	32.0%	3849	30.1%	< 0.0001
Rapid re-housing	18,346	62.9%	8337	65.2%
Both	38	0.1%	15	0.1%
Missing	1463	5.0%	584	4.6%
Homeless programs
HUD-VASH	6089	20.9%	1434	11.2%	< 0.0001
GPD	3235	11.1%	1400	11.0%	0.686
Other	4377	15.0%	1739	13.6%	< 0.0001
Charlson Comorbidity Index	1.0	2.0	0.9	1.9	0.000
Mental health diagnosis	15,973	54.7%	6618	51.8%	< 0.0001

Source: Authors’ analysis of VA data from cohort of SSVF enrollees

Note: SSI supplemental security income, SNAP Supplemental Nutrition Assistance Program, HUD-VASH US Department of Housing and Urban Development-VA Supportive Housing, GPD Grant and Per Diem. A p-value of 0.05 was used as the threshold for statistical significance

Supplemental Fig. 1 shows that for Veterans enrolled in the RRH component of SSVF, the percentages of all-cause mortality (1.9% vs. 2.2%), suicide attempt (0.8% vs. 0.9%), and suicidal ideation (6.0% vs. 6.4%) were lower for those who received TFA compared to those who did not over a 365-day time horizon. For the most part, this was true for the 730-day time horizon as well as for Veterans enrolled in the HP component of SSVF (Supplemental Fig. 2).

Figures 1 and 2 show Kaplan–Meier survival curves for all-cause mortality, suicide attempt, and suicidal ideation outcomes for RRH and HP, respectively. It is clear from these curves that suicidal ideation occurs more frequently than mortality or suicide attempt. In addition, there appears to be separation between the TFA and no TFA curves in these figures for the mortality and suicidal ideation outcomes.

Fig. 1.

Kaplan–Meier curves depicting the proportion of individuals in our cohort who have not had an event (mortality, suicide attempt, suicidal ideation) at a given time up to 730 days from the index date—rapid re-housing only.

Fig. 2.

Kaplan–Meier curves depicting the proportion of individuals in our cohort who have not had an event (mortality, suicide attempt, suicidal ideation) at a given time up to 730 days from the index date—homelessness prevention only.

In multivariable IPTW analyses (Table 2), TFA was associated with a decreases in the risk of mortality at 365 days (HR: 0.755, p = 0.004) and suicidal ideation at 365 (HR: 0.844, p = 0.002) and 730 (HR: 0.897, p = 0.013) days. These effects were driven entirely by Veterans in the RRH component of SSVF as we found no impact of TFA on any outcomes for those in the HP component.

Table 2.

Multivariable IPTW Cox Proportional Hazards Regression Relating TFA Receipt to All-Cause Mortality and Suicide Outcomes

	365 days				730 days
			95% CI				95% CI
Outcome	HR	p-value	LL	UL	HR	p-value	LL	UL
Overall (N = 41,969)
All-cause mortality	0.755	0.004	0.624	0.915	0.887	0.079	0.776	1.014
Suicide attempt	0.780	0.084	0.589	1.034	0.922	0.471	0.740	1.149
Suicidal ideation	0.844	0.002	0.758	0.939	0.897	0.013	0.823	0.978
Rapid re-housing only (N = 26,683)
All-cause mortality	0.726	0.007	0.574	0.917	0.892	0.165	0.760	1.048
Suicide attempt	0.813	0.201	0.591	1.117	0.949	0.685	0.735	1.224
Suicidal ideation	0.834	0.005	0.735	0.945	0.895	0.034	0.807	0.991
Homelessness prevention only (N = 13,185)
All-cause mortality	0.826	0.367	0.545	1.251	0.850	0.275	0.636	1.138
Suicide attempt	0.797	0.509	0.406	1.564	0.849	0.538	0.505	1.428
Suicidal ideation	0.846	0.164	0.668	1.070	0.909	0.310	0.755	1.093

Note: Multivariable IPTW Cox proportional hazards regression models included the following covariates: demographic variables (age, sex, presence of spouse or partner, presence of children, and race); socioeconomic status (total monthly income, education, employment, number of times the Veteran was homeless in the previous 3 years); indicators for the type of income (earned, supplemental security income (SSI), VA disability, and other); indicators for publicly funded benefit programs (Supplemental Nutrition Assistance Program (SNAP) and other benefits); health insurance variables (Medicaid, Medicare, VA healthcare, and other health insurance); indicators for enrollment in other VA homelessness programs (US Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) vouchers, Grant and Per Diem (GPD), and other programs); Charlson Comorbidity Index; mental health diagnoses; VA healthcare cost in the 365 days prior to the index date; rurality; fiscal year of the SSVF episode; zip code Area Deprivation Index; and indicator for grantee. A p-value of 0.05 was used as the threshold for statistical significance

Compared to those in the RRH group receiving no TFA, Veterans receiving between $2001–$4000 (HR: 0.753, p = 0.036) or $4001–$6000 (HR: 0.582, p < 0.001) in TFA had a lower risk of all-cause mortality at 365 days and those receiving $4001–$6000 in TFA (HR: 0.704, p = 0.001) had a lower risk of all-cause mortality at 730 days using the multivariable regression approach (Table 3). Using this same approach, we found a negative association between suicidal ideation and nearly all amounts of TFA with HRs ranging from 0.811 (p = 0.005) for $1–$2000 to 0.860 (p = 0.034) for more than $6000 at 365 days. At 730 days, Veterans receiving $1–$2000 (HR: 0.874, p = 0.024) in TFA were less likely to have a diagnosis of suicidal ideation than those receiving no TFA.

Table 3.

Multivariable IPTW Cox Proportional Hazards Regression Results Relating Amount of TFA Received to All-Cause Mortality and Suicide Morbidity Outcomes (N = 41,969)

	365 days				730 days
			95% CI				95% CI
Outcome	HR	p-value	LL	UL	HR	p-value	LL	UL
All-cause mortality
Total amount of TFA (ref = $0)	-	-	-	-	-	-	-	-
$0–$2000	0.806	0.100	0.623	1.042	0.951	0.576	0.796	1.135
$2000–$4000	0.753	0.036	0.577	0.982	0.909	0.291	0.761	1.085
$4000–$6000	0.582	< 0.001	0.430	0.788	0.704	0.001	0.570	0.869
$6000 +	0.815	0.108	0.635	1.046	0.918	0.333	0.772	1.091
Suicide attempt
Total amount of TFA (ref = $0)	-	-	-	-	-	-	-	-
$0–$2000	0.850	0.404	0.582	1.244	1.039	0.795	0.780	1.383
$2000–$4000	0.712	0.080	0.486	1.041	0.922	0.582	0.691	1.230
$4000–$6000	0.695	0.109	0.446	1.084	0.849	0.347	0.604	1.194
$6000 +	0.831	0.342	0.567	1.217	0.868	0.365	0.640	1.178
Suicidal ideation
Total amount of TFA (ref = $0)	-	-	-	-	-	-	-	-
$0–$2000	0.811	0.005	0.701	0.938	0.874	0.024	0.777	0.983
$2000–$4000	0.842	0.020	0.728	0.974	0.906	0.094	0.807	1.017
$4000–$6000	0.865	0.072	0.739	1.013	0.916	0.172	0.807	1.039
$6000 +	0.860	0.034	0.748	0.989	0.897	0.060	0.802	1.005

Note: TFA temporary financial assistance, SSVF Supportive Services for Veteran Families, RRH rapid-re-housing, HP homelessness prevention. Multivariable IPTW Cox proportional hazards regression models with random effects for the Veteran and quarter included the following covariates: demographic variables (age, sex, presence of spouse or partner, presence of children, and race); socioeconomic status (total monthly income, education, employment, number of times the Veteran was homeless in the previous 3 years); indicators for the type of income (earned, supplemental security income (SSI), VA disability, and other); indicators for publicly funded benefit programs (Supplemental Nutrition Assistance Program (SNAP) and other benefits); health insurance variables (Medicaid, Medicare, VA healthcare, and other health insurance); indicators for enrollment in other VA homelessness programs (US Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) vouchers, Grant and Per Diem (GPD), and other programs); Charlson Comorbidity Index; mental health diagnoses; VA healthcare cost in the 365 days prior to the index date; rurality; fiscal year of the SSVF episode; zip code Area Deprivation Index; and indicator for grantee. A p-value of 0.05 was used as the threshold for statistical significance

As shown in Supplemental Tables 1 and 2, the associations between TFA amount and all-cause mortality and suicidal ideation were driven entirely by Veterans in the RRH component of SSVF.

DISCUSSION

In this study, we found that receipt of TFA was associated with a decrease in the incidence of all-cause mortality and suicidal ideation for those in the RRH component of SSVF (i.e., those experiencing homelessness at the time of enrollment in the SSVF program). However, we found no association between TFA and rates of suicide attempt in the RRH Veterans or on any of the outcomes in those enrolled in the HP component of SSVF (i.e., those at risk of homelessness at the time of enrollment in the SSVF program). Moreover, we did not find evidence that the receipt of relatively more TFA in dollar terms was associated with additional reductions in risk of our outcomes, a finding that is consistent with recent research²⁸ showing that the monetary value of federal low-income housing assistance is associated with reduced health care hardship, but not with improvements in overall health, chronic health, or acute health conditions.

Since 2012, the VA has had an electronic health record–based universal screen for housing instability.³⁰ Veterans who screen positive for housing insecurity are then connected with services, including SSVF, through a VA social worker or VA homeless program staff member. However, there is wide variability in how this screener is administered³¹ and in the type of services to which a Veteran is connected following a positive screen.³² Unfortunately, with an ever-expanding list of regular clinical reminders, especially in primary care, overburdened clinicians will often ignore or bypass these reminders.³³ With our findings of health improvements from an intervention that provides financial assistance for housing expenses, VA healthcare providers could see a clear link between addressing a social determinant of health and actual health outcomes. As a result, healthcare providers may feel more confident in administering the VA housing instability screener since there is a specific program available with a wide variety of benefits to which a Veteran can be connected in the event of a positive screen.

Another interesting implication of our findings is that our data pre-date a number of new components that have been introduced in SSVF recently and which may bolster the impact of TFA receipt on health outcomes. One such component is healthcare navigators, which were introduced in October 2020 as part of new funding from the Coronavirus Aid, Relief, and Economic Security (CARES) Act. These healthcare navigators help Veterans enrolled in the SSVF program connect to healthcare services both within and beyond the VA healthcare system. While our results show an important health benefit associated with financial assistance, future work should investigate whether healthcare navigators provide even more health benefits to SSVF enrollees. Moreover, our findings may have implications that extend beyond the VA to the community-based homeless assistance system, where the availability of programs that provide RRH services (including TFA) has increased by roughly three-fold between 2014 and 2022.³⁴ Future research should thus expand the scope of the present study to examine the impact of TFA on the non-Veteran homeless population.

Among the few studies that have examined the impact of housing programs on mortality and suicide outcomes, most have looked at permanent supportive housing rather than temporary financial assistance, as we have done here. However, those other studies report mixed results^35–37 despite a well-established relationship between homelessness and health.³⁸ Similarly, a randomized trial of Housing First in 5 Canadian cities found no effect on suicidal ideation or suicide attempt. Evidence of a protective relationship between housing interventions and mortality outcomes has been more promising within the VA system. Montgomery and colleagues found that accessing any of the 6 VA homeless programs was associated with a reduced risk of death.¹⁸

Our study had several limitations. First, although our study controlled for a range of comorbidities, demographic characteristics, and socioeconomic factors among persons who received and did not receive TFA, it remains possible that persons were selected for TFA based on characteristics not captured in our database. Second, because the TFA intervention is specific to the SSVF program and the US Veteran population, caution is recommended before generalizing our findings to other groups of homeless individuals. While Veterans may have similar observable characteristics to Medicare enrollees, they are very different from those enrolled in Medicaid or private insurance.³⁹ Third, our suicide attempt and suicidal ideation outcomes were only measured through encounters in the VA healthcare system. It is relatively common for US Veterans to obtain care from non-VA facilities and, therefore, we may not have fully captured all of the suicide attempts or suicidal ideation events that these individuals experienced. Also, as documented by other researchers, suicidal ideation and suicide attempt are often underreported in ICD codes. Fourth, data are recorded in HMIS by personnel at SSVF grantees throughout the course of a Veteran’s SSVF experience. These data elements are often self-reported to grantee personnel by SSVF enrollees and, therefore, may be subject to error.

While it is important to keep these limitations in mind, our study also had a number of important strengths. First, to our knowledge, this is the first study to seek evidence of impact of TFA on health outcomes. TFA itself is a unique intervention in that, by design, it is short-term (the mean SSVF episode length is only 90 days) and relatively inexpensive (roughly $6000 per episode, on average). Other housing interventions, including permanent supportive housing, consist of long-term housing subsidies along with case management and other supportive services which can place a large financial burden on local housing agencies which often have limited funds. The fact that we identified an association between TFA and mortality and suicidal ideation only for those enrolled in the RRH component of SSVF could suggest that there may be a larger mental health benefit in helping currently homeless persons access stable housing as compared to providing persons at-risk of homelessness with assistance in maintaining their housing. The mechanism has to do with each intervention’s actual effect on individuals’ housing: re-housing a homeless individual removes them from the immediate threat to their health of continued homelessness, whereas homelessness prevention is difficult to efficiently target,²⁹ and thus, providing prevention services may have less impact on individuals’ mental health status.

Second, we used the VA Vital Status file to obtain death dates which includes data from the VA, Medicare, and the Social Security Administration and has sensitivity greater than 97%.⁴⁰ Third, while many published studies assessing the impact of housing interventions on individual outcomes in the USA have focused on limited geographic areas,^{41, 42} our study focused on a nationwide program with participants in nearly every state in the USA.

Our findings of a positive health benefit from TFA from this study support the continuation of these benefits for Veterans within the SSVF program but also expansion of this mechanism for other individuals facing housing instability. Future studies should build off these analyses to examine the impact of SSVF as a whole, not just the TFA component, on mortality and suicide outcomes. In addition, the results described here could be used as inputs to an economic evaluation comparing the relative benefits and costs of TFA as a housing intervention.

Supplementary Information

Below is the link to the electronic supplementary material.

Data Availability

All data from the this study are stored on secured, password-protected VA servers behind a firewall used by the Department of Veterans Affairs (VA) in a secure research environment known as the VA Informatics and Computing Infrastructure (VINCI). Sensitive patient data does not leave the VA environment; only aggregate summary statistics and results of our analyses are permitted to be removed from behind the VA firewall in compliance with the VA information security program policies, procedures, and practices. Access to a deidentified dataset can be made available pending ethical approval and in accordance with VA guidelines. Those wishing to access the study data may contact the corresponding author to discuss the VA data access approval process.

Declarations

Conflict of Interest

All authors declare that they have no conflicts of interest.