Misconduct-related separations from the military are associated with subsequent adverse civilian outcomes that are of substantial public health concern.1 We investigated the association between misconduct-related separations and homelessness among recently returned active-duty military service members.
We analyzed Veterans Health Administration (VHA) data from US active-duty military service members who were (1) separated (end date of last deployment) from the military between October 1, 2001, and December 31, 2011, (2) deployed in Afghanistan or Iraq, and (3) eligible for and subsequently used VHA services. Homelessness was determined by an assignment of “lack of housing” using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code V60.0 during a VHA encounter, by participation in a VHA homelessness program, or both.2 The US Department of Defense assigns an interservice separation code upon separation from military service.3,4 These codes were categorized into misconduct (drugs, alcoholism, offenses, infractions, other), disability, early release, disqualified, normal, and other or unknown.
To assess the immediate and long-term associations between military misconduct and postdeployment homelessness, and address individual variation during follow-up, 3 cohorts were constructed to determine the incidence of homelessness: (1) on the day of the first VHA encounter after separation (October 1, 2001-April 30, 2012), (2) within 1 year of first VHA encounter (October 1, 2001-April 30, 2011), and (3) within 5 years of first VHA encounter (October 1, 2001-April 30, 2007). All patients were followed up through April 30, 2012, and were included in a given cohort only if they contributed data for the duration of the period.
Using R version 3.2 (R Foundation for Statistical Computing), risk for homelessness as a function of separation category was estimated using logistic regression (2-tailed α≤.05), adjusting for demographic and military service covariates. The University of Utah institutional review board and the Research and Development committee at the VA Salt Lake City Health Care System approved this study with waiver of consent.
Of the 448 290 active-duty service members separated during this period, 63.2% were 18-29 years of age, 87.8% were male, and 39.8% were white (Table 1). Homelessness was determined by ICD-9-CM code (43.1%), participation in a homelessness program (35.2%), or both (27.1%). With 1 744 725 person-years of observation, the overall incidence of homelessness was 0.3% at time of first VHA encounter (n = 1259), 1.0% within 1 year (n = 4067), and 2.1% within 5 years (n = 3441); the 5-year incidence was significantly higher than at the first encounter or 1 year (P < .001).
Although only 5.6% (n = 24 992) separated for misconduct, they represented 25.6% of homeless veterans at first VHA encounter (n = 322), 28.1% within 1 year (n = 1141), and 20.6% within 5 years (n = 709). Incidence of homelessness was significantly greater for misconduct vs normal separations at first VHA encounter (1.3% vs 0.2%; adjusted odds ratio [AOR], 4.7 [95% CI, 4.1-5.5]), within 1 year (5.4% vs 0.6%; AOR, 6.9 [95% CI, 6.4-7.5]), and 5 years (9.8% vs 1.4%; AOR, 6.3 [95% CI, 5.7-6.9]) of first VHA encounter (Table 1 and Table 2).
To our knowledge, this is the first study to establish an association between a history of military misconduct and subsequent homelessness among active-duty US military veterans who returned from Afghanistan and Iraq and were eligible for VHA benefits. Homelessness increased with time since separation. This finding supports reports of recently returned veterans with records of misconduct having difficulties reentering civilian life.1 This association takes on added significance because the incidence of misconduct-related separations is increasing5 at a time when ending homelessness among veterans is a federal government priority.2
Military misconduct may be a proxy indicator for a variety of risk factors associated with homelessness among veterans,6 including premilitary history of criminality, adverse deployment experiences, mental health issues, alcohol and substance abuse, postdeployment financial instability, and unemployment.
Veterans who dishonorably separate from the military were not included in this study because those individuals are not eligible for VHA services and are not in VHA databases. Other limitations include a lack of detail on the nature of misconduct and its consequences during military service, possible underspecification of veteran homelessness in VHA administrative data, and inability to determine a causal link between misconduct and homelessness.
Identification of those with misconduct-related separations and provision of case management and rehabilitative services at separation by the Department of Defense and the VHA should be investigated as methods to prevent homelessness.
Corresponding Author: Adi V. Gundlapalli, MD, PhD, MS, Informatics, Decision Enhancement, and Analytic Sciences (IDEAS 2.0) Center, VA Salt Lake City Health Care System, 500 Foothill Dr, Mail Stop 182, Salt Lake City, UT 84148 (email@example.com).
Author Contributions: Drs Gundlapalli and Fargo had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Gundlapalli and Fargo contributed equally to this study.
Study concept and design: Gundlapalli, Fargo, Metraux, Kane, Culhane.
Acquisition, analysis, or interpretation of data: Gundlapalli, Fargo, Carter, Samore, Culhane.
Drafting of the manuscript: Gundlapalli, Fargo, Metraux, Carter, Kane.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Gundlapalli, Fargo, Culhane.
Obtained funding: Gundlapalli, Culhane.
Administrative, technical, or material support: Gundlapalli, Carter, Samore, Kane, Culhane.
Study supervision: Gundlapalli.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: Funding for this project was provided by US Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development projects HIR 10-002 and IIR 12-084 and funding from the US Department of Veterans Affairs, National Center on Homelessness Among Veterans.
Role of the Funder/Sponsor: The US Department of Veterans Affairs had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The views expressed in this article are those of the authors and do not necessarily represent the views, position, or policy of the US Department of Veterans Affairs or the US government.
Additional Contributions: We thank our team members for their assistance with this project: Emily Brignone, BS, for literature review, Rebecca Blais, PhD, for advice on separation categories, and Rachel Peterson, MA, for data extraction and management (all 3 with Utah State University, Logan), Steve Pickard, MBA, Anusha Muthukutty, MS, Ying Suo, MS, and Tao He, MS, for data extraction and management, Andrew Redd, PhD, for input on statistical methods, and Deborah Hofmann for study coordination and assistance (all 6 with the IDEAS Center). We appreciate and acknowledge our colleagues Jonathan Nebeker, MD, and Scott Duvall, PhD at VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, for their assistance with accessing big data. No compensation was received by any of the persons mentioned. Resources and administrative support were provided by the IDEAS Center at VA Salt Lake City Health Care System.
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