Abstract
Objective
To evaluate universal suicide risk screening and evaluation processes among newly homeless Veterans.
Study Setting
Not applicable.
Study Design
Examination of Veterans Health Administration (VHA) using newly homeless patients' health record data in Calendar Year 2021.
Data Collection
Not applicable.
Data Source
Health record data.
Principal Findings
Most patients received suicide risk screening and/or evaluation in the year prior to and/or following homeless identification (n = 49,505; 87.4%). Smaller percentages of patients were screened and/or evaluated in close proximity to identification (n = 7358; 16.0%), 1–30 days prior to identification (n = 12,840; 39.6%), or 1–30 days following identification (n = 14,263; 34.3%). Common settings for screening included primary care, emergency and urgent care, and mental health services. Of positive screens (i.e., potentially elevated risk for suicide), 72.6% had a Comprehensive Suicide Risk Evaluation (CSRE) completed in a timely manner (i.e., same day or within 24 h). Age, race, and sex were largely unrelated to screening and/or evaluation.
Conclusions
Although many newly identified homeless patients were screened and/or evaluated for suicide risk, approximately 13% were not screened; and 27% of positive screens did not receive a timely CSRE. Continued efforts are warranted to facilitate suicide risk identification to ensure homeless patients have access to evidence‐based interventions.
Keywords: homeless, suicide risk evaluation, suicide risk screening, Veteran
What is known on this topic
Homeless Veterans are at elevated risk for suicide, with pronounced risk upon the onset of homelessness.
Suicide prevention for these Veterans requires adequate identification through screening and evaluation.
Nonetheless, suicide risk screening and evaluation can be challenging with this population of Veterans given their often complex medical and psychosocial needs.
What this study adds
This is the first large‐scale evaluation of suicide risk screening and evaluation among newly homeless Veterans.
Many newly identified homeless patients were screened and/or evaluated; however, approximately 13% were not screened; and 27% of positive screens did not receive a timely suicide risk evaluation.
Although universal suicide risk screening and evaluation initiatives can be implemented for homeless patients, additional efforts to identify facilitators and barriers to identify risk and provide evidence‐based intervention remain necessary.
1. INTRODUCTION
Homeless Veterans are at elevated risk for suicide relative to non‐Veteran homeless adults 1 and members of the general Veteran population. 2 , 3 This risk is pronounced during the period immediately preceding an episode of homelessness. Culhane and colleagues 4 found suicide‐related treatment (i.e., treatment focused on addressing suicidal ideation and/or preventing a future suicide attempt) often peaked 2 weeks preceding the onset of homelessness, during which Veterans were eight times more likely to seek suicide‐related services.
Identification of suicide risk near the onset of homelessness is therefore critical to prevention efforts. Population‐level, standardized suicide risk screening can facilitate detection among these Veterans. In 2018, the Department of Veterans Affairs (VA) Suicide Risk Identification Strategy (i.e., VA Risk ID) 5 was implemented enterprise‐wide. In 2021, the VA Risk ID policy was updated to require all patients be screened and/or evaluated for risk, annually (i.e., at first encounter or within a year of their prior screening). If patients screen positive for elevated suicide risk (i.e., suicidal intent, plan, method, recent suicide attempt per the Columbia‐Suicide Severity Rating Scale [C‐SSRS] Screener), it is then required that providers conduct a timely (i.e., same day or within 24 h depending on setting) Comprehensive Suicide Risk Evaluation (CSRE). 5 , 6 , 7 VA Risk ID also mandates more frequent screening for risk in specific service settings. Two settings frequently accessed by homeless patients with additional requirements include (1) homeless programs, which provide services to those experiencing or at risk for homelessness (at intake, unless the patient was screened or evaluated 30 days prior), and (2) emergency and urgent care settings (at every encounter).
Given that some homeless Veterans may not use Veterans Health Administration (VHA) homeless services, 8 suicide prevention for newly identified homeless Veterans requires an enterprise‐wide approach. Homeless Veterans often seek emergency or urgent care services to address acute symptoms (e.g., exposure to extreme temperatures). Despite many Veterans in these settings being initially identified as homeless, some do not engage with homeless services even after outreach. As such, it is important that VA Risk ID be evaluated across VHA to ensure that best practices are implemented and equitable care is available.
There has been limited evaluation of VA Risk ID among patients accessing VHA services who are newly identified as being homeless. We examined whether VHA patients newly identified as homeless in calendar year 2021 received suicide risk screening and/or evaluation in the year prior to or following identification. Data collected included timing from identification of homelessness to suicide risk screening, VHA service setting where screening occurred, and suicide risk stratification. In addition, we examined whether sociodemographic factors were related to screening and/or evaluation.
2. METHODS
2.1. Participants and procedure
Patients who were documented as newly homeless in Calendar Year 2021 were identified using the VHA Corporate Data Warehouse (CDW; see Supplementary Table 1). Patients were excluded if they were identified in CDW as homeless prior to 2021. Patient sociodemographic factors (i.e., age, sex, race) were also obtained from CDW. This study was exempted for review by the local Institutional Review Board and approved by the local VA Research and Development Committee. For additional information regarding VA Risk ID, see Bahraini et al. 6
2.2. Measures
The C‐SSRS Screener assesses for suicidal ideation, method, intent, and plan in the past 30 days. Additional items assess recent (i.e., past 3 months) and lifetime suicide attempt. A positive screen for elevated suicide risk on the C‐SSRS Screener is defined as the patient endorsing suicidal intent, presence of a suicide plan or method, or a recent suicide attempt. The C‐SSRS Screener has evidence of reliability and validity. 6 , 8
The CSRE is a clinical tool, developed by the VA Risk ID workgroup, that facilitates evaluation of evidence‐based factors related to suicide including suicidal ideation, plan, intent, suicidal behaviors, and risk and protective factors. Practitioners synthesize these data to stratify the patient's acute (i.e., in the immediate future, such as hours or days) and chronic (i.e., longer‐term, such as weeks or months) risk for suicide (i.e., low, intermediate, high). Suicide risk stratification informs a suicide risk mitigation plan (e.g., Safety Plan, hospitalization). 9 For additional information regarding the CSRE, see Bahraini et al. 6
2.3. Analytic plan
Using data from Calendar Year 2021, we determined each patient's earliest date in which they were identified as homeless. Using this date, we identified whether the patient had at least one eligible encounter (workload outpatient encounter [e.g., a visit with an International Classification of Diseases [ICD] diagnosis and Current Procedural Terminology [CPT] procedure] or inpatient admission) during six different timeframes: (1) same day as identification (for emergency and urgent care as well as inpatient services, same day was defined as within 24 h); (2) 1–30 days prior to identification; (3) 31–365 days prior to identification; (4) 1–30 days following identification; (5) 31–365 days following identification; and (6) 365 days prior to identification through 365 days following identification. We further identified if the patient had at least one C‐SSRS and/or CSRE during each timeframe. If a patient did not have an eligible encounter during a timeframe, they were not included in the numerator and denominator for that timeframe. The percentage of patients that received suicide risk screening (i.e., C‐SSRS) and/or evaluation (i.e., CSRE) was then calculated. Providers have the option to administer the CSRE without a suicide risk screening (e.g., Veteran reports a recent suicide attempt unprompted). As such, we calculated the proportion of patients who had a “C‐SSRS,” “CSRE,” and “C‐SSRS or CSRE” for each timeframe.
Of those screened, we determined the number of patients who screened positive at least once within each timeframe. In addition, we looked at all positive screens within the overall timeframe and calculated the number of timely CSREs (i.e., within 24 h). For those who received a CSRE, we reported the distribution of acute and chronic suicide risk stratification during each timeframe (i.e., low, intermediate, high). When more than one CSRE was completed in a timeframe, we used the most severe for each risk stratification (i.e., acute, chronic).
We also looked at completion of the C‐SSRS within specific VHA service settings (i.e., homeless services, inpatient, emergency and urgent care, primary care, mental health, and other outpatient services). Number of unique patients screened at least once, percentage of the cohort screened, as well as average and median number of times a patient was screened were reported. Finally, chi‐square analyses were used to compare sociodemographic factors (i.e., age, race, sex) between those who received a C‐SSRS and/or CSRE and those who did not.
3. RESULTS
3.1. Suicide risk screening and evaluation
Suicide risk screening and/or evaluation in the year prior to and following identification of homelessness can be seen in Table 1. Of patients with an eligible encounter during the given timeframe, 16.0% (n = 7358) received screening and/or evaluation on the same day as identification. 39.6% (n = 12,840) received screening and/or evaluation 1–30 days prior to identification and 34.3% (n = 14,263) were screened and/or evaluated 1–30 days following identification. When collapsing the timeframes of 30 days prior, same day, and 30 days following, 26,797 out of 54,895 patients identified as newly homeless (48.8%) were screened and/or evaluated for suicide risk.
TABLE 1.
Suicide Risk Screening (C‐SSRS) and Evaluation (CSRE) among newly identified homeless patients in Calendar Year 2021.
| Administration of C‐SSRS and/or CSRE based on identification of homelessness | C‐SSRS | CSRE | C‐SSRS or CSRE | |||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| Same day (n = 45,976) | 7046 | 15.3% | 1023 | 2.2% | 7358 | 16.0% |
| 1–30 days prior (n = 32,408) | 12,535 | 38.7% | 2328 | 7.2% | 12,840 | 39.6% |
| 31–365 days prior (n = 39,798) | 27,373 | 68.8% | 3447 | 8.7% | 27,581 | 69.3% |
| 1–30 days after (n = 41,542) a | 13,551 | 32.6% | 2666 | 6.4% | 14,263 | 34.3% |
| 31–365 days after (n = 49,908) b | 36,408 | 73.0% | 5377 | 10.8% | 36,848 | 73.8% |
| 365 days prior through 365 days after (n = 56,649) c | 49,309 | 87.0% | 9974 | 17.6% | 49,505 | 87.4% |
Note: C‐SSRS=Columbia‐Suicide Severity Rating Screener; CSRE = Comprehensive Suicide Risk Evaluation.
One hundred and thirty‐one died during following identification but had at least one encounter during the timeframe.
One thousand six hundred and fifty‐five died during following identification but had at least one encounter during the timeframe.
Two thousand two hundred seventy‐eight died during following identification but had at least one encounter during the timeframe.
When expanded to the year prior to and following identification of homelessness, a larger proportion of patients received suicide risk screening and/or evaluation (87.4%; n = 49,505). 69.3% (n = 27,581) received suicide risk screening and/or evaluation 31–365 days prior to identification, while 73.8% (n = 36,848) received suicide risk screening and/or evaluation 31–365 days following identification. The service settings where the highest number of patients were screened included primary care (48.5%; n = 23,894); emergency and urgent care (46.9%; n = 23,149); and mental health (43.6%; n = 21,508; see Supplementary Table 2). In addition, more than one in five patients were screened for suicide risk when seeking VHA homeless services (21.1%; n = 10,411).
3.2. Positive screens and stratification of risk
Of newly identified homeless patients who were screened for suicide risk, the majority did not have a positive C‐SSRS screen during the timeframes of interest (see Table 2). 26,281 patients had at least one C‐SSRS either 30 days prior to, same day as, or 30 days following identification of homelessness. Of those patients, 9.9% screened positive at least once during that timeframe (n = 2601).
TABLE 2.
Positive C‐SSRS screening results among newly identified homeless patients in Calendar Year 2021.
| Administration of C‐SSRS based on identification of homelessness | Positive C‐SSRS | |
|---|---|---|
| n | % | |
| Same day (n = 7046) | 571 | 8.1% |
| 1–30 days prior (n = 12,535) | 1347 | 10.7% |
| 31–365 days prior (n = 27,373) | 2133 | 7.8% |
| 1–30 days after (n = 13,551) | 1197 | 8.8% |
| 31–365 days after (n = 36,408) | 2697 | 7.4% |
| 365 days prior through 365 days after (n = 49,309) | 5923 | 12.0% |
Abbreviation: C‐SSRS, Columbia‐Suicide Severity Rating Screener.
In the year prior to and year following identification, the proportion of positive screens for newly identified homeless patients was 12.0% (n = 5923). Of patients receiving a suicide risk evaluation (see Table 3), the most common suicide risk level for acute risk was low and the most common suicide risk level for chronic risk was intermediate. As patients could receive multiple C‐SSRS screeners in the year prior to and following identification of homelessness, we also examined timeliness of CSRE (i.e., within 24 h) among all patients with a positive screen. There were 11,977 positive screens, and of those, 8694 (72.6%) received a timely CSRE.
TABLE 3.
Acute and chronic suicide risk stratification based on timeframe of suicide risk evaluation relative to identification of homelessness.
| Timeframe of suicide risk evaluation based on identification of homelessness | Low | Intermediate | High | |||
|---|---|---|---|---|---|---|
| n | % | n | % | n | % | |
| Acute suicide risk | ||||||
| Same day (n = 1023) | 592 | 57.9% | 302 | 29.5% | 128 | 12.5% |
| 1–30 days prior (n = 2328) | 1130 | 48.5% | 761 | 32.7% | 437 | 18.8% |
| 31–365 days prior (n = 3447) | 1719 | 49.9% | 1131 | 32.8% | 597 | 17.3% |
| 1–30 days after (n = 2667) | 1761 | 66.0% | 719 | 27.0% | 186 | 7.0% |
| 31–365 days after (n = 5377) | 3080 | 57.3% | 1533 | 28.5% | 764 | 14.2% |
| 365 days prior through 365 days after (n = 9974) | 4995 | 50.1% | 3123 | 31.3% | 1856 | 18.6% |
| Chronic suicide risk | ||||||
| Same day (n = 1023) | 461 | 45.1% | 429 | 41.9% | 132 | 12.9% |
| 1–30 days prior (n = 2328) | 813 | 34.9% | 1092 | 46.9% | 422 | 18.1% |
| 31–365 days prior (n = 3447) | 1196 | 34.7% | 1606 | 46.6% | 643 | 18.7% |
| 1–30 days after (n = 2667) | 1141 | 42.8% | 1181 | 44.3% | 340 | 12.7% |
| 31–365 days after (n = 5377) | 2008 | 37.3% | 2393 | 44.5% | 972 | 18.1% |
| 365 days prior through 365 days after (n = 9974) | 3613 | 36.2% | 4323 | 43.3% | 2033 | 20.4% |
3.3. Relation of sociodemographic factors to provision of C‐SSRS and CSRE
There were no significant differences based on age or sex between those who did or did not receive suicide risk screening/evaluation (see Supplementary Table 3). However, there was a significant difference in race between these groups. Of the group who received a C‐SSRS and/or CSRE, 11.5% did not have race documented in their electronic medical record (i.e., “unknown”) compared to 24.7% in the group who did not receive a C‐SSRS or CSRE. For all other racial identifications, the proportions of patients who received screening/evaluation were higher than or not significantly different from those who did not receive the C‐SSRS or CSRE.
4. DISCUSSION
Over 87% of patients newly identified as homeless in Calendar Year 2021 were screened and/or evaluated for suicide risk in the year prior to or following identification. The majority of these patients did not screen positive for suicide risk; however, approximately one in ten patients screened positive in the year before or after identification of homelessness. This proportion is elevated when compared to prior evaluations of VA Risk ID focusing on different patient populations (e.g., those accessing VA mental health services). 10 Although we did not examine factors driving positive screens among newly identified homeless patients, high proportions may be due to the types of VHA services these individuals use. Homeless patients often access VHA emergency and urgent care services 11 where suicide risk screening is mandated at every encounter. Patients at elevated risk for suicide are also more likely to access emergency and urgent care services as a method of managing their risk. 12
In addition, of positive screens, 72.6% were followed by a timely CSRE. Among those with a documented CSRE, 50.1% of patients were determined to be at low acute risk. Given what is known about rates of suicidal ideation and behavior among homeless Veterans, 3 we anticipated that a greater number of patients would be noted as having intermediate to high acute risk for suicide. This begs the question as to whether there are barriers to conducting comprehensive evaluations with these patients. Time is often reported as a barrier to suicide screening and evaluation, 13 , 14 and this may be particularly true in fast paced emergency and urgent care settings. Further research is also required to understand why over a quarter of individuals who screened positive did not have a timely CSRE, as well as the higher‐than‐anticipated number of individuals at low acute risk.
Across timepoints, greater than half of newly identified homeless patients evaluated for suicide risk were stratified as being at intermediate to high chronic risk. Several factors may increase chronic risk among those experiencing homelessness. These individuals often experience long‐standing health conditions, which may exacerbate housing instability, such as serious mental illness and traumatic brain injury. 7 , 12 , 15 In addition, concurrent stressors, such as justice involvement and unemployment, may result in sustained impact on functioning. 12 Given this, suicide risk evaluation is a critical intercept for identifying health and social service needs and connecting homeless patients to care. Such early identification and intervention may be important for mitigating the impact of these factors on their chronic risk for suicide. Additional evaluation is needed to examine referral patterns and care received among newly identified homeless patients following suicide risk evaluation.
A notable number of patients were not screened and/or evaluated during mandated timeframes (i.e., same day as identification of homelessness, 30 days prior to or following identification of homelessness). Some of these patients were seen in services that did not require them to be re‐screened (e.g., primary care only requires annual screening), which may explain the lack of screening during specific timeframes. Providers working with homeless patients may also initially focus on acute health conditions (e.g., hyperthermia) or stressors (e.g., eviction), 16 which may lead to a delay in suicide risk screening. Given the association between homelessness and suicide, 2 evaluating homelessness and suicide risk concurrently upon disclosure may prove beneficial. Nonetheless, as reasons for delaying or not conducting suicide risk screening were not examined in this evaluation, additional examination is warranted to determine how VHA can support providers working with these patients.
Several limitations should be acknowledged. Results are specific to newly identified homeless patients accessing VHA care in Calendar Year 2021. As VA Risk ID is an evolving dissemination effort, including shifts in policy and implementation of trainings, suicide risk screening and evaluation results likely have changed in years since. This study did not strictly examine VA homeless service users, but newly identified homeless patients broadly. Data from VHA homeless service users as captured in other administrative datasets (e.g., Homeless Operations Management Evaluation System [HOMES]), 17 may have been missed. It is also possible newly identified homeless patients had a history of homelessness that preceded VHA service use (e.g., prior to military service). Several contextual factors were not examined, including characteristics such as rurality of service setting or current staffing shortages. Similarly, as data were from Calendar Year 2021, it is difficult to determine how the COVID‐19 pandemic affected results. Sociodemographic characteristics were also largely not related to receipt of screening or evaluation. Nonetheless, patients lacking race data were less likely to be screened. Given that these patients' racial identification was not documented in the electronic medical record, it is hard to determine whether this represents an issue with the data or a true difference.
It should also be noted that this sample was not limited to Veterans; humanitarian and other non‐Veteran patients were included. That is, VA policy requires providing emergency medical care or services, humanitarian service, to individuals who are not generally VHA eligible. Additionally, identification of “homelessness” was based on participation in VA homeless programs and/or an ICD‐10 Z‐code of “homelessness.” As such, some individuals included in the newly homeless sample may have been at‐risk, rather than currently, homeless. Finally, a portion of patients died within 365 days of being identified as homeless. Given this, some patients did not have the opportunity to be screened and/or evaluated in the full timeframe of interest.
Although a substantial number of VHA using patients newly identified as homeless in Calendar Year 2021 received a C‐SSRS and/or CSRE, approximately 13% were not screened and of positive screens, and approximately 27% did not received a timely CSRE. Additional research is needed to elucidate barriers and facilitators to suicide risk screening and evaluation among these patients.
FUNDING INFORMATION
This material is based on work supported by the Department of Veterans Affairs (VA), VA Office of Mental Health and Suicide Prevention (PI: Holliday), and VA Rocky Mountain Mental Illness Research, Education and Clinical Center for Suicide Prevention.
CONFLICT OF INTEREST STATEMENT
The authors have no additional conflicts to declare.
Supporting information
Supplementary Table 1. Methods of identifying newly homeless Veterans Health Administration (VHA) patients.
Supplementary Table 2. Columbia‐Suicide Severity Rating Scale (C‐SSRS) Screening by VHA service setting for newly identified homeless patients in Calendar Year 2021 (n = 49,309).
Supplementary Table 3. Relationship of sociodemographics by completion of C‐SSRS and/or Comprehensive Suicide Risk Evaluation (CSRE) within year prior or following homeless identification.
ACKNOWLEDGMENTS
The views expressed are those of the authors and do not necessarily represent the views or policy of the VA or U.S. Government.
Holliday R, Hostetter T, Brenner LA, Bahraini N, Tsai J. Suicide risk screening and evaluation among patients accessing VHA services and identified as being newly homeless. Health Serv Res. 2024;59(5):e14301. doi: 10.1111/1475-6773.14301
REFERENCES
- 1. Tsai J, Cao X. Association between suicide attempts and homelessness in a population‐based sample of US veterans and non‐veterans. J Epidemiol Community Health. 2019;73(4):346‐352. [DOI] [PubMed] [Google Scholar]
- 2. Hoffberg AS, Spitzer E, Mackelprang JL, Farro SA, Brenner LA. Suicidal self‐directed violence among homeless US veterans: a systematic review. Suicide Life Threat Behav. 2018;48(4):481‐498. [DOI] [PubMed] [Google Scholar]
- 3. Holliday R, Forster JE, Desai A, et al. Association of lifetime homelessness and justice involvement with psychiatric symptoms, suicidal ideation, and suicide attempt among post‐9/11 veterans. J Psychiatr Res. 2021;144:455‐461. [DOI] [PubMed] [Google Scholar]
- 4. Culhane D, Szymkowiak D, Schinka JA. Suicidality and the onset of homelessness: evidence for a temporal association from VHA treatment records. Psychiatr Serv. 2019;70(11):1049‐1052. [DOI] [PubMed] [Google Scholar]
- 5. Department of Veterans Affairs . Memorandum re: Suicide Risk Screening and Assessment Requirements. Department of Veterans Affairs; 2018. [Google Scholar]
- 6. Bahraini N, Brenner LA, Barry C, et al. Assessment of rates of suicide risk screening and prevalence of positive screening results among US veterans after implementation of the veterans affairs suicide risk IDentification strategy. JAMA Netw Open. 2020;3(10):e2022531. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Holliday R, Desai A, Gerard G, Liu S, Stimmel M. Understanding the intersection of homelessness and justice involvement: enhancing veteran suicide prevention through VA programming. Fed Pract. 2022;39(1):8‐11. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Posner K, Brown GK, Stanley B, et al. The Columbia‐suicide severity rating scale: initial validity and internal consistency findings from three multisite studies with adolescents and adults. Am J Psychiatry. 2011;168(12):1266‐1277. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Wortzel HS, Homaifar B, Matarazzo B, et al. Therapeutic risk management of the suicidal patient: stratifying risk in terms of severity and temporality. J Psychiatr Pract. 2014;20(1):63‐67. [DOI] [PubMed] [Google Scholar]
- 10. Gujral K, Bahraini N, Brenner LA, et al. VA's implementation of universal screening and evaluation for the suicide risk identification program in November 2020 ‐implications for veterans with prior mental health needs. PLoS One. 2023;18(4):e0283633. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Gabrielian S, Yuan AH, Andersen RM, Rubenstein LV, Gelberg L. VA health service utilization for homeless and low‐income veterans. Med Care. 2014;52(5):454‐461. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Holliday R, Desai A, Stimmel M, Liu S, Monteith LL, Stewart KE. Meeting the health and social service needs of veterans who interact with the criminal justice system and experience homelessness: a holistic conceptualization and recommendations for tailoring care. Curr Treat Options Psychiatry. 2022;9:174‐185. [Google Scholar]
- 13. Diamond GS, O'Malley A, Wintersteen MB, et al. Attitudes, practices, and barriers to adolescent suicide and mental health screening: a survey of Pennsylvania primary care providers. J Prim Care Community Health. 2012;3:29‐35. [DOI] [PubMed] [Google Scholar]
- 14. Petrik ML, Gutierrez PM, Berlin JS, Saunders SM. Barriers and facilitators of suicide risk assessment in emergency departments: a qualitative study of provider perspective. Gen Hosp Psychiatry. 2015;37(6):581‐586. [DOI] [PubMed] [Google Scholar]
- 15. Weber J, Lee RC, Martsolf D. Understanding the health of veterans who are homeless: a review of the literature. Public Health Nurs. 2017;34(5):505‐511. [DOI] [PubMed] [Google Scholar]
- 16. O'Toole TP, Johnson EE, Borgia ML, et al. Tailoring outreach efforts to increase primary care use among homeless veterans: a randomized controlled trial. J Gen Intern Med. 2015;30(7):886‐898. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Tsai J, Szymkowiak D, Jutkowitz E. Developing an operational definition of housing instability and homelessness in veterans health Administration's medical records. PLoS One. 2022;17(12):e0279973. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplementary Table 1. Methods of identifying newly homeless Veterans Health Administration (VHA) patients.
Supplementary Table 2. Columbia‐Suicide Severity Rating Scale (C‐SSRS) Screening by VHA service setting for newly identified homeless patients in Calendar Year 2021 (n = 49,309).
Supplementary Table 3. Relationship of sociodemographics by completion of C‐SSRS and/or Comprehensive Suicide Risk Evaluation (CSRE) within year prior or following homeless identification.