Homeless Veterans More Likely to Utilize Acute Care Services for Disease Management

Key Takeaways:

• Thirty percent of veterans on the US Veterans Health Administration’s (VHA’s) Homeless Registry had 1 or more hospitalizations and/or 2 or more emergency department (ED) visits between 2018 and 2022. These individuals, known as hot spotters, were more likely to receive acute care than those who did not meet Hot Spotter status.
• Hot spotters are more likely to have chronic conditions such as mood disorders, hyperlipidemia, and diabetes. These patients also have higher rates of mental health disorders such as depression, substance use disorder, self-harm, and suicide.
• Health care services and nonprofits could partner to develop social programs that would address the needs of homeless veterans, expand access, and improve care management.

Homelessness is a major barrier to care, with veterans accounting for a large number of the US homeless population. Furthermore, people facing housing insecurity are more likely to utilize acute care services such as hospital and ED visits.

Acute care patients tend to suffer from chronic diseases while also experiencing various barriers to care that make disease management challenging. Homeless veterans in particular have higher rates of substance use and mental illness, leading to higher utilization of acute care services.

Hot Spotter Programs Developed for Acute Care Patients

Hot Spotter programs were established as early intervention tools to identify high-risk patients and assist in their care management. The VHA developed Hot Spotter Reports which identify veterans on the Homeless Registry who had 1 or more hospitalizations and/or 2 or more ED visits in the past quarter.

Researchers assessed the prevalence and patient characteristics of veterans recorded in Hot Spotter Reports who received acute care. The study identified 1 469 893 veterans from the VHA’s Homeless Registry during the fiscal years 2018 to 2022. Those who met Hot Spotter status (patients with 1 or more hospitalizations and/or 2 or more ED visits) constituted the analytic cohort.

Acute Care Utilization by Hot Spotters

Among the 1 469 893 veterans identified in the VHA’s Homeless Registry, 30.4% (446 974) met Hot Spotter status for at least 1 quarter. Each quarter, an average of 4.8% homeless veterans were considered hot spotters. Over half of the analytic cohort (56%) met Hot Spotter status for 2 or more quarters.

During the 4-year period, nearly 71% of hot spotters were hospitalized at least once, for an average of 2.22 hospitalizations. Within the analytic cohort, 50% were hospitalized in a medical health setting, and 25% were hospitalized in a mental health setting.

During the 4-year period, over 90% of hot spotters visited the ED, for an average of 7.12 visits.

Hot Spotter Patient Characteristics

The analytic cohort had a higher percentage of Black veterans than the non-analytic cohort, 35.9% and 28.1%, respectively.

Hot spotters had higher rates of chronic conditions than non-hot spotters, 4.29 and 1.37, respectively. The most common illnesses were mood disorders, hyperlipidemia, and diabetes. Repeat hot spotters had higher rates of chronic conditions than those who met Hot Spotter status once, 5.08 vs 3.29.

Additionally, hot spotters were more likely to have mental health disorders, including suicide and self-harm. Depression affected 58.5% of hot spotters, and 50.9% had substance use disorder. The prevalence of mental health conditions was higher for repeat hot spotters.

Outpatient Utilization by Hot Spotters

The majority of veterans in the analytic cohort received some type of outpatient service, such as primary care, general and specialty medicine, surgical care, rehabilitation, or mental health services. Primary care and mental health services had the highest level of engagement, with a median of 17 and 16 total visits, respectively.

However, outpatient social services had lower rates of utilization. Only 20.8% of hot spotters utilized peer support services, 17.4% received employment assistance, 15.4% received home-based care, 12.3% participated in veterans justice programs, and 10.5% received extended care.

Addressing the Social Needs of Homeless Veterans

Medical respite care programs could potentially lower hospital utilization among hot spotters by reducing the length of stays and lowering the chance of readmission. They could also promote the use of telehealth services, which might assist patient monitoring and disease management.

Additionally, since the number of older veterans without stable housing is quickly rising, the researchers urge hot spotter programs to collaborate with geriatric services to coordinate care for this growing population. Outreach services such as mobile medical units could help expand access to these individuals.

According to the researchers, “Future work should endeavor to identify patterns and types of care utilization that lower the risk of acute care utilization among patients in hot spotter programs and identify facilitators and barriers to the adoption and sustainment of these programs in health care systems.”

Reference

Blonigen DM, Macia KS, Raikov I, Yoon J, Weber J. Risk for acute care utilization in housing-insecure adults: a national study of a hot spotter program in the US Veterans Health Administration. Med Care. 2026;64(4):207-215. doi:10.1097/MLR.0000000000002287