Evaluating the Impact of COVID-19 on Case Management, Health Care Utilization, and Housing Outcomes for HUD-VASH Veterans

Background: The US Department of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program offers permanent, subsidized independent housing and case management to over 60,000 Veterans annually. In response to COVID-19, HUD-VASH shifted case management from in-person to telephone/video interactions. The goal of this project is to examine the effect of HUD-VASH's shift to virtual care on Veteran engagement and outcomes in the program. Our proposal is motivated by a working theory that virtual care increased access to case management, primary care, and improved behavioral quality measures conducive to phone/video interactions (e.g., follow-up after a psych hospitalization), but decreased access to specialist care and worsened quality measures not conducive to phone/video interactions (e.g., meds for opioid use disorder). Significance: The VA is dedicated to improving the housing and health of Veterans. Our project will advance policy by helping the National Homeless Programs Office understand the impact of virtual care in HUD-VASH to maximize program reach, engagement, and outcomes. The project addresses VA's FY 2018- 2024 Strategic Objective 2.2 ("VA ensures at-risk and underserved Veterans receive what they need to eliminate Veteran suicide, homelessness, and poverty"), objectives of RFA HX-21-025 (changes to virtual care on Veteran outcomes), and objectives of HSR&D (virtual care and social determinants of health). Specific Aims: Aim 1. Determine the effect of HUD-VASH's shift to virtual care during the COVID-19 pandemic on case management services: Hypothesis: HUD-VASH's shift to virtual care during the pandemic resulted in more total, telephone and video case management as compared to a pre-pandemic period. Secondary analysis: Identify associations between Veteran factors (e.g., mental health diagnosis) with the use of case management before and after the shift to virtual care, and Veteran factors associated with not engaging in any virtual care. Aim 2. Evaluate the effect of HUD-VASH's shift to virtual care during the pandemic on Veteran's health care utilization and continuity of care. Hypothesis: HUD-VASH's shift to virtual care during the pandemic increased the use of primary care and improved some behavioral quality measures while decreased other behavioral quality measures not conducive to virtual care and the use of outpatient specialist care. Secondary analysis: Examine Veteran factors associated with HUD-VASH program exits and utilization of health care in the year after program exit. Aim 3. Examine Veteran and provider experiences with virtual case management in HUD- VASH. Semi-structured interviews with VA leadership, case managers, and Veterans who experienced HUD- VASH's shift to virtual care, will provide an understanding of the barriers to and facilitators of the implementation of virtual case management. Methodology: A convergent parallel mixed-methods design will be used. Data from the VA's Corporate Data Warehouse (CDW) will be linked with Homeless Operations Management and Evaluation System (HOMES) for analysis. Using these data, Aims 1 and 2 will use an interrupted time series design with segmented regression to examine utilization outcomes before and after HUD-VASH's shift to virtual care. For Aim 3, qualitative interviews with VA leadership, case managers and Veterans will capture the experience of implementing and receiving virtual care and give context to our quantitative findings. Next Steps/ Implementation: Our findings will inform the evolution of virtual care within the HUD-VASH program. This project will also inform the Homeless Programs Office of the impact and experience of transitioning to virtual care during the pandemic and the extent this transition and pandemic disrupted VA care of homeless Veterans.