Federal Practitioner

The Psychopharmacologic Drugs Advisory Committee of the FDA is set to meet on July 18 to consider a supplemental new drug application for brexpiprazole (Rexulti, Otsuka Pharmaceutical Co., Ltd.), in combination with sertraline, for the treatment of adults with posttraumatic stress disorder (PTSD).

If approved, it would be the first new treatment for PTSD in more than 20 years.

“It is my hope that the FDA does approve this treatment for two related reasons — the data look positive and compelling, and there’s a tremendous unmet need in PTSD,” Roger McIntyre, MD, professor of psychiatry and pharmacology and head of the Mood Disorders Psychopharmacology Unit, University of Toronto, Toronto, Ontario, Canada, told this news organization.

 

What’s in the Treatment Toolbox Now?

PTSD is a “common, severe, and nonremitting condition,” McIntyre noted. According to the National Center for PTSD, the condition affects roughly 13 million adults in the US in any given year. This represents about 5% of the adult population.

PTSD can develop following exposure to traumatic events such as combat, assault, disasters, or severe accidents. Core symptoms of PTSD include intrusive memories and flashbacks, avoidance behaviors, negative alterations in mood and cognition, and hyperarousal.

Currently, the selective serotonin reuptake inhibitors (SSRI), sertraline and paroxetine, are the only FDA-approved medications for PTSD, and while these medications can be effective, many patients fail to achieve remission or discontinue treatment due to adverse effects or lack of response.

Other medications used off-label to treat PTSD — including prazosin, mirtazapine, atypical antipsychotics, and mood stabilizers — have shown variable efficacy. 

There has not been a new FDA-approved drug for PTSD in over two decades, underscoring the need for better therapeutic options, particularly for patients who do not fully respond to SSRI alone.

 

Why Brexpiprazole Plus Sertraline?

Brexpiprazole is an atypical antipsychotic currently approved as adjunctive treatment of major depressive disorder (MDD) in adults; treatment of schizophrenia in adults and adolescents aged 13 years or older; and treatment of agitation associated with Alzheimer’s dementia.

The combination of brexpiprazole and sertraline could address the limitations of SSRI alone by working synergistically to treat PTSD.

Sertraline increases serotonin levels in the brain to improve mood and reduce anxiety. Brexpiprazole has a complex mechanism of action involving multiple neurotransmitter systems, including but not limited to serotonin and dopamine.

Together, they may target different aspects of PTSD, potentially leading to a more comprehensive reduction in symptoms.

 

What Do the Phase 3 Data Show?

In a pivotal, double-blind, randomized controlled, phase 3 trial, brexpiprazole plus sertraline provided significantly greater relief of PTSD symptoms than sertraline plus placebo.

The results were published late last year in JAMA Psychiatry and reported by this news organization at that time.

The trial enrolled 416 adults (mean age, 37 years; 75% women) aged 18-65 years with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis of PTSD and symptoms for at least 6 months prior to screening.

At baseline, participants had a mean Clinician Administered PTSD Scale (CAPS-5) for DSM-5 total score of 38.4, indicating moderate to high severity PTSD. The average time from the index traumatic event was 4 years, and three fourths had no prior exposure to PTSD prescription medications.

Participants underwent a 1-week placebo run-in period followed by randomization to daily oral brexpiprazole 2-3 mg plus sertraline 150 mg or daily sertraline 150 mg plus placebo for 11 weeks.

At week 10, brexpiprazole plus sertraline demonstrated statistically significant greater improvement in the CAPS-5 total score (primary outcome) than sertraline plus placebo (mean change, -19.2 points vs -13.6 points; P < .001).

Brexpiprazole plus sertraline also led to statistically significant greater improvement on all key secondary and other efficacy endpoints, both clinician-reported and patient-reported, including measures of anxiety, depression, intrusive symptoms, hyperarousal, and overall functioning.

Combining an atypical antipsychotic with an antidepressant for PTSD “builds on what we’ve been doing in depression,” Elspeth Ritchie, MD, chair of Psychiatry, MedStar Washington Hospital Center, Washington, DC, noted in an interview with this news organization.

“We have found that a combination of a low-dose antipsychotic and an antidepressant is helpful for depression, so it makes sense that it will be helpful for PTSD. However, this has been mostly based on clinical decisions, without a heavy research background. Good science is always helpful to support those clinical decisions,” Ritchie told this news organization.

 

What About Safety?

In the phase 3 trial, brexpiprazole plus sertraline had a safety profile consistent with that of brexpiprazole in approved indications. The rate of discontinuation due to adverse events was low (3.9% for brexpiprazole plus sertraline vs 10.2% for sertraline plus placebo), indicating that most participants tolerated the brexpiprazole and sertraline combination treatment, the study team said.

In both treatment groups, the only treatment-emergent adverse event (TEAE) with incidence greater than 10% was nausea, a known adverse effect of sertraline treatment.

Weight gain was greater in participants receiving the combination. At the last visit, a weight gain of 7% or greater from week 1 was experienced by 8% of participants taking brexpiprazole with the sertraline group and 5% of those taking the sertraline plus placebo. Previous analyses in schizophrenia and MDD show that brexpiprazole is associated with moderate weight gain (+3 to 4 kg over 1 year).

The incidence of sedating TEAEs (a concern with some antipsychotics) was generally low, although fatigue (7% vs 4%) and somnolence (5% vs 3%) were more common with brexpiprazole plus sertraline than with sertraline alone.

There were no clinically meaningful between-group differences in changes in laboratory test parameters, vital signs, or ECG and participant-reported TEAEs related to suicidality.

 

Potential Concerns

As with any new drug application, several questions and issues are likely to be raised by the advisory committee. They could include whether the clinical benefit is substantial enough to warrant approval and how the observed effect sizes compare to existing approved therapies and evidence-based psychotherapies.

McIntyre told this news organization what’s particularly noteworthy is that the magnitude of the improvement in PTSD symptoms with brexpiprazole plus sertraline is greater than with sertraline alone. “That’s a very important statement. And this high level of efficacy was consistent on the secondary outcome measures, and the overall tolerability and safety seemed very acceptable,” he said.

What’s equally important, said McIntyre, is that most people with PTSD have depression and anxiety, and the brexpiprazole plus sertraline combination was more helpful than sertraline alone on the measures of anxiety and depression. “This is really important, especially in light of the fact that this medication [brexpiprazole] is already approved for adults living with major depressive disorder and inadequate response to antidepressants,” McIntyre said.

McIntyre added he suspects some questions the committee may have could relate to the extent to which it’s the case that brexpiprazole is effective in PTSD regardless of the antidepressant that is prescribed with it.

“There also will be the inevitable questions about the absence of long-term data which I think will need to be addressed given how chronic and relapse prone this condition is,” McIntyre said.

The committee may ask how trauma and PTSD will be screened in primary care and how outcomes related to this therapy will be evaluated in everyday clinical practice, McIntyre said.

Overall, McIntyre said brexpiprazole plus sertraline in PTSD is a “very positive” development for the field.

“PTSD is a terrible condition. It’s so darn common, and we just don’t have enough treatments for it. The data look good for my perspective. My fingers are crossed for the patients with PTSD and their families,” said McIntyre.

Ritchie reported having no relevant disclosures. McIntyre received speaker/consultation fees from Lundbeck, Janssen, Alkermes, Neumora Therapeutics, Boehringer Ingelheim, Sage, Biogen, Mitsubishi Tanabe, Purdue, Pfizer, Otsuka, Takeda, Neurocrine, Sunovion, Bausch Health, Axsome, Novo Nordisk, Kris, Sanofi, Eisai, Intra-Cellular, NewBridge Pharmaceuticals, Viatris, AbbVie, and atai Life Sciences. McIntyre is a CEO of Braxia Scientific Corp.

A version of this article first appeared on Medscape.com.

The Psychopharmacologic Drugs Advisory Committee of the FDA is set to meet on July 18 to consider a supplemental new drug application for brexpiprazole (Rexulti, Otsuka Pharmaceutical Co., Ltd.), in combination with sertraline, for the treatment of adults with posttraumatic stress disorder (PTSD).

If approved, it would be the first new treatment for PTSD in more than 20 years.

“It is my hope that the FDA does approve this treatment for two related reasons — the data look positive and compelling, and there’s a tremendous unmet need in PTSD,” Roger McIntyre, MD, professor of psychiatry and pharmacology and head of the Mood Disorders Psychopharmacology Unit, University of Toronto, Toronto, Ontario, Canada, told this news organization.

 

What’s in the Treatment Toolbox Now?

PTSD is a “common, severe, and nonremitting condition,” McIntyre noted. According to the National Center for PTSD, the condition affects roughly 13 million adults in the US in any given year. This represents about 5% of the adult population.

PTSD can develop following exposure to traumatic events such as combat, assault, disasters, or severe accidents. Core symptoms of PTSD include intrusive memories and flashbacks, avoidance behaviors, negative alterations in mood and cognition, and hyperarousal.

Currently, the selective serotonin reuptake inhibitors (SSRI), sertraline and paroxetine, are the only FDA-approved medications for PTSD, and while these medications can be effective, many patients fail to achieve remission or discontinue treatment due to adverse effects or lack of response.

Other medications used off-label to treat PTSD — including prazosin, mirtazapine, atypical antipsychotics, and mood stabilizers — have shown variable efficacy. 

There has not been a new FDA-approved drug for PTSD in over two decades, underscoring the need for better therapeutic options, particularly for patients who do not fully respond to SSRI alone.

 

Why Brexpiprazole Plus Sertraline?

Brexpiprazole is an atypical antipsychotic currently approved as adjunctive treatment of major depressive disorder (MDD) in adults; treatment of schizophrenia in adults and adolescents aged 13 years or older; and treatment of agitation associated with Alzheimer’s dementia.

The combination of brexpiprazole and sertraline could address the limitations of SSRI alone by working synergistically to treat PTSD.

Sertraline increases serotonin levels in the brain to improve mood and reduce anxiety. Brexpiprazole has a complex mechanism of action involving multiple neurotransmitter systems, including but not limited to serotonin and dopamine.

Together, they may target different aspects of PTSD, potentially leading to a more comprehensive reduction in symptoms.

 

What Do the Phase 3 Data Show?

In a pivotal, double-blind, randomized controlled, phase 3 trial, brexpiprazole plus sertraline provided significantly greater relief of PTSD symptoms than sertraline plus placebo.

The results were published late last year in JAMA Psychiatry and reported by this news organization at that time.

The trial enrolled 416 adults (mean age, 37 years; 75% women) aged 18-65 years with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis of PTSD and symptoms for at least 6 months prior to screening.

At baseline, participants had a mean Clinician Administered PTSD Scale (CAPS-5) for DSM-5 total score of 38.4, indicating moderate to high severity PTSD. The average time from the index traumatic event was 4 years, and three fourths had no prior exposure to PTSD prescription medications.

Participants underwent a 1-week placebo run-in period followed by randomization to daily oral brexpiprazole 2-3 mg plus sertraline 150 mg or daily sertraline 150 mg plus placebo for 11 weeks.

At week 10, brexpiprazole plus sertraline demonstrated statistically significant greater improvement in the CAPS-5 total score (primary outcome) than sertraline plus placebo (mean change, -19.2 points vs -13.6 points; P < .001).

Brexpiprazole plus sertraline also led to statistically significant greater improvement on all key secondary and other efficacy endpoints, both clinician-reported and patient-reported, including measures of anxiety, depression, intrusive symptoms, hyperarousal, and overall functioning.

Combining an atypical antipsychotic with an antidepressant for PTSD “builds on what we’ve been doing in depression,” Elspeth Ritchie, MD, chair of Psychiatry, MedStar Washington Hospital Center, Washington, DC, noted in an interview with this news organization.

“We have found that a combination of a low-dose antipsychotic and an antidepressant is helpful for depression, so it makes sense that it will be helpful for PTSD. However, this has been mostly based on clinical decisions, without a heavy research background. Good science is always helpful to support those clinical decisions,” Ritchie told this news organization.

 

What About Safety?

In the phase 3 trial, brexpiprazole plus sertraline had a safety profile consistent with that of brexpiprazole in approved indications. The rate of discontinuation due to adverse events was low (3.9% for brexpiprazole plus sertraline vs 10.2% for sertraline plus placebo), indicating that most participants tolerated the brexpiprazole and sertraline combination treatment, the study team said.

In both treatment groups, the only treatment-emergent adverse event (TEAE) with incidence greater than 10% was nausea, a known adverse effect of sertraline treatment.

Weight gain was greater in participants receiving the combination. At the last visit, a weight gain of 7% or greater from week 1 was experienced by 8% of participants taking brexpiprazole with the sertraline group and 5% of those taking the sertraline plus placebo. Previous analyses in schizophrenia and MDD show that brexpiprazole is associated with moderate weight gain (+3 to 4 kg over 1 year).

The incidence of sedating TEAEs (a concern with some antipsychotics) was generally low, although fatigue (7% vs 4%) and somnolence (5% vs 3%) were more common with brexpiprazole plus sertraline than with sertraline alone.

There were no clinically meaningful between-group differences in changes in laboratory test parameters, vital signs, or ECG and participant-reported TEAEs related to suicidality.

 

Potential Concerns

As with any new drug application, several questions and issues are likely to be raised by the advisory committee. They could include whether the clinical benefit is substantial enough to warrant approval and how the observed effect sizes compare to existing approved therapies and evidence-based psychotherapies.

McIntyre told this news organization what’s particularly noteworthy is that the magnitude of the improvement in PTSD symptoms with brexpiprazole plus sertraline is greater than with sertraline alone. “That’s a very important statement. And this high level of efficacy was consistent on the secondary outcome measures, and the overall tolerability and safety seemed very acceptable,” he said.

What’s equally important, said McIntyre, is that most people with PTSD have depression and anxiety, and the brexpiprazole plus sertraline combination was more helpful than sertraline alone on the measures of anxiety and depression. “This is really important, especially in light of the fact that this medication [brexpiprazole] is already approved for adults living with major depressive disorder and inadequate response to antidepressants,” McIntyre said.

McIntyre added he suspects some questions the committee may have could relate to the extent to which it’s the case that brexpiprazole is effective in PTSD regardless of the antidepressant that is prescribed with it.

“There also will be the inevitable questions about the absence of long-term data which I think will need to be addressed given how chronic and relapse prone this condition is,” McIntyre said.

The committee may ask how trauma and PTSD will be screened in primary care and how outcomes related to this therapy will be evaluated in everyday clinical practice, McIntyre said.

Overall, McIntyre said brexpiprazole plus sertraline in PTSD is a “very positive” development for the field.

“PTSD is a terrible condition. It’s so darn common, and we just don’t have enough treatments for it. The data look good for my perspective. My fingers are crossed for the patients with PTSD and their families,” said McIntyre.

Ritchie reported having no relevant disclosures. McIntyre received speaker/consultation fees from Lundbeck, Janssen, Alkermes, Neumora Therapeutics, Boehringer Ingelheim, Sage, Biogen, Mitsubishi Tanabe, Purdue, Pfizer, Otsuka, Takeda, Neurocrine, Sunovion, Bausch Health, Axsome, Novo Nordisk, Kris, Sanofi, Eisai, Intra-Cellular, NewBridge Pharmaceuticals, Viatris, AbbVie, and atai Life Sciences. McIntyre is a CEO of Braxia Scientific Corp.

A version of this article first appeared on Medscape.com.

The Psychopharmacologic Drugs Advisory Committee of the FDA is set to meet on July 18 to consider a supplemental new drug application for brexpiprazole (Rexulti, Otsuka Pharmaceutical Co., Ltd.), in combination with sertraline, for the treatment of adults with posttraumatic stress disorder (PTSD).

If approved, it would be the first new treatment for PTSD in more than 20 years.

“It is my hope that the FDA does approve this treatment for two related reasons — the data look positive and compelling, and there’s a tremendous unmet need in PTSD,” Roger McIntyre, MD, professor of psychiatry and pharmacology and head of the Mood Disorders Psychopharmacology Unit, University of Toronto, Toronto, Ontario, Canada, told this news organization.

 

What’s in the Treatment Toolbox Now?

PTSD is a “common, severe, and nonremitting condition,” McIntyre noted. According to the National Center for PTSD, the condition affects roughly 13 million adults in the US in any given year. This represents about 5% of the adult population.

PTSD can develop following exposure to traumatic events such as combat, assault, disasters, or severe accidents. Core symptoms of PTSD include intrusive memories and flashbacks, avoidance behaviors, negative alterations in mood and cognition, and hyperarousal.

Currently, the selective serotonin reuptake inhibitors (SSRI), sertraline and paroxetine, are the only FDA-approved medications for PTSD, and while these medications can be effective, many patients fail to achieve remission or discontinue treatment due to adverse effects or lack of response.

Other medications used off-label to treat PTSD — including prazosin, mirtazapine, atypical antipsychotics, and mood stabilizers — have shown variable efficacy. 

There has not been a new FDA-approved drug for PTSD in over two decades, underscoring the need for better therapeutic options, particularly for patients who do not fully respond to SSRI alone.

 

Why Brexpiprazole Plus Sertraline?

Brexpiprazole is an atypical antipsychotic currently approved as adjunctive treatment of major depressive disorder (MDD) in adults; treatment of schizophrenia in adults and adolescents aged 13 years or older; and treatment of agitation associated with Alzheimer’s dementia.

The combination of brexpiprazole and sertraline could address the limitations of SSRI alone by working synergistically to treat PTSD.

Sertraline increases serotonin levels in the brain to improve mood and reduce anxiety. Brexpiprazole has a complex mechanism of action involving multiple neurotransmitter systems, including but not limited to serotonin and dopamine.

Together, they may target different aspects of PTSD, potentially leading to a more comprehensive reduction in symptoms.

 

What Do the Phase 3 Data Show?

In a pivotal, double-blind, randomized controlled, phase 3 trial, brexpiprazole plus sertraline provided significantly greater relief of PTSD symptoms than sertraline plus placebo.

The results were published late last year in JAMA Psychiatry and reported by this news organization at that time.

The trial enrolled 416 adults (mean age, 37 years; 75% women) aged 18-65 years with a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnosis of PTSD and symptoms for at least 6 months prior to screening.

At baseline, participants had a mean Clinician Administered PTSD Scale (CAPS-5) for DSM-5 total score of 38.4, indicating moderate to high severity PTSD. The average time from the index traumatic event was 4 years, and three fourths had no prior exposure to PTSD prescription medications.

Participants underwent a 1-week placebo run-in period followed by randomization to daily oral brexpiprazole 2-3 mg plus sertraline 150 mg or daily sertraline 150 mg plus placebo for 11 weeks.

At week 10, brexpiprazole plus sertraline demonstrated statistically significant greater improvement in the CAPS-5 total score (primary outcome) than sertraline plus placebo (mean change, -19.2 points vs -13.6 points; P < .001).

Brexpiprazole plus sertraline also led to statistically significant greater improvement on all key secondary and other efficacy endpoints, both clinician-reported and patient-reported, including measures of anxiety, depression, intrusive symptoms, hyperarousal, and overall functioning.

Combining an atypical antipsychotic with an antidepressant for PTSD “builds on what we’ve been doing in depression,” Elspeth Ritchie, MD, chair of Psychiatry, MedStar Washington Hospital Center, Washington, DC, noted in an interview with this news organization.

“We have found that a combination of a low-dose antipsychotic and an antidepressant is helpful for depression, so it makes sense that it will be helpful for PTSD. However, this has been mostly based on clinical decisions, without a heavy research background. Good science is always helpful to support those clinical decisions,” Ritchie told this news organization.

 

What About Safety?

In the phase 3 trial, brexpiprazole plus sertraline had a safety profile consistent with that of brexpiprazole in approved indications. The rate of discontinuation due to adverse events was low (3.9% for brexpiprazole plus sertraline vs 10.2% for sertraline plus placebo), indicating that most participants tolerated the brexpiprazole and sertraline combination treatment, the study team said.

In both treatment groups, the only treatment-emergent adverse event (TEAE) with incidence greater than 10% was nausea, a known adverse effect of sertraline treatment.

Weight gain was greater in participants receiving the combination. At the last visit, a weight gain of 7% or greater from week 1 was experienced by 8% of participants taking brexpiprazole with the sertraline group and 5% of those taking the sertraline plus placebo. Previous analyses in schizophrenia and MDD show that brexpiprazole is associated with moderate weight gain (+3 to 4 kg over 1 year).

The incidence of sedating TEAEs (a concern with some antipsychotics) was generally low, although fatigue (7% vs 4%) and somnolence (5% vs 3%) were more common with brexpiprazole plus sertraline than with sertraline alone.

There were no clinically meaningful between-group differences in changes in laboratory test parameters, vital signs, or ECG and participant-reported TEAEs related to suicidality.

 

Potential Concerns

As with any new drug application, several questions and issues are likely to be raised by the advisory committee. They could include whether the clinical benefit is substantial enough to warrant approval and how the observed effect sizes compare to existing approved therapies and evidence-based psychotherapies.

McIntyre told this news organization what’s particularly noteworthy is that the magnitude of the improvement in PTSD symptoms with brexpiprazole plus sertraline is greater than with sertraline alone. “That’s a very important statement. And this high level of efficacy was consistent on the secondary outcome measures, and the overall tolerability and safety seemed very acceptable,” he said.

What’s equally important, said McIntyre, is that most people with PTSD have depression and anxiety, and the brexpiprazole plus sertraline combination was more helpful than sertraline alone on the measures of anxiety and depression. “This is really important, especially in light of the fact that this medication [brexpiprazole] is already approved for adults living with major depressive disorder and inadequate response to antidepressants,” McIntyre said.

McIntyre added he suspects some questions the committee may have could relate to the extent to which it’s the case that brexpiprazole is effective in PTSD regardless of the antidepressant that is prescribed with it.

“There also will be the inevitable questions about the absence of long-term data which I think will need to be addressed given how chronic and relapse prone this condition is,” McIntyre said.

The committee may ask how trauma and PTSD will be screened in primary care and how outcomes related to this therapy will be evaluated in everyday clinical practice, McIntyre said.

Overall, McIntyre said brexpiprazole plus sertraline in PTSD is a “very positive” development for the field.

“PTSD is a terrible condition. It’s so darn common, and we just don’t have enough treatments for it. The data look good for my perspective. My fingers are crossed for the patients with PTSD and their families,” said McIntyre.

Ritchie reported having no relevant disclosures. McIntyre received speaker/consultation fees from Lundbeck, Janssen, Alkermes, Neumora Therapeutics, Boehringer Ingelheim, Sage, Biogen, Mitsubishi Tanabe, Purdue, Pfizer, Otsuka, Takeda, Neurocrine, Sunovion, Bausch Health, Axsome, Novo Nordisk, Kris, Sanofi, Eisai, Intra-Cellular, NewBridge Pharmaceuticals, Viatris, AbbVie, and atai Life Sciences. McIntyre is a CEO of Braxia Scientific Corp.

A version of this article first appeared on Medscape.com.

Veterans experiencing homelessness are at an elevated risk for adverse health outcomes, including suicide. This population also experiences chronic health conditions (eg, cardiovascular disease and sexually transmitted infections) and psychiatric conditions (eg, substance use disorders and posttraumatic stress disorder) with a greater propensity than veterans without history of homelessness.^1,2 Similarly, veterans experiencing homelessness often report concurrent stressors, such as justice involvement and unemployment, which further impact social functioning.³

The US Department of Veterans Affairs (VA) offers a range of health and social services to veterans experiencing homelessness. These programs are designed to respond to the multifactorial challenges faced by this population and are aimed at achieving sustained, permanent housing.⁴ To facilitate this effort, these programs provide targeted and tailored health (eg, primary care) and social (eg, case management and vocational rehabilitation) services to address barriers to housing stability (eg, substance use, serious mental illness, interacting with the criminal legal system, and unemployment).

Despite the availability of these programs, engaging veterans in VA services—whether in general or tailored for those experiencing or at risk for homelessness—remains challenging. Many veterans at risk for or experiencing homelessness overuse service settings that provide immediate care, such as urgent care or emergency departments (EDs).^5,6 These individuals often visit an ED to augment or complement medical care they received in an outpatient setting, which can result in an elevated health care burden as well as impacted provision of treatment, especially surrounding care for chronic conditions (eg, cardiovascular health or serious mental illness).^7-9

VA EDs offer urgent care and emergency services and often serve as a point of entry for veterans experiencing homelessness.¹⁰ They offer veterans expedient access to care that can address immediate needs (eg, substance use withdrawal, pain management, and suicide risk). EDs may be easier to access given they have longer hours of operation and patients can present without a scheduled appointment. VA EDs are an important point to identify homelessness and connect individuals to social service resources and outpatient health care referrals (eg, primary care and mental health).^4,11

Some clinicians experience uncertainty in navigating or providing care for veterans experiencing or at risk for homelessness. A qualitative study conducted outside the VA found many clinicians did not know how to approach clinical conversations among unstably housed individuals, particularly when they discussed how to manage care for complex health conditions in the context of ongoing case management challenges, such as discharge planning.12 Another study found that clinicians working with individuals experiencing homelessness may have limited prior training or experience treating these patients.¹³ As a result, these clinicians may be unaware of available social services or unknowingly have biases that negatively impact care. Research remains limited surrounding beliefs about and methods of enhancing care among VA clinicians working with veterans experiencing homelessness in the ED.

This multiphase pilot study sought to understand service delivery processes and gaps in VA ED settings. Phase 1 examined ED clinician perceptions of care, facilitators, and barriers to providing care (including suicide risk assessments) and making postdischarge outpatient referrals among VA ED clinicians who regularly work with veterans experiencing homelessness. Phase 2 used this information to develop a clinical psychoeducational resource to enhance post-ED access to care for veterans experiencing or at risk for homelessness.

QUALITATIVE INTERVIEWS

Semistructured qualitative interviews were conducted with 11 VA ED clinicians from 6 Veteran Integrated Service Networks between August 2022 and February 2023. Clinicians were eligible if they currently worked within a VA ED setting (including urgent care) and indicated that some of their patients were veterans experiencing homelessness. All health care practitioners (HCPs) participated in an interview and a postinterview self-report survey that assessed demographic and job-related characteristics. Eight HCPs identified as female and 3 identified as male. All clinicians identified as White and 3 as Hispanic or Latino. Eight clinicians were licensed clinical social workers, 2 were ED nurses, and 1 was an ED physician.

After each clinician provided informed consent, they were invited to complete a telephone or Microsoft Teams interview. All interviews were recorded and subsequently transcribed. Interviews explored clinicians’ experiences caring for veterans experiencing homelessness, with a focus on services provided within the ED, as well as mandated ED screenings such as a suicide risk assessment. Interview questions also addressed postdischarge knowledge and experiences with referrals to VA health services (eg, primary care, mental health) and social services (eg, housing programs). Interviews lasted 30 to 90 minutes.

Recruitment ended after attaining sufficient thematic data, accomplished via an information power approach to sampling. This occurred when the study aims, sample characteristics, existing theory, and depth and quality of interviews dynamically informed the decision to cease recruitment of additional participants.^14,15 Given the scope of study (examining service delivery and knowledge gaps), the specificity of the targeted sample (VA ED clinicians providing care to veterans experiencing homelessness), the level of pre-existing theoretical background informing the study aims, and depth and quality of interview dialogue, this information power approach provides justification for attaining small sample sizes. Following the interview, HCPs completed a demographic questionnaire. Participants were not compensated.

Data Analysis

Directed content analysis was used to analyze qualitative data, with the framework method employed as an analytic instrument to facilitate analysis.^16-18 Analysts engaged in bracketing and discussed reflexivity before data analysis to reflect on personal subjectivities and reduce potential bias.^19,20

A prototype coding framework was developed that enabled coders to meaningfully summarize and condense data within transcripts into varying domains, categories, or topics found within the interview guide. Domain examples included clinical backgrounds, suicide risk and assessment protocols among veterans experiencing homelessness, beliefs about service delivery for veterans experiencing homelessness, and barriers and facilitators that may impact their ability to provide post-ED discharge care. Coders discussed the findings and if there was a need to modify templates. All transcripts were double coded. Once complete, individual templates were merged into a unified Microsoft Excel sheet, which allowed for more discrete analyses, enabling analysts to examine trends across content areas within the dataset.

Clinical Resource Development

HCPs were queried regarding available outpatient resources for post-ED care (eg, printed discharge paperwork and best practice alerts or automated workflows within the electronic health record). Resources used by participants were examined, as well as which resources clinicians thought would help them care for veterans experiencing homelessness. Noted gaps were used to develop a tailored resource for clinicians who treat veterans experiencing homelessness in the ED. This resource was created with the intention it could inform all ED clinicians, with the option for personalization to align with the needs of local services, based on needed content areas identified (eg, emergency shelters and suicide prevention resources).

Resource development followed an information systems research (ISR) framework that used a 3-pronged process of identifying circumstances for how a tool is developed, the problems it aims to address, and the knowledge that informs its development, implementation, and evaluation.^21,22 Initial wireframes of the resource were provided via email to 10 subject matter experts (SMEs) in veteran suicide prevention, emergency medicine, and homeless programs. SMEs were identified via professional listservs, VA program office leadership, literature searches of similar research, and snowball sampling. Solicited feedback on the resource from the SMEs included its design, language, tone, flow, format, and content (ideation and prototyping). The feedback was collated and used to revise the resource. SMEs then reviewed and provided feedback on the revised resource. This iterative cycle (prototype review, commentary, ideation, prototype review) continued until the SMEs offered no additional edits to the resource. In total, 7 iterations of the resource were developed, critiqued, and revised.

INTERVIEW RESULTS

Compassion Fatigue

Many participants expressed concerns about compassion fatigue among VA ED clinicians. Those interviewed indicated that treating veterans experiencing homelessness sometimes led to the development of what they described as a “callus,” a “sixth sense,” or an inherent sense of “suspicion” or distrust. These feelings resulted from concerns about an individual’s secondary gain or potential hidden agenda (eg, a veteran reporting suicidal ideation to attain shelter on a cold night), with clinicians not wanting to feel as if they were taken advantage of or deceived.

Many clinicians noted that compassion fatigue resulted from witnessing the same veterans experiencing homelessness routinely use emergency services for nonemergent or nonmedical needs. Some also expressed that over time this may result in them becoming less empathetic when caring for veterans experiencing homelessness. They hypothesized that clinicians may experience burnout, which could potentially result in a lack of curiosity and concern about a veteran’s risk for suicide or need for social services. Others may “take things for granted,” leading them to discount stressors that are “very real to the patient, this person.”

Clinicians indicated that such sentiments may impact overall care. Potential negative consequences included stigmatization of veterans experiencing homelessness, incomplete or partial suicide risk screenings with this population, inattentive or impersonal care, and expedited discharge from the ED without appropriate safety planning or social service referrals. Clinicians interviewed intended to find ways to combat compassion fatigue and maintain a commitment to provide comprehensive care to all veterans, including those experiencing homelessness. They felt conflict between a lack of empathy for individuals experiencing homelessness and becoming numb to the problem due to overexposure. However, these clinicians remained committed to providing care to these veterans and fighting to maintain the purpose of recovery-focused care.

Knowledge Gaps on Available Services

While many clinicians knew of general resources available to veterans experiencing homelessness, few had detailed information on where to seek consults for other homeless programs, who to contact regarding these services, when they were available, or how to refer to them. Many reported feeling uneasy when discharging veterans experiencing homelessness from care, often being unable to provide local, comprehensive referrals to support their needs and ensure their well-being. These sentiments were compounded when the veteran reported suicidal thoughts or recent suicidal behavior; clinicians felt concerned about the methods to engage these individuals into evidence-based mental health care within the context of unstable housing arrangements.

Some clinicians appeared to lack awareness of the wide array of VA homeless programming. Most could acknowledge at least some aspects of available programming (eg, the US Department of Housing and Urban Development– VA Supportive Housing program), while others were unaware of services tailored to the needs of those experiencing homelessness (eg, homeless patient aligned care teams), or of services targeting concurrent psychosocial stressors (eg, Veterans Justice Programs). Interviewees hypothesized this as being particularly notable among clinicians who are new to the VA or those who work in VA settings as part of their graduate or medical school training. Those aware of the services were uncertain of the referral process, relying on a single social worker or nurse to connect individuals experiencing homelessness to health and social services.

Interviewed clinicians noted that suicide risk screening of veterans experiencing homelessness was only performed by a limited number of individuals within the ED. Some did not feel sufficiently trained, comfortable, or knowledgeable about how to navigate care for veterans experiencing homelessness and at risk of suicide. Clinicians described “an uncomfortableness about suicidal ideation, where people just freeze up” and “don’t know what to do and don’t know what to say.”

Lack of Tangible Resources, Trainings, and Referrals

HCPs reported occasionally lacking the necessary clinical resources and information in the ED to properly support veterans experiencing homelessness and suicidal ideation. Common concerns included case management and discharge planning, as well as navigating health factors, such as elevated suicide risk. Some HCPs felt the local resources they do have access to—discharge packets or other forms of patient information—were not always tailored for the needs (eg, transportation) or abilities of veterans experiencing homelessness. One noted: “We give them a sheet of paper with some resources, which they don’t have the skills to follow up [with] anyway.”

Many interviewees wished for additional training in working with veterans experiencing homelessness. They reported that prior training from the VA Talent Management System or through unit-based programming could assist in educating clinicians on homeless services and suicide risk assessment. When queried on what training they had received, many noted there was “no formal training on what the VA offers homeless vets,” leading many to describe it as on-the-job training. This appeared especially among newer clinicians, who reported they were reliant upon learning from other, more senior staff within the ED.

The absence of training further illustrates the issue of institutional knowledge on these services and referrals, which was often confined to a single individual or team. Not having readily accessible resources, training, or information appropriate for all skill levels and positions within the ED hindered the ability of HCPs to connect veterans experiencing homelessness with social services to ensure their health and safety postdischarge: “If we had a better knowledge base of what the VA offers and the steps to go through in order to get the veteran set up for those things, it would be helpful.”

CLINICAL RESOURCE

A psychoeducational resource was developed for HCPs treating veterans experiencing homelessness (Figure). The resource was designed to mitigate compassion fatigue and recenter attention on the VA commitment to care while emphasizing the need to be responsive to the concerns of these individuals. Initial wireframes of the resource were developed by a small group of authors in review and appraisal of qualitative findings (EP, RH). These wireframes were developed to broadly illustrate the arrangement/structure of content, range of resources to potentially include (eg, available VA homeless programs or consultation resources), and to draft initial wording and phrasing. Subject matter expert feedback refined these wireframes, providing commentary on specific programs to include or exclude, changes and alterations to the design and flow of the resource, and edits to language, word choice, and tone over numerous iterations.

Given that many ED HCPs presented concerns surrounding secondary gain in the context of suicide risk, this resource focused on suicide risk. At the top of the resource, it states “Veterans at risk for homelessness experience more than double the risk for suicide than stably housed veterans.”²³ Also at the top, the resource states: “For many, the last health care visit prior to suicide is often with VA emergency services."²⁴ The goal of these statements was to educate users on the elevated risk for suicide in veterans experiencing homelessness and their role in preventing such deaths.

Text in this section emphasizes that every veteran deserves the best care possible and recenters HCP attention on providing quality, comprehensive care regardless of housing status. The inclusion of this material was prioritized given the concerns expressed regarding compassion fatigue and suspicions of secondary gain (eg, a veteran reporting suicidal ideation to attain shelter or respite from outside conditions).

The resource also attempts to address high rates of emergency service by veterans experiencing homelessness: “Due to challenges with accessing care, Veterans experiencing homelessness may use emergency or urgent care services more frequently than other Veterans.”²⁵ The resource also indicates that VA resources are available to help homeless and at-risk veterans to acquire stable housing, employment, and engage in healthcare, which are outlined with specific contact information. Given the breadth of local and VA services, a portion of the resource is dedicated to local health and social services available for veterans experiencing homelessness. HCPs complete the first page, which is devoted to local homeless service and program resources.

Following SME consultation, the list of programs provided underwent a series of iterations. The program types listed are deemed to be of greatest benefit to veterans experiencing homelessness and most consulted by HCPs. Including VA and non-VA emergency shelters allows clinicians flexible options if a particular shelter is full, closed, or would not meet the veteran’s needs or preference (eg, lack of childcare or does not allow pets). The second column of this section is left intentionally blank; here, the HCP is to list a local point-of- contact at each program. This encourages clinical teams to seek out and make direct contact with these programs and establish (in)formal relationships with them. The HCP then completes the third column with contact information.

Once completed, the resource acts as a living document. Clinicians and SMEs consulted for this study expressed the desire to have an easily accessible resource that can be updated based on necessary changes (eg, emergency shelter address or hours of operation). The resource can be housed within each local VA emergency or urgent care service setting alongside other available clinical tools.

While local resources are the primary focus, interviewees also suggested that some HCPs are not aware of the available VA services . This material, found on the back of the resource, provides a general overview of services available through VA homeless programs. SME consultation and discussion led to selecting the 5 listed categories: housing services, health care services, case management, employment services, and justice-related programming, each with a brief description.

Information for the National Call Center for Homeless Veterans, community service hotline, and Veterans Crisis Line are included on the front page. These hotlines and phone numbers are always available for veterans experiencing homelessness, enabling them to make these connections themselves, if desired. Additionally, given the challenges noted by some HCPs in performing suicide risk screening, evaluation, and intervention, a prompt for the VA Suicide Risk Management Consultation service was also included on the back page.

Creating a Shared and Local Resource

This clinical resource was developed to establish a centralized, shared, local resource available to VA ED HCPs who lacked knowledge of available services or reported discomfort conducting suicide risk screening for veterans experiencing homelessness. In many cases, ED referrals to homeless programs and suicide prevention care was assigned to a single individual, often a nurse or social worker. As a result, an undue amount of work and strain was placed on these individuals, as this forced them to act as the sole bridge between care in the ED and postdischarge social (eg, homeless programs) and mental health (eg, suicide prevention) services. The creation of a unified, easily accessible document aimed to distribute this responsibility more equitably across ED staff.

DISCUSSION

This project intended to develop a clinician resource to support VA ED clinicians caring for veterans experiencing homelessness and their access to services postdischarge. Qualitative interviews provided insights into the burnout and compassion fatigue present in these settings, as well as the challenges and needs regarding knowledge of local and VA services. Emphasis was placed on leveraging extant resources and subject matter expertise to develop a resource capable of providing brief and informative guidance.

This resource is particularly relevant for HCPs new to the VA, including trainees and new hires, who may be less aware of VA and local social services. It has the potential to reduce the burden on VA ED staff to provide guidance and recommendations surrounding postdischarge social services. The resource acknowledges homeless programming focused on social determinants of health that can destabilize housing (eg, legal or occupational challenges). This can incentivize clinicians to discuss these programs with veterans to facilitate their ability to navigate complex health and psychosocial challenges.

HCPs interviewed for this study indicated their apprehension regarding suicide risk screening and evaluation, a process currently mandated within VA ED settings.²⁶ This may be compounded among HCPs with minimal mental health training or those who have worked in community-based settings where such screening and evaluation efforts are not required. The resource reminds clinicians of available VA consultation services, which can provide additional training, clinical guidance, and review of existing local ED processes.

While the resource was directly informed by qualitative interviews conducted with VA emergency service HCPs and developed through an iterative process with SMEs, further research is necessary to determine its effectiveness at increasing access to health and social services among veterans experiencing homelessness. The resource has not been used by HCPs working in these settings to examine uptake or sustained use, nor clinicians’ perceptions of its utility, including acceptability and feasibility; these are important next steps to understand if the resource is functioning as intended.

Compassion fatigue, as well as associated sequelae (eg, burnout, distress, and psychiatric symptoms), is well-documented among individuals working with individuals experiencing homelessness, including VA HCPs.^27-30 Such experiences are likely driven by several factors, including the clinical complexity and service needs of this veteran population. Although compassion fatigue was noted by many clinicians interviewed for this study, it is unclear if the resource alone would address factors driving compassion fatigue, or if additional programming or services may be necessary.

Limitations

The resource requires local HCPs to routinely update its content (eg, establishment of a new emergency shelter in the community or change in hours or contact information of an existing one), which may be challenging. This is especially true as it relates to community resources, which may be more likely to change than national VA programming.

This resource was initially developed following qualitative interviews with a small sample of VA HCPs (explicitly those working within ED settings) and may not be representative of all HCPs engaged in VA care with veterans experiencing homelessness. The perspectives and experiences of those interviewed do not represent the views of all VA ED HCPs and may differ from the perspectives of those in regions with unique cultural and regional considerations.³¹

Given that most of the interviewees were social workers in EDs engaged in care for veterans experiencing homelessness, these findings and informational needs may differ among other types of HCPs who provide services for veterans experiencing homelessness in other settings. Content in the resource was included based on clinician input, and may not reflect the perspectives of veterans, who may perceive some resources as more important (eg, access to primary care or dental services).²⁸

CONCLUSIONS

This project represents the culmination of qualitative interviews and SME input to develop a free-to-use clinician resource to facilitate service delivery and connection to services following discharge from VA EDs for veterans experiencing homelessness. Serving as a template, this resource can be customized to increase knowledge of local VA and community resources to support these individuals. Continued refinement and piloting of this resource to evaluate acceptability, implementation barriers, and use remains warranted.

Veterans experiencing homelessness are at an elevated risk for adverse health outcomes, including suicide. This population also experiences chronic health conditions (eg, cardiovascular disease and sexually transmitted infections) and psychiatric conditions (eg, substance use disorders and posttraumatic stress disorder) with a greater propensity than veterans without history of homelessness.^1,2 Similarly, veterans experiencing homelessness often report concurrent stressors, such as justice involvement and unemployment, which further impact social functioning.³

The US Department of Veterans Affairs (VA) offers a range of health and social services to veterans experiencing homelessness. These programs are designed to respond to the multifactorial challenges faced by this population and are aimed at achieving sustained, permanent housing.⁴ To facilitate this effort, these programs provide targeted and tailored health (eg, primary care) and social (eg, case management and vocational rehabilitation) services to address barriers to housing stability (eg, substance use, serious mental illness, interacting with the criminal legal system, and unemployment).

Despite the availability of these programs, engaging veterans in VA services—whether in general or tailored for those experiencing or at risk for homelessness—remains challenging. Many veterans at risk for or experiencing homelessness overuse service settings that provide immediate care, such as urgent care or emergency departments (EDs).^5,6 These individuals often visit an ED to augment or complement medical care they received in an outpatient setting, which can result in an elevated health care burden as well as impacted provision of treatment, especially surrounding care for chronic conditions (eg, cardiovascular health or serious mental illness).^7-9

VA EDs offer urgent care and emergency services and often serve as a point of entry for veterans experiencing homelessness.¹⁰ They offer veterans expedient access to care that can address immediate needs (eg, substance use withdrawal, pain management, and suicide risk). EDs may be easier to access given they have longer hours of operation and patients can present without a scheduled appointment. VA EDs are an important point to identify homelessness and connect individuals to social service resources and outpatient health care referrals (eg, primary care and mental health).^4,11

Some clinicians experience uncertainty in navigating or providing care for veterans experiencing or at risk for homelessness. A qualitative study conducted outside the VA found many clinicians did not know how to approach clinical conversations among unstably housed individuals, particularly when they discussed how to manage care for complex health conditions in the context of ongoing case management challenges, such as discharge planning.12 Another study found that clinicians working with individuals experiencing homelessness may have limited prior training or experience treating these patients.¹³ As a result, these clinicians may be unaware of available social services or unknowingly have biases that negatively impact care. Research remains limited surrounding beliefs about and methods of enhancing care among VA clinicians working with veterans experiencing homelessness in the ED.

This multiphase pilot study sought to understand service delivery processes and gaps in VA ED settings. Phase 1 examined ED clinician perceptions of care, facilitators, and barriers to providing care (including suicide risk assessments) and making postdischarge outpatient referrals among VA ED clinicians who regularly work with veterans experiencing homelessness. Phase 2 used this information to develop a clinical psychoeducational resource to enhance post-ED access to care for veterans experiencing or at risk for homelessness.

QUALITATIVE INTERVIEWS

Semistructured qualitative interviews were conducted with 11 VA ED clinicians from 6 Veteran Integrated Service Networks between August 2022 and February 2023. Clinicians were eligible if they currently worked within a VA ED setting (including urgent care) and indicated that some of their patients were veterans experiencing homelessness. All health care practitioners (HCPs) participated in an interview and a postinterview self-report survey that assessed demographic and job-related characteristics. Eight HCPs identified as female and 3 identified as male. All clinicians identified as White and 3 as Hispanic or Latino. Eight clinicians were licensed clinical social workers, 2 were ED nurses, and 1 was an ED physician.

After each clinician provided informed consent, they were invited to complete a telephone or Microsoft Teams interview. All interviews were recorded and subsequently transcribed. Interviews explored clinicians’ experiences caring for veterans experiencing homelessness, with a focus on services provided within the ED, as well as mandated ED screenings such as a suicide risk assessment. Interview questions also addressed postdischarge knowledge and experiences with referrals to VA health services (eg, primary care, mental health) and social services (eg, housing programs). Interviews lasted 30 to 90 minutes.

Recruitment ended after attaining sufficient thematic data, accomplished via an information power approach to sampling. This occurred when the study aims, sample characteristics, existing theory, and depth and quality of interviews dynamically informed the decision to cease recruitment of additional participants.^14,15 Given the scope of study (examining service delivery and knowledge gaps), the specificity of the targeted sample (VA ED clinicians providing care to veterans experiencing homelessness), the level of pre-existing theoretical background informing the study aims, and depth and quality of interview dialogue, this information power approach provides justification for attaining small sample sizes. Following the interview, HCPs completed a demographic questionnaire. Participants were not compensated.

Data Analysis

Directed content analysis was used to analyze qualitative data, with the framework method employed as an analytic instrument to facilitate analysis.^16-18 Analysts engaged in bracketing and discussed reflexivity before data analysis to reflect on personal subjectivities and reduce potential bias.^19,20

A prototype coding framework was developed that enabled coders to meaningfully summarize and condense data within transcripts into varying domains, categories, or topics found within the interview guide. Domain examples included clinical backgrounds, suicide risk and assessment protocols among veterans experiencing homelessness, beliefs about service delivery for veterans experiencing homelessness, and barriers and facilitators that may impact their ability to provide post-ED discharge care. Coders discussed the findings and if there was a need to modify templates. All transcripts were double coded. Once complete, individual templates were merged into a unified Microsoft Excel sheet, which allowed for more discrete analyses, enabling analysts to examine trends across content areas within the dataset.

Clinical Resource Development

HCPs were queried regarding available outpatient resources for post-ED care (eg, printed discharge paperwork and best practice alerts or automated workflows within the electronic health record). Resources used by participants were examined, as well as which resources clinicians thought would help them care for veterans experiencing homelessness. Noted gaps were used to develop a tailored resource for clinicians who treat veterans experiencing homelessness in the ED. This resource was created with the intention it could inform all ED clinicians, with the option for personalization to align with the needs of local services, based on needed content areas identified (eg, emergency shelters and suicide prevention resources).

Resource development followed an information systems research (ISR) framework that used a 3-pronged process of identifying circumstances for how a tool is developed, the problems it aims to address, and the knowledge that informs its development, implementation, and evaluation.^21,22 Initial wireframes of the resource were provided via email to 10 subject matter experts (SMEs) in veteran suicide prevention, emergency medicine, and homeless programs. SMEs were identified via professional listservs, VA program office leadership, literature searches of similar research, and snowball sampling. Solicited feedback on the resource from the SMEs included its design, language, tone, flow, format, and content (ideation and prototyping). The feedback was collated and used to revise the resource. SMEs then reviewed and provided feedback on the revised resource. This iterative cycle (prototype review, commentary, ideation, prototype review) continued until the SMEs offered no additional edits to the resource. In total, 7 iterations of the resource were developed, critiqued, and revised.

INTERVIEW RESULTS

Compassion Fatigue

Many participants expressed concerns about compassion fatigue among VA ED clinicians. Those interviewed indicated that treating veterans experiencing homelessness sometimes led to the development of what they described as a “callus,” a “sixth sense,” or an inherent sense of “suspicion” or distrust. These feelings resulted from concerns about an individual’s secondary gain or potential hidden agenda (eg, a veteran reporting suicidal ideation to attain shelter on a cold night), with clinicians not wanting to feel as if they were taken advantage of or deceived.

Many clinicians noted that compassion fatigue resulted from witnessing the same veterans experiencing homelessness routinely use emergency services for nonemergent or nonmedical needs. Some also expressed that over time this may result in them becoming less empathetic when caring for veterans experiencing homelessness. They hypothesized that clinicians may experience burnout, which could potentially result in a lack of curiosity and concern about a veteran’s risk for suicide or need for social services. Others may “take things for granted,” leading them to discount stressors that are “very real to the patient, this person.”

Clinicians indicated that such sentiments may impact overall care. Potential negative consequences included stigmatization of veterans experiencing homelessness, incomplete or partial suicide risk screenings with this population, inattentive or impersonal care, and expedited discharge from the ED without appropriate safety planning or social service referrals. Clinicians interviewed intended to find ways to combat compassion fatigue and maintain a commitment to provide comprehensive care to all veterans, including those experiencing homelessness. They felt conflict between a lack of empathy for individuals experiencing homelessness and becoming numb to the problem due to overexposure. However, these clinicians remained committed to providing care to these veterans and fighting to maintain the purpose of recovery-focused care.

Knowledge Gaps on Available Services

While many clinicians knew of general resources available to veterans experiencing homelessness, few had detailed information on where to seek consults for other homeless programs, who to contact regarding these services, when they were available, or how to refer to them. Many reported feeling uneasy when discharging veterans experiencing homelessness from care, often being unable to provide local, comprehensive referrals to support their needs and ensure their well-being. These sentiments were compounded when the veteran reported suicidal thoughts or recent suicidal behavior; clinicians felt concerned about the methods to engage these individuals into evidence-based mental health care within the context of unstable housing arrangements.

Some clinicians appeared to lack awareness of the wide array of VA homeless programming. Most could acknowledge at least some aspects of available programming (eg, the US Department of Housing and Urban Development– VA Supportive Housing program), while others were unaware of services tailored to the needs of those experiencing homelessness (eg, homeless patient aligned care teams), or of services targeting concurrent psychosocial stressors (eg, Veterans Justice Programs). Interviewees hypothesized this as being particularly notable among clinicians who are new to the VA or those who work in VA settings as part of their graduate or medical school training. Those aware of the services were uncertain of the referral process, relying on a single social worker or nurse to connect individuals experiencing homelessness to health and social services.

Interviewed clinicians noted that suicide risk screening of veterans experiencing homelessness was only performed by a limited number of individuals within the ED. Some did not feel sufficiently trained, comfortable, or knowledgeable about how to navigate care for veterans experiencing homelessness and at risk of suicide. Clinicians described “an uncomfortableness about suicidal ideation, where people just freeze up” and “don’t know what to do and don’t know what to say.”

Lack of Tangible Resources, Trainings, and Referrals

HCPs reported occasionally lacking the necessary clinical resources and information in the ED to properly support veterans experiencing homelessness and suicidal ideation. Common concerns included case management and discharge planning, as well as navigating health factors, such as elevated suicide risk. Some HCPs felt the local resources they do have access to—discharge packets or other forms of patient information—were not always tailored for the needs (eg, transportation) or abilities of veterans experiencing homelessness. One noted: “We give them a sheet of paper with some resources, which they don’t have the skills to follow up [with] anyway.”

Many interviewees wished for additional training in working with veterans experiencing homelessness. They reported that prior training from the VA Talent Management System or through unit-based programming could assist in educating clinicians on homeless services and suicide risk assessment. When queried on what training they had received, many noted there was “no formal training on what the VA offers homeless vets,” leading many to describe it as on-the-job training. This appeared especially among newer clinicians, who reported they were reliant upon learning from other, more senior staff within the ED.

The absence of training further illustrates the issue of institutional knowledge on these services and referrals, which was often confined to a single individual or team. Not having readily accessible resources, training, or information appropriate for all skill levels and positions within the ED hindered the ability of HCPs to connect veterans experiencing homelessness with social services to ensure their health and safety postdischarge: “If we had a better knowledge base of what the VA offers and the steps to go through in order to get the veteran set up for those things, it would be helpful.”

CLINICAL RESOURCE

A psychoeducational resource was developed for HCPs treating veterans experiencing homelessness (Figure). The resource was designed to mitigate compassion fatigue and recenter attention on the VA commitment to care while emphasizing the need to be responsive to the concerns of these individuals. Initial wireframes of the resource were developed by a small group of authors in review and appraisal of qualitative findings (EP, RH). These wireframes were developed to broadly illustrate the arrangement/structure of content, range of resources to potentially include (eg, available VA homeless programs or consultation resources), and to draft initial wording and phrasing. Subject matter expert feedback refined these wireframes, providing commentary on specific programs to include or exclude, changes and alterations to the design and flow of the resource, and edits to language, word choice, and tone over numerous iterations.

Given that many ED HCPs presented concerns surrounding secondary gain in the context of suicide risk, this resource focused on suicide risk. At the top of the resource, it states “Veterans at risk for homelessness experience more than double the risk for suicide than stably housed veterans.”²³ Also at the top, the resource states: “For many, the last health care visit prior to suicide is often with VA emergency services."²⁴ The goal of these statements was to educate users on the elevated risk for suicide in veterans experiencing homelessness and their role in preventing such deaths.

Text in this section emphasizes that every veteran deserves the best care possible and recenters HCP attention on providing quality, comprehensive care regardless of housing status. The inclusion of this material was prioritized given the concerns expressed regarding compassion fatigue and suspicions of secondary gain (eg, a veteran reporting suicidal ideation to attain shelter or respite from outside conditions).

The resource also attempts to address high rates of emergency service by veterans experiencing homelessness: “Due to challenges with accessing care, Veterans experiencing homelessness may use emergency or urgent care services more frequently than other Veterans.”²⁵ The resource also indicates that VA resources are available to help homeless and at-risk veterans to acquire stable housing, employment, and engage in healthcare, which are outlined with specific contact information. Given the breadth of local and VA services, a portion of the resource is dedicated to local health and social services available for veterans experiencing homelessness. HCPs complete the first page, which is devoted to local homeless service and program resources.

Following SME consultation, the list of programs provided underwent a series of iterations. The program types listed are deemed to be of greatest benefit to veterans experiencing homelessness and most consulted by HCPs. Including VA and non-VA emergency shelters allows clinicians flexible options if a particular shelter is full, closed, or would not meet the veteran’s needs or preference (eg, lack of childcare or does not allow pets). The second column of this section is left intentionally blank; here, the HCP is to list a local point-of- contact at each program. This encourages clinical teams to seek out and make direct contact with these programs and establish (in)formal relationships with them. The HCP then completes the third column with contact information.

Once completed, the resource acts as a living document. Clinicians and SMEs consulted for this study expressed the desire to have an easily accessible resource that can be updated based on necessary changes (eg, emergency shelter address or hours of operation). The resource can be housed within each local VA emergency or urgent care service setting alongside other available clinical tools.

While local resources are the primary focus, interviewees also suggested that some HCPs are not aware of the available VA services . This material, found on the back of the resource, provides a general overview of services available through VA homeless programs. SME consultation and discussion led to selecting the 5 listed categories: housing services, health care services, case management, employment services, and justice-related programming, each with a brief description.

Information for the National Call Center for Homeless Veterans, community service hotline, and Veterans Crisis Line are included on the front page. These hotlines and phone numbers are always available for veterans experiencing homelessness, enabling them to make these connections themselves, if desired. Additionally, given the challenges noted by some HCPs in performing suicide risk screening, evaluation, and intervention, a prompt for the VA Suicide Risk Management Consultation service was also included on the back page.

Creating a Shared and Local Resource

This clinical resource was developed to establish a centralized, shared, local resource available to VA ED HCPs who lacked knowledge of available services or reported discomfort conducting suicide risk screening for veterans experiencing homelessness. In many cases, ED referrals to homeless programs and suicide prevention care was assigned to a single individual, often a nurse or social worker. As a result, an undue amount of work and strain was placed on these individuals, as this forced them to act as the sole bridge between care in the ED and postdischarge social (eg, homeless programs) and mental health (eg, suicide prevention) services. The creation of a unified, easily accessible document aimed to distribute this responsibility more equitably across ED staff.

DISCUSSION

This project intended to develop a clinician resource to support VA ED clinicians caring for veterans experiencing homelessness and their access to services postdischarge. Qualitative interviews provided insights into the burnout and compassion fatigue present in these settings, as well as the challenges and needs regarding knowledge of local and VA services. Emphasis was placed on leveraging extant resources and subject matter expertise to develop a resource capable of providing brief and informative guidance.

This resource is particularly relevant for HCPs new to the VA, including trainees and new hires, who may be less aware of VA and local social services. It has the potential to reduce the burden on VA ED staff to provide guidance and recommendations surrounding postdischarge social services. The resource acknowledges homeless programming focused on social determinants of health that can destabilize housing (eg, legal or occupational challenges). This can incentivize clinicians to discuss these programs with veterans to facilitate their ability to navigate complex health and psychosocial challenges.

HCPs interviewed for this study indicated their apprehension regarding suicide risk screening and evaluation, a process currently mandated within VA ED settings.²⁶ This may be compounded among HCPs with minimal mental health training or those who have worked in community-based settings where such screening and evaluation efforts are not required. The resource reminds clinicians of available VA consultation services, which can provide additional training, clinical guidance, and review of existing local ED processes.

While the resource was directly informed by qualitative interviews conducted with VA emergency service HCPs and developed through an iterative process with SMEs, further research is necessary to determine its effectiveness at increasing access to health and social services among veterans experiencing homelessness. The resource has not been used by HCPs working in these settings to examine uptake or sustained use, nor clinicians’ perceptions of its utility, including acceptability and feasibility; these are important next steps to understand if the resource is functioning as intended.

Compassion fatigue, as well as associated sequelae (eg, burnout, distress, and psychiatric symptoms), is well-documented among individuals working with individuals experiencing homelessness, including VA HCPs.^27-30 Such experiences are likely driven by several factors, including the clinical complexity and service needs of this veteran population. Although compassion fatigue was noted by many clinicians interviewed for this study, it is unclear if the resource alone would address factors driving compassion fatigue, or if additional programming or services may be necessary.

Limitations

The resource requires local HCPs to routinely update its content (eg, establishment of a new emergency shelter in the community or change in hours or contact information of an existing one), which may be challenging. This is especially true as it relates to community resources, which may be more likely to change than national VA programming.

This resource was initially developed following qualitative interviews with a small sample of VA HCPs (explicitly those working within ED settings) and may not be representative of all HCPs engaged in VA care with veterans experiencing homelessness. The perspectives and experiences of those interviewed do not represent the views of all VA ED HCPs and may differ from the perspectives of those in regions with unique cultural and regional considerations.³¹

Given that most of the interviewees were social workers in EDs engaged in care for veterans experiencing homelessness, these findings and informational needs may differ among other types of HCPs who provide services for veterans experiencing homelessness in other settings. Content in the resource was included based on clinician input, and may not reflect the perspectives of veterans, who may perceive some resources as more important (eg, access to primary care or dental services).²⁸

CONCLUSIONS

This project represents the culmination of qualitative interviews and SME input to develop a free-to-use clinician resource to facilitate service delivery and connection to services following discharge from VA EDs for veterans experiencing homelessness. Serving as a template, this resource can be customized to increase knowledge of local VA and community resources to support these individuals. Continued refinement and piloting of this resource to evaluate acceptability, implementation barriers, and use remains warranted.

Veterans experiencing homelessness are at an elevated risk for adverse health outcomes, including suicide. This population also experiences chronic health conditions (eg, cardiovascular disease and sexually transmitted infections) and psychiatric conditions (eg, substance use disorders and posttraumatic stress disorder) with a greater propensity than veterans without history of homelessness.^1,2 Similarly, veterans experiencing homelessness often report concurrent stressors, such as justice involvement and unemployment, which further impact social functioning.³

The US Department of Veterans Affairs (VA) offers a range of health and social services to veterans experiencing homelessness. These programs are designed to respond to the multifactorial challenges faced by this population and are aimed at achieving sustained, permanent housing.⁴ To facilitate this effort, these programs provide targeted and tailored health (eg, primary care) and social (eg, case management and vocational rehabilitation) services to address barriers to housing stability (eg, substance use, serious mental illness, interacting with the criminal legal system, and unemployment).

Despite the availability of these programs, engaging veterans in VA services—whether in general or tailored for those experiencing or at risk for homelessness—remains challenging. Many veterans at risk for or experiencing homelessness overuse service settings that provide immediate care, such as urgent care or emergency departments (EDs).^5,6 These individuals often visit an ED to augment or complement medical care they received in an outpatient setting, which can result in an elevated health care burden as well as impacted provision of treatment, especially surrounding care for chronic conditions (eg, cardiovascular health or serious mental illness).^7-9

VA EDs offer urgent care and emergency services and often serve as a point of entry for veterans experiencing homelessness.¹⁰ They offer veterans expedient access to care that can address immediate needs (eg, substance use withdrawal, pain management, and suicide risk). EDs may be easier to access given they have longer hours of operation and patients can present without a scheduled appointment. VA EDs are an important point to identify homelessness and connect individuals to social service resources and outpatient health care referrals (eg, primary care and mental health).^4,11

Some clinicians experience uncertainty in navigating or providing care for veterans experiencing or at risk for homelessness. A qualitative study conducted outside the VA found many clinicians did not know how to approach clinical conversations among unstably housed individuals, particularly when they discussed how to manage care for complex health conditions in the context of ongoing case management challenges, such as discharge planning.12 Another study found that clinicians working with individuals experiencing homelessness may have limited prior training or experience treating these patients.¹³ As a result, these clinicians may be unaware of available social services or unknowingly have biases that negatively impact care. Research remains limited surrounding beliefs about and methods of enhancing care among VA clinicians working with veterans experiencing homelessness in the ED.

This multiphase pilot study sought to understand service delivery processes and gaps in VA ED settings. Phase 1 examined ED clinician perceptions of care, facilitators, and barriers to providing care (including suicide risk assessments) and making postdischarge outpatient referrals among VA ED clinicians who regularly work with veterans experiencing homelessness. Phase 2 used this information to develop a clinical psychoeducational resource to enhance post-ED access to care for veterans experiencing or at risk for homelessness.

QUALITATIVE INTERVIEWS

Semistructured qualitative interviews were conducted with 11 VA ED clinicians from 6 Veteran Integrated Service Networks between August 2022 and February 2023. Clinicians were eligible if they currently worked within a VA ED setting (including urgent care) and indicated that some of their patients were veterans experiencing homelessness. All health care practitioners (HCPs) participated in an interview and a postinterview self-report survey that assessed demographic and job-related characteristics. Eight HCPs identified as female and 3 identified as male. All clinicians identified as White and 3 as Hispanic or Latino. Eight clinicians were licensed clinical social workers, 2 were ED nurses, and 1 was an ED physician.

After each clinician provided informed consent, they were invited to complete a telephone or Microsoft Teams interview. All interviews were recorded and subsequently transcribed. Interviews explored clinicians’ experiences caring for veterans experiencing homelessness, with a focus on services provided within the ED, as well as mandated ED screenings such as a suicide risk assessment. Interview questions also addressed postdischarge knowledge and experiences with referrals to VA health services (eg, primary care, mental health) and social services (eg, housing programs). Interviews lasted 30 to 90 minutes.

Recruitment ended after attaining sufficient thematic data, accomplished via an information power approach to sampling. This occurred when the study aims, sample characteristics, existing theory, and depth and quality of interviews dynamically informed the decision to cease recruitment of additional participants.^14,15 Given the scope of study (examining service delivery and knowledge gaps), the specificity of the targeted sample (VA ED clinicians providing care to veterans experiencing homelessness), the level of pre-existing theoretical background informing the study aims, and depth and quality of interview dialogue, this information power approach provides justification for attaining small sample sizes. Following the interview, HCPs completed a demographic questionnaire. Participants were not compensated.

Data Analysis

Directed content analysis was used to analyze qualitative data, with the framework method employed as an analytic instrument to facilitate analysis.^16-18 Analysts engaged in bracketing and discussed reflexivity before data analysis to reflect on personal subjectivities and reduce potential bias.^19,20

A prototype coding framework was developed that enabled coders to meaningfully summarize and condense data within transcripts into varying domains, categories, or topics found within the interview guide. Domain examples included clinical backgrounds, suicide risk and assessment protocols among veterans experiencing homelessness, beliefs about service delivery for veterans experiencing homelessness, and barriers and facilitators that may impact their ability to provide post-ED discharge care. Coders discussed the findings and if there was a need to modify templates. All transcripts were double coded. Once complete, individual templates were merged into a unified Microsoft Excel sheet, which allowed for more discrete analyses, enabling analysts to examine trends across content areas within the dataset.

Clinical Resource Development

HCPs were queried regarding available outpatient resources for post-ED care (eg, printed discharge paperwork and best practice alerts or automated workflows within the electronic health record). Resources used by participants were examined, as well as which resources clinicians thought would help them care for veterans experiencing homelessness. Noted gaps were used to develop a tailored resource for clinicians who treat veterans experiencing homelessness in the ED. This resource was created with the intention it could inform all ED clinicians, with the option for personalization to align with the needs of local services, based on needed content areas identified (eg, emergency shelters and suicide prevention resources).

Resource development followed an information systems research (ISR) framework that used a 3-pronged process of identifying circumstances for how a tool is developed, the problems it aims to address, and the knowledge that informs its development, implementation, and evaluation.^21,22 Initial wireframes of the resource were provided via email to 10 subject matter experts (SMEs) in veteran suicide prevention, emergency medicine, and homeless programs. SMEs were identified via professional listservs, VA program office leadership, literature searches of similar research, and snowball sampling. Solicited feedback on the resource from the SMEs included its design, language, tone, flow, format, and content (ideation and prototyping). The feedback was collated and used to revise the resource. SMEs then reviewed and provided feedback on the revised resource. This iterative cycle (prototype review, commentary, ideation, prototype review) continued until the SMEs offered no additional edits to the resource. In total, 7 iterations of the resource were developed, critiqued, and revised.

INTERVIEW RESULTS

Compassion Fatigue

Many participants expressed concerns about compassion fatigue among VA ED clinicians. Those interviewed indicated that treating veterans experiencing homelessness sometimes led to the development of what they described as a “callus,” a “sixth sense,” or an inherent sense of “suspicion” or distrust. These feelings resulted from concerns about an individual’s secondary gain or potential hidden agenda (eg, a veteran reporting suicidal ideation to attain shelter on a cold night), with clinicians not wanting to feel as if they were taken advantage of or deceived.

Many clinicians noted that compassion fatigue resulted from witnessing the same veterans experiencing homelessness routinely use emergency services for nonemergent or nonmedical needs. Some also expressed that over time this may result in them becoming less empathetic when caring for veterans experiencing homelessness. They hypothesized that clinicians may experience burnout, which could potentially result in a lack of curiosity and concern about a veteran’s risk for suicide or need for social services. Others may “take things for granted,” leading them to discount stressors that are “very real to the patient, this person.”

Clinicians indicated that such sentiments may impact overall care. Potential negative consequences included stigmatization of veterans experiencing homelessness, incomplete or partial suicide risk screenings with this population, inattentive or impersonal care, and expedited discharge from the ED without appropriate safety planning or social service referrals. Clinicians interviewed intended to find ways to combat compassion fatigue and maintain a commitment to provide comprehensive care to all veterans, including those experiencing homelessness. They felt conflict between a lack of empathy for individuals experiencing homelessness and becoming numb to the problem due to overexposure. However, these clinicians remained committed to providing care to these veterans and fighting to maintain the purpose of recovery-focused care.

Knowledge Gaps on Available Services

While many clinicians knew of general resources available to veterans experiencing homelessness, few had detailed information on where to seek consults for other homeless programs, who to contact regarding these services, when they were available, or how to refer to them. Many reported feeling uneasy when discharging veterans experiencing homelessness from care, often being unable to provide local, comprehensive referrals to support their needs and ensure their well-being. These sentiments were compounded when the veteran reported suicidal thoughts or recent suicidal behavior; clinicians felt concerned about the methods to engage these individuals into evidence-based mental health care within the context of unstable housing arrangements.

Some clinicians appeared to lack awareness of the wide array of VA homeless programming. Most could acknowledge at least some aspects of available programming (eg, the US Department of Housing and Urban Development– VA Supportive Housing program), while others were unaware of services tailored to the needs of those experiencing homelessness (eg, homeless patient aligned care teams), or of services targeting concurrent psychosocial stressors (eg, Veterans Justice Programs). Interviewees hypothesized this as being particularly notable among clinicians who are new to the VA or those who work in VA settings as part of their graduate or medical school training. Those aware of the services were uncertain of the referral process, relying on a single social worker or nurse to connect individuals experiencing homelessness to health and social services.

Interviewed clinicians noted that suicide risk screening of veterans experiencing homelessness was only performed by a limited number of individuals within the ED. Some did not feel sufficiently trained, comfortable, or knowledgeable about how to navigate care for veterans experiencing homelessness and at risk of suicide. Clinicians described “an uncomfortableness about suicidal ideation, where people just freeze up” and “don’t know what to do and don’t know what to say.”

Lack of Tangible Resources, Trainings, and Referrals

HCPs reported occasionally lacking the necessary clinical resources and information in the ED to properly support veterans experiencing homelessness and suicidal ideation. Common concerns included case management and discharge planning, as well as navigating health factors, such as elevated suicide risk. Some HCPs felt the local resources they do have access to—discharge packets or other forms of patient information—were not always tailored for the needs (eg, transportation) or abilities of veterans experiencing homelessness. One noted: “We give them a sheet of paper with some resources, which they don’t have the skills to follow up [with] anyway.”

Many interviewees wished for additional training in working with veterans experiencing homelessness. They reported that prior training from the VA Talent Management System or through unit-based programming could assist in educating clinicians on homeless services and suicide risk assessment. When queried on what training they had received, many noted there was “no formal training on what the VA offers homeless vets,” leading many to describe it as on-the-job training. This appeared especially among newer clinicians, who reported they were reliant upon learning from other, more senior staff within the ED.

The absence of training further illustrates the issue of institutional knowledge on these services and referrals, which was often confined to a single individual or team. Not having readily accessible resources, training, or information appropriate for all skill levels and positions within the ED hindered the ability of HCPs to connect veterans experiencing homelessness with social services to ensure their health and safety postdischarge: “If we had a better knowledge base of what the VA offers and the steps to go through in order to get the veteran set up for those things, it would be helpful.”

CLINICAL RESOURCE

A psychoeducational resource was developed for HCPs treating veterans experiencing homelessness (Figure). The resource was designed to mitigate compassion fatigue and recenter attention on the VA commitment to care while emphasizing the need to be responsive to the concerns of these individuals. Initial wireframes of the resource were developed by a small group of authors in review and appraisal of qualitative findings (EP, RH). These wireframes were developed to broadly illustrate the arrangement/structure of content, range of resources to potentially include (eg, available VA homeless programs or consultation resources), and to draft initial wording and phrasing. Subject matter expert feedback refined these wireframes, providing commentary on specific programs to include or exclude, changes and alterations to the design and flow of the resource, and edits to language, word choice, and tone over numerous iterations.

Given that many ED HCPs presented concerns surrounding secondary gain in the context of suicide risk, this resource focused on suicide risk. At the top of the resource, it states “Veterans at risk for homelessness experience more than double the risk for suicide than stably housed veterans.”²³ Also at the top, the resource states: “For many, the last health care visit prior to suicide is often with VA emergency services."²⁴ The goal of these statements was to educate users on the elevated risk for suicide in veterans experiencing homelessness and their role in preventing such deaths.

Text in this section emphasizes that every veteran deserves the best care possible and recenters HCP attention on providing quality, comprehensive care regardless of housing status. The inclusion of this material was prioritized given the concerns expressed regarding compassion fatigue and suspicions of secondary gain (eg, a veteran reporting suicidal ideation to attain shelter or respite from outside conditions).

The resource also attempts to address high rates of emergency service by veterans experiencing homelessness: “Due to challenges with accessing care, Veterans experiencing homelessness may use emergency or urgent care services more frequently than other Veterans.”²⁵ The resource also indicates that VA resources are available to help homeless and at-risk veterans to acquire stable housing, employment, and engage in healthcare, which are outlined with specific contact information. Given the breadth of local and VA services, a portion of the resource is dedicated to local health and social services available for veterans experiencing homelessness. HCPs complete the first page, which is devoted to local homeless service and program resources.

Following SME consultation, the list of programs provided underwent a series of iterations. The program types listed are deemed to be of greatest benefit to veterans experiencing homelessness and most consulted by HCPs. Including VA and non-VA emergency shelters allows clinicians flexible options if a particular shelter is full, closed, or would not meet the veteran’s needs or preference (eg, lack of childcare or does not allow pets). The second column of this section is left intentionally blank; here, the HCP is to list a local point-of- contact at each program. This encourages clinical teams to seek out and make direct contact with these programs and establish (in)formal relationships with them. The HCP then completes the third column with contact information.

Once completed, the resource acts as a living document. Clinicians and SMEs consulted for this study expressed the desire to have an easily accessible resource that can be updated based on necessary changes (eg, emergency shelter address or hours of operation). The resource can be housed within each local VA emergency or urgent care service setting alongside other available clinical tools.

While local resources are the primary focus, interviewees also suggested that some HCPs are not aware of the available VA services . This material, found on the back of the resource, provides a general overview of services available through VA homeless programs. SME consultation and discussion led to selecting the 5 listed categories: housing services, health care services, case management, employment services, and justice-related programming, each with a brief description.

Information for the National Call Center for Homeless Veterans, community service hotline, and Veterans Crisis Line are included on the front page. These hotlines and phone numbers are always available for veterans experiencing homelessness, enabling them to make these connections themselves, if desired. Additionally, given the challenges noted by some HCPs in performing suicide risk screening, evaluation, and intervention, a prompt for the VA Suicide Risk Management Consultation service was also included on the back page.

Creating a Shared and Local Resource

This clinical resource was developed to establish a centralized, shared, local resource available to VA ED HCPs who lacked knowledge of available services or reported discomfort conducting suicide risk screening for veterans experiencing homelessness. In many cases, ED referrals to homeless programs and suicide prevention care was assigned to a single individual, often a nurse or social worker. As a result, an undue amount of work and strain was placed on these individuals, as this forced them to act as the sole bridge between care in the ED and postdischarge social (eg, homeless programs) and mental health (eg, suicide prevention) services. The creation of a unified, easily accessible document aimed to distribute this responsibility more equitably across ED staff.

DISCUSSION

This project intended to develop a clinician resource to support VA ED clinicians caring for veterans experiencing homelessness and their access to services postdischarge. Qualitative interviews provided insights into the burnout and compassion fatigue present in these settings, as well as the challenges and needs regarding knowledge of local and VA services. Emphasis was placed on leveraging extant resources and subject matter expertise to develop a resource capable of providing brief and informative guidance.

This resource is particularly relevant for HCPs new to the VA, including trainees and new hires, who may be less aware of VA and local social services. It has the potential to reduce the burden on VA ED staff to provide guidance and recommendations surrounding postdischarge social services. The resource acknowledges homeless programming focused on social determinants of health that can destabilize housing (eg, legal or occupational challenges). This can incentivize clinicians to discuss these programs with veterans to facilitate their ability to navigate complex health and psychosocial challenges.

HCPs interviewed for this study indicated their apprehension regarding suicide risk screening and evaluation, a process currently mandated within VA ED settings.²⁶ This may be compounded among HCPs with minimal mental health training or those who have worked in community-based settings where such screening and evaluation efforts are not required. The resource reminds clinicians of available VA consultation services, which can provide additional training, clinical guidance, and review of existing local ED processes.

While the resource was directly informed by qualitative interviews conducted with VA emergency service HCPs and developed through an iterative process with SMEs, further research is necessary to determine its effectiveness at increasing access to health and social services among veterans experiencing homelessness. The resource has not been used by HCPs working in these settings to examine uptake or sustained use, nor clinicians’ perceptions of its utility, including acceptability and feasibility; these are important next steps to understand if the resource is functioning as intended.

Compassion fatigue, as well as associated sequelae (eg, burnout, distress, and psychiatric symptoms), is well-documented among individuals working with individuals experiencing homelessness, including VA HCPs.^27-30 Such experiences are likely driven by several factors, including the clinical complexity and service needs of this veteran population. Although compassion fatigue was noted by many clinicians interviewed for this study, it is unclear if the resource alone would address factors driving compassion fatigue, or if additional programming or services may be necessary.

Limitations

The resource requires local HCPs to routinely update its content (eg, establishment of a new emergency shelter in the community or change in hours or contact information of an existing one), which may be challenging. This is especially true as it relates to community resources, which may be more likely to change than national VA programming.

This resource was initially developed following qualitative interviews with a small sample of VA HCPs (explicitly those working within ED settings) and may not be representative of all HCPs engaged in VA care with veterans experiencing homelessness. The perspectives and experiences of those interviewed do not represent the views of all VA ED HCPs and may differ from the perspectives of those in regions with unique cultural and regional considerations.³¹

Given that most of the interviewees were social workers in EDs engaged in care for veterans experiencing homelessness, these findings and informational needs may differ among other types of HCPs who provide services for veterans experiencing homelessness in other settings. Content in the resource was included based on clinician input, and may not reflect the perspectives of veterans, who may perceive some resources as more important (eg, access to primary care or dental services).²⁸

CONCLUSIONS

This project represents the culmination of qualitative interviews and SME input to develop a free-to-use clinician resource to facilitate service delivery and connection to services following discharge from VA EDs for veterans experiencing homelessness. Serving as a template, this resource can be customized to increase knowledge of local VA and community resources to support these individuals. Continued refinement and piloting of this resource to evaluate acceptability, implementation barriers, and use remains warranted.

“Gold card” programs were supposed to make it easier for frustrated physicians to deal with insurers’ burdensome prior authorization demands.

The idea: Insurers would reward doctors whose past prior authorization requests were typically approved by exempting them from red tape in the future.

At least 10 states have required insurers to establish gold card programs amid mounting concerns nationwide that overuse of prior authorization jeopardizes patient health. Last month, leading insurers joined with the White House in a voluntary pledge to reduce their use of the practice, which they contend is necessary to control costs and minimize unnecessary care.

But Texas’ experience with gold card programs may signal the limits of that approach.

 

Only 3% of Clinicians Qualified

The Lone Star State was an early adopter, passing a 2021 law enabling health providers with a high prior authorization success rate to earn a “gold card” exemption from insurers.

But statewide, only 3% of providers met that bar, according to a testimony provided by the Texas Department of Insurance earlier this year.

“I think it’s safe to say that the impact of this law on prior authorizations for our physicians is underwhelming,” said Ezequiel “Zeke” Silva III, MD, a San Antonio-based interventional radiologist who chairs the Texas Medical Association’s Council on Legislation. “We would have hoped for a greater percentage of our physicians to have been granted the ‘gold card’ status.”

At least nine other states have enacted gold card laws, according to the National Conference of State Legislatures (NCSL).

 

Care Delayed and Denied

Physicians maintain that excessive prior authorization paperwork impedes timely patient care, with clinicians and staffers devoting 13 hours weekly to documentation, according to a 2024 American Medical Association survey.

Insurers view the review as a guardrail against unnecessary care driving up costs. Studies show that restricting prior authorization could boost premiums by 5.6%-16.7%, a Texas Association of Health Plans official testified during the legislative session.

In June, Texas Gov. Greg Abbott signed a revised version of the state’s “gold card” law — part of an emerging national attempt to streamline the prior review process. Cigna, Humana, UnitedHealthcare, and other large insurers have voluntarily committed to reducing the scope of claims involved, according to the America’s Health Insurance Plans trade group.

Meanwhile, federal officials have finalized requirements that direct some insurers, including Medicaid and Medicare Advantage programs, to speed up responses to prior authorization requests, among other measures. Some of those requirements begin in 2026.

 

Gold Card Designs

As in other states, Texas’ “gold card” legislation applies only to state-regulated insurers, which comprise about one fifth of the state’s market. Under HB 3812, which takes effect on September 1, insurers will evaluate health providers based on a year of prior authorization requests rather than 6 months under the 2021 law.

To be evaluated, providers must have submitted at least five requests for a specific health service during that period. To achieve “gold card” status, insurers must approve at least 90% of requests, the same threshold as set by the 2021 law. But the new law stipulates that insurers review a broader pool of requests, including those made directly to the health plan as well as any related affiliates, according to the Texas Department of Insurance. 

The new law continues to limit exemptions only to “top-performing physicians” who repeatedly provide cost-effective care, said Blake Hutson, director of public affairs at the Texas Association of Health Plans. “Even with the change to 1 year, and the bill also adds in a broader array of claims that will be looked at, you still have to meet 90%.”

A key addition requires insurers to release an annual report detailing how many exemptions they have granted or denied, making decisions more transparent to the public, Silva said. “Not just what’s being approved and what’s not being approved, but to potentially evaluate for trends that presently we just have no ability to evaluate,” he said.

Gold card laws vary from state to state, and some exclude prescription drugs, according to an NCSL legislative summary. Other states with gold card programs include Arkansas, Colorado, Illinois, Louisiana, Michigan, New Mexico, Vermont, West Virginia, and Wyoming.

In Illinois, legislation passed last year targeted hospital services for Medicaid patients, as denial rates were routinely higher in that population, said Dave Gross, senior vice president of Government Relations and Communications at the Illinois Health and Hospital Association, Naperville, Illinois. “We’re not seeing this problem in the commercial space,” he noted.

 

Real-World Implications

To some degree, the “gold card” concept makes intuitive sense, recognizing physicians who have a track record of getting their medical care requests approved, said Ravi Gupta, MD, an assistant professor of medicine at Johns Hopkins University School of Medicine, Baltimore, who has studied prior authorization patterns.

But Gupta raised equity concerns. Physicians in large medical groups and hospital systems will have access to staff and other resources to better navigate the prior approval process than those in smaller private practices.

Plus, he added, there’s the potential that physicians who achieve exemptions may become “more indiscriminate” about the services that they recommend.

Insurers’ stated aim is to reduce unnecessary and low-value medical care through prior authorization gatekeeping, Gupta said. But a study he helped conduct, assessing policies across five Medicare Advantage insurers, found a significant lack of consensus on what treatments should be included. Treatments comprising only 12% of Medicare spending would have required prior authorization by all five insurers. Most of that consensus, he wrote, “was devoted to a small number of costly services.”

The administrative burdens affect patients as well. Two thirds of patients with cancer in one 2023 study become personally involved, including calling the insurer or appealing a denial. The patients also reported less trust in insurers and the health system overall, which could have worrisome downstream effects, Fumiko Chino, MD, the study’s lead author and an assistant professor of radiation oncology at Houston’s MD Anderson Cancer Center, said.

“If you don’t trust healthcare,” she said, “why on earth would you get a vaccine or get cancer screening or get your blood pressure checked?”

 

More Than X Percent?

Gupta views the leading health insurers’ pledge as encouraging in concept — but he notes that they are voluntary commitments without any accountability.

In the interim, gold carding remains no more than a workaround, he said.

“Gold cards aren’t really fixing that [prior authorization] problem,” he said. “They’re just rewarding certain clinicians who can demonstrate that they have been able to get through the prior authorization process successfully for X amount of time before they’re rewarded with a gold card.”

In Illinois, regulators are still hashing out gold card rules, including whether the required 90% approval threshold will be based on a specific hospital service or a broader pool of services, Gross said. The hospital association also will closely watch whether Illinois’ experience begins to mirror that in Texas, he said.

“We have some of the best hospitals in the country here in Chicago,” he said. “If we end up with a 3% approval rating of gold cards, we’re going to have to go back to the legislature.”

A version of this article first appeared on Medscape.com.

“Gold card” programs were supposed to make it easier for frustrated physicians to deal with insurers’ burdensome prior authorization demands.

The idea: Insurers would reward doctors whose past prior authorization requests were typically approved by exempting them from red tape in the future.

At least 10 states have required insurers to establish gold card programs amid mounting concerns nationwide that overuse of prior authorization jeopardizes patient health. Last month, leading insurers joined with the White House in a voluntary pledge to reduce their use of the practice, which they contend is necessary to control costs and minimize unnecessary care.

But Texas’ experience with gold card programs may signal the limits of that approach.

 

Only 3% of Clinicians Qualified

The Lone Star State was an early adopter, passing a 2021 law enabling health providers with a high prior authorization success rate to earn a “gold card” exemption from insurers.

But statewide, only 3% of providers met that bar, according to a testimony provided by the Texas Department of Insurance earlier this year.

“I think it’s safe to say that the impact of this law on prior authorizations for our physicians is underwhelming,” said Ezequiel “Zeke” Silva III, MD, a San Antonio-based interventional radiologist who chairs the Texas Medical Association’s Council on Legislation. “We would have hoped for a greater percentage of our physicians to have been granted the ‘gold card’ status.”

At least nine other states have enacted gold card laws, according to the National Conference of State Legislatures (NCSL).

 

Care Delayed and Denied

Physicians maintain that excessive prior authorization paperwork impedes timely patient care, with clinicians and staffers devoting 13 hours weekly to documentation, according to a 2024 American Medical Association survey.

Insurers view the review as a guardrail against unnecessary care driving up costs. Studies show that restricting prior authorization could boost premiums by 5.6%-16.7%, a Texas Association of Health Plans official testified during the legislative session.

In June, Texas Gov. Greg Abbott signed a revised version of the state’s “gold card” law — part of an emerging national attempt to streamline the prior review process. Cigna, Humana, UnitedHealthcare, and other large insurers have voluntarily committed to reducing the scope of claims involved, according to the America’s Health Insurance Plans trade group.

Meanwhile, federal officials have finalized requirements that direct some insurers, including Medicaid and Medicare Advantage programs, to speed up responses to prior authorization requests, among other measures. Some of those requirements begin in 2026.

 

Gold Card Designs

As in other states, Texas’ “gold card” legislation applies only to state-regulated insurers, which comprise about one fifth of the state’s market. Under HB 3812, which takes effect on September 1, insurers will evaluate health providers based on a year of prior authorization requests rather than 6 months under the 2021 law.

To be evaluated, providers must have submitted at least five requests for a specific health service during that period. To achieve “gold card” status, insurers must approve at least 90% of requests, the same threshold as set by the 2021 law. But the new law stipulates that insurers review a broader pool of requests, including those made directly to the health plan as well as any related affiliates, according to the Texas Department of Insurance. 

The new law continues to limit exemptions only to “top-performing physicians” who repeatedly provide cost-effective care, said Blake Hutson, director of public affairs at the Texas Association of Health Plans. “Even with the change to 1 year, and the bill also adds in a broader array of claims that will be looked at, you still have to meet 90%.”

A key addition requires insurers to release an annual report detailing how many exemptions they have granted or denied, making decisions more transparent to the public, Silva said. “Not just what’s being approved and what’s not being approved, but to potentially evaluate for trends that presently we just have no ability to evaluate,” he said.

Gold card laws vary from state to state, and some exclude prescription drugs, according to an NCSL legislative summary. Other states with gold card programs include Arkansas, Colorado, Illinois, Louisiana, Michigan, New Mexico, Vermont, West Virginia, and Wyoming.

In Illinois, legislation passed last year targeted hospital services for Medicaid patients, as denial rates were routinely higher in that population, said Dave Gross, senior vice president of Government Relations and Communications at the Illinois Health and Hospital Association, Naperville, Illinois. “We’re not seeing this problem in the commercial space,” he noted.

 

Real-World Implications

To some degree, the “gold card” concept makes intuitive sense, recognizing physicians who have a track record of getting their medical care requests approved, said Ravi Gupta, MD, an assistant professor of medicine at Johns Hopkins University School of Medicine, Baltimore, who has studied prior authorization patterns.

But Gupta raised equity concerns. Physicians in large medical groups and hospital systems will have access to staff and other resources to better navigate the prior approval process than those in smaller private practices.

Plus, he added, there’s the potential that physicians who achieve exemptions may become “more indiscriminate” about the services that they recommend.

Insurers’ stated aim is to reduce unnecessary and low-value medical care through prior authorization gatekeeping, Gupta said. But a study he helped conduct, assessing policies across five Medicare Advantage insurers, found a significant lack of consensus on what treatments should be included. Treatments comprising only 12% of Medicare spending would have required prior authorization by all five insurers. Most of that consensus, he wrote, “was devoted to a small number of costly services.”

The administrative burdens affect patients as well. Two thirds of patients with cancer in one 2023 study become personally involved, including calling the insurer or appealing a denial. The patients also reported less trust in insurers and the health system overall, which could have worrisome downstream effects, Fumiko Chino, MD, the study’s lead author and an assistant professor of radiation oncology at Houston’s MD Anderson Cancer Center, said.

“If you don’t trust healthcare,” she said, “why on earth would you get a vaccine or get cancer screening or get your blood pressure checked?”

 

More Than X Percent?

Gupta views the leading health insurers’ pledge as encouraging in concept — but he notes that they are voluntary commitments without any accountability.

In the interim, gold carding remains no more than a workaround, he said.

“Gold cards aren’t really fixing that [prior authorization] problem,” he said. “They’re just rewarding certain clinicians who can demonstrate that they have been able to get through the prior authorization process successfully for X amount of time before they’re rewarded with a gold card.”

In Illinois, regulators are still hashing out gold card rules, including whether the required 90% approval threshold will be based on a specific hospital service or a broader pool of services, Gross said. The hospital association also will closely watch whether Illinois’ experience begins to mirror that in Texas, he said.

“We have some of the best hospitals in the country here in Chicago,” he said. “If we end up with a 3% approval rating of gold cards, we’re going to have to go back to the legislature.”

A version of this article first appeared on Medscape.com.

“Gold card” programs were supposed to make it easier for frustrated physicians to deal with insurers’ burdensome prior authorization demands.

The idea: Insurers would reward doctors whose past prior authorization requests were typically approved by exempting them from red tape in the future.

At least 10 states have required insurers to establish gold card programs amid mounting concerns nationwide that overuse of prior authorization jeopardizes patient health. Last month, leading insurers joined with the White House in a voluntary pledge to reduce their use of the practice, which they contend is necessary to control costs and minimize unnecessary care.

But Texas’ experience with gold card programs may signal the limits of that approach.

 

Only 3% of Clinicians Qualified

The Lone Star State was an early adopter, passing a 2021 law enabling health providers with a high prior authorization success rate to earn a “gold card” exemption from insurers.

But statewide, only 3% of providers met that bar, according to a testimony provided by the Texas Department of Insurance earlier this year.

“I think it’s safe to say that the impact of this law on prior authorizations for our physicians is underwhelming,” said Ezequiel “Zeke” Silva III, MD, a San Antonio-based interventional radiologist who chairs the Texas Medical Association’s Council on Legislation. “We would have hoped for a greater percentage of our physicians to have been granted the ‘gold card’ status.”

At least nine other states have enacted gold card laws, according to the National Conference of State Legislatures (NCSL).

 

Care Delayed and Denied

Physicians maintain that excessive prior authorization paperwork impedes timely patient care, with clinicians and staffers devoting 13 hours weekly to documentation, according to a 2024 American Medical Association survey.

Insurers view the review as a guardrail against unnecessary care driving up costs. Studies show that restricting prior authorization could boost premiums by 5.6%-16.7%, a Texas Association of Health Plans official testified during the legislative session.

In June, Texas Gov. Greg Abbott signed a revised version of the state’s “gold card” law — part of an emerging national attempt to streamline the prior review process. Cigna, Humana, UnitedHealthcare, and other large insurers have voluntarily committed to reducing the scope of claims involved, according to the America’s Health Insurance Plans trade group.

Meanwhile, federal officials have finalized requirements that direct some insurers, including Medicaid and Medicare Advantage programs, to speed up responses to prior authorization requests, among other measures. Some of those requirements begin in 2026.

 

Gold Card Designs

As in other states, Texas’ “gold card” legislation applies only to state-regulated insurers, which comprise about one fifth of the state’s market. Under HB 3812, which takes effect on September 1, insurers will evaluate health providers based on a year of prior authorization requests rather than 6 months under the 2021 law.

To be evaluated, providers must have submitted at least five requests for a specific health service during that period. To achieve “gold card” status, insurers must approve at least 90% of requests, the same threshold as set by the 2021 law. But the new law stipulates that insurers review a broader pool of requests, including those made directly to the health plan as well as any related affiliates, according to the Texas Department of Insurance. 

The new law continues to limit exemptions only to “top-performing physicians” who repeatedly provide cost-effective care, said Blake Hutson, director of public affairs at the Texas Association of Health Plans. “Even with the change to 1 year, and the bill also adds in a broader array of claims that will be looked at, you still have to meet 90%.”

A key addition requires insurers to release an annual report detailing how many exemptions they have granted or denied, making decisions more transparent to the public, Silva said. “Not just what’s being approved and what’s not being approved, but to potentially evaluate for trends that presently we just have no ability to evaluate,” he said.

Gold card laws vary from state to state, and some exclude prescription drugs, according to an NCSL legislative summary. Other states with gold card programs include Arkansas, Colorado, Illinois, Louisiana, Michigan, New Mexico, Vermont, West Virginia, and Wyoming.

In Illinois, legislation passed last year targeted hospital services for Medicaid patients, as denial rates were routinely higher in that population, said Dave Gross, senior vice president of Government Relations and Communications at the Illinois Health and Hospital Association, Naperville, Illinois. “We’re not seeing this problem in the commercial space,” he noted.

 

Real-World Implications

To some degree, the “gold card” concept makes intuitive sense, recognizing physicians who have a track record of getting their medical care requests approved, said Ravi Gupta, MD, an assistant professor of medicine at Johns Hopkins University School of Medicine, Baltimore, who has studied prior authorization patterns.

But Gupta raised equity concerns. Physicians in large medical groups and hospital systems will have access to staff and other resources to better navigate the prior approval process than those in smaller private practices.

Plus, he added, there’s the potential that physicians who achieve exemptions may become “more indiscriminate” about the services that they recommend.

Insurers’ stated aim is to reduce unnecessary and low-value medical care through prior authorization gatekeeping, Gupta said. But a study he helped conduct, assessing policies across five Medicare Advantage insurers, found a significant lack of consensus on what treatments should be included. Treatments comprising only 12% of Medicare spending would have required prior authorization by all five insurers. Most of that consensus, he wrote, “was devoted to a small number of costly services.”

The administrative burdens affect patients as well. Two thirds of patients with cancer in one 2023 study become personally involved, including calling the insurer or appealing a denial. The patients also reported less trust in insurers and the health system overall, which could have worrisome downstream effects, Fumiko Chino, MD, the study’s lead author and an assistant professor of radiation oncology at Houston’s MD Anderson Cancer Center, said.

“If you don’t trust healthcare,” she said, “why on earth would you get a vaccine or get cancer screening or get your blood pressure checked?”

 

More Than X Percent?

Gupta views the leading health insurers’ pledge as encouraging in concept — but he notes that they are voluntary commitments without any accountability.

In the interim, gold carding remains no more than a workaround, he said.

“Gold cards aren’t really fixing that [prior authorization] problem,” he said. “They’re just rewarding certain clinicians who can demonstrate that they have been able to get through the prior authorization process successfully for X amount of time before they’re rewarded with a gold card.”

In Illinois, regulators are still hashing out gold card rules, including whether the required 90% approval threshold will be based on a specific hospital service or a broader pool of services, Gross said. The hospital association also will closely watch whether Illinois’ experience begins to mirror that in Texas, he said.

“We have some of the best hospitals in the country here in Chicago,” he said. “If we end up with a 3% approval rating of gold cards, we’re going to have to go back to the legislature.”

A version of this article first appeared on Medscape.com.

The initial plan to reduce the US Department of Veterans Affairs (VA) workforce by 15%—roughly 83,000 employees—has been revised. The VA announced that it expected to reduce its workforce by 30,000 positions through normal attrition, early retirements, and resignations by the end of fiscal year 2025, “eliminating the need for a large-scale reduction-in-force.” Most of the positions will not be replaced due to the federal hiring freeze, which has been extended for 3 months.

“Since March, we’ve been conducting a holistic review of the department centered on reducing bureaucracy and improving services to Veterans,” VA Secretary Doug Collins said in a press release. “A department-wide RIF is off the table, but that doesn’t mean we’re done improving VA.”

About 17,000 VA employees have left their jobs as of June 1. From now and Sept. 30, the department expects another reduction of nearly 12,000. Pete Kasperowicz, a VA spokesperson, said there would not be any reductions beyond the 30,000 planned.

The VA says it has multiple safeguards in place to ensure the reductions do not impact veteran care or benefits. All VA mission-critical positions are exempt from the voluntary early retirement authority and deferred resignation program, and > 350,000 positions are exempt from the federal hiring freeze. 

The release noted several other improvements regarding VA performance in 2025, among them that the disability claims backlog has been reduced by 30% and a record 2 million disability claims have been processed by June. More than 60,000 VA employees have also returned to the office, according to the release.

“As a result of our efforts, VA is headed in the right direction – both in terms of staff levels and customer service,” Collins said. “Our review has resulted in a host of new ideas for better serving Veterans that we will continue to pursue.” 

The initial plan to reduce the US Department of Veterans Affairs (VA) workforce by 15%—roughly 83,000 employees—has been revised. The VA announced that it expected to reduce its workforce by 30,000 positions through normal attrition, early retirements, and resignations by the end of fiscal year 2025, “eliminating the need for a large-scale reduction-in-force.” Most of the positions will not be replaced due to the federal hiring freeze, which has been extended for 3 months.

“Since March, we’ve been conducting a holistic review of the department centered on reducing bureaucracy and improving services to Veterans,” VA Secretary Doug Collins said in a press release. “A department-wide RIF is off the table, but that doesn’t mean we’re done improving VA.”

About 17,000 VA employees have left their jobs as of June 1. From now and Sept. 30, the department expects another reduction of nearly 12,000. Pete Kasperowicz, a VA spokesperson, said there would not be any reductions beyond the 30,000 planned.

The VA says it has multiple safeguards in place to ensure the reductions do not impact veteran care or benefits. All VA mission-critical positions are exempt from the voluntary early retirement authority and deferred resignation program, and > 350,000 positions are exempt from the federal hiring freeze. 

The release noted several other improvements regarding VA performance in 2025, among them that the disability claims backlog has been reduced by 30% and a record 2 million disability claims have been processed by June. More than 60,000 VA employees have also returned to the office, according to the release.

“As a result of our efforts, VA is headed in the right direction – both in terms of staff levels and customer service,” Collins said. “Our review has resulted in a host of new ideas for better serving Veterans that we will continue to pursue.” 

The initial plan to reduce the US Department of Veterans Affairs (VA) workforce by 15%—roughly 83,000 employees—has been revised. The VA announced that it expected to reduce its workforce by 30,000 positions through normal attrition, early retirements, and resignations by the end of fiscal year 2025, “eliminating the need for a large-scale reduction-in-force.” Most of the positions will not be replaced due to the federal hiring freeze, which has been extended for 3 months.

“Since March, we’ve been conducting a holistic review of the department centered on reducing bureaucracy and improving services to Veterans,” VA Secretary Doug Collins said in a press release. “A department-wide RIF is off the table, but that doesn’t mean we’re done improving VA.”

About 17,000 VA employees have left their jobs as of June 1. From now and Sept. 30, the department expects another reduction of nearly 12,000. Pete Kasperowicz, a VA spokesperson, said there would not be any reductions beyond the 30,000 planned.

The VA says it has multiple safeguards in place to ensure the reductions do not impact veteran care or benefits. All VA mission-critical positions are exempt from the voluntary early retirement authority and deferred resignation program, and > 350,000 positions are exempt from the federal hiring freeze. 

The release noted several other improvements regarding VA performance in 2025, among them that the disability claims backlog has been reduced by 30% and a record 2 million disability claims have been processed by June. More than 60,000 VA employees have also returned to the office, according to the release.

“As a result of our efforts, VA is headed in the right direction – both in terms of staff levels and customer service,” Collins said. “Our review has resulted in a host of new ideas for better serving Veterans that we will continue to pursue.” 

Sarcoidosis is a multiorgan granulomatous disorder of unknown etiology that impacts many US veterans.¹ At diagnosis, clinical manifestations vary and partially depend on the extent and severity of organ involvement, particularly of the lungs, heart, and eyes.^2,3 Sarcoidosis may lead to progressive organ dysfunction, long-term disability, and death.^1-3 Clinical practice guidelines recommend prednisone 20 to 40 mg daily or equivalent-prednisone dose followed by a slow tapering, as first-line pharmacotherapy for patients with active sarcoidosis who are naïve to systemic corticosteroids.^2-4

Use of prolonged, high-dosage prednisone (> 40 mg daily) is discouraged due to a high risk of corticosteroid-related adverse events and associated health care costs.^5,6 Research suggests that initial lower prednisone dosage (< 20 mg daily) may be effective in systemic corticosteroid-naïve patients with active sarcoidosis.³

Adherence to this regimen by specialists (eg, pulmonologists, dermatologists, ophthalmologists, rheumatologists, and cardiologists) has not been established. This study sought to determine the starting dosages for prednisone prescribed at the Jesse Brown Department of Veterans Affairs Medical Center (JBVAMC) to patients with active sarcoidosis who were systemic corticosteroid-naïve.

Methods

Patient data were reviewed from the Computerized Patient Record System (CPRS) for individuals diagnosed with sarcoidosis who were corticosteroid-naïve and prescribed initial prednisone dosages by health care practitioners (HCPs) from several specialties between 2014 and 2023 at JBVAMC. This 200-bed acute care facility serves about 62,000 veterans who live in Illinois or Indiana. JBVAMC is affiliated with the University of Illinois College of Medicine at Chicago, Northwestern University Feinberg School of Medicine, and the University of Chicago Pritzker School of Medicine; many JBVAMC HCPs hold academic appointments with these medical schools.

Patient demographics, prescriber specialty, and daily starting dosage were recorded. The decision to initiate prednisone therapy and its dosage were at the discretion of HCPs who diagnosed active sarcoidosis based on compatible clinical and ancillary test findings as documented in CPRS.^2-4,6-10 Statistical analyses were conducted using a t test, and a threshold of P < .05 was considered statistically significant. This study was reviewed and determined to be exempt by the JBVAMC institutional review board.

Results

Sixty-eight patients who were systemic corticosteroid- naïve and had sarcoidosis were prescribed prednisone by HCPs at JBVAMC. Fifty-two were Black (76%), 62 were male (91%), and 53 were current or former smokers (78%). The mean (SD) age was 63 (11) years (Table 1). Forty patients (59%) had lung involvement, 6 had eye (9%), 6 had skin (9%), and 5 had musculoskeletal system (7%) involvement.

Pulmonologists predominantly prescribed initial dosage of 20 mg to 40 mg (median, 35 mg daily) (Figure). Other HCPs, including primary care, tended to prescribe prednisone < 20 mg (median, 17.5 mg; P < .05) (Table 2). The highest initial prednisone dosage was 80 mg daily, prescribed by a neurologist for a patient with neurosarcoidosis. Voortman et al recommend 20 to 40 mg prednisone daily for neurosarcoidosis.⁷ Both groups, pulmonologists and nonpulmonologists, had no significant differences in patient characteristics.

Discussion

Disparate prescription patterns of initial prednisone dosages were observed between pulmonologists and nonpulmonologists treating systemic corticosteroid-naïve patients with active sarcoidosis at JBVAMC. This study did not determine the underlying reasons for this phenomenon, nor its impact on patient outcomes.

Clinical practice guidelines have not been independently validated for each organ affected by sarcoidosis.^2-4,6-10 Variations in clinical practice for other specialties may account for the variable prednisone starting dosage selection. For example, among 6 patients with active ocular sarcoidosis treated by ophthalmologists, 4 were prescribed an initial prednisone dosage of ≥ 10 mg daily. The American Academy of Ophthalmology recommends an initial short-term course of prednisone at 1 to 1.5 mg/kg daily, tapered down to the lowest effective dosage.¹⁰

Limitations

This study used a small, single-center predominantly older Black male patient cohort. The generalizability of these observations is unknown. A larger, multicenter prospective study is warranted to further evaluate these initial observations.

Conclusions

HCPs treating patients who are systemic corticosteroid-naïve with active sarcoidosis for whom prednisone is indicated should adhere to current clinical practice guidelines by prescribing prednisone in the 20 to 40 mg daily range.

Sarcoidosis is a multiorgan granulomatous disorder of unknown etiology that impacts many US veterans.¹ At diagnosis, clinical manifestations vary and partially depend on the extent and severity of organ involvement, particularly of the lungs, heart, and eyes.^2,3 Sarcoidosis may lead to progressive organ dysfunction, long-term disability, and death.^1-3 Clinical practice guidelines recommend prednisone 20 to 40 mg daily or equivalent-prednisone dose followed by a slow tapering, as first-line pharmacotherapy for patients with active sarcoidosis who are naïve to systemic corticosteroids.^2-4

Use of prolonged, high-dosage prednisone (> 40 mg daily) is discouraged due to a high risk of corticosteroid-related adverse events and associated health care costs.^5,6 Research suggests that initial lower prednisone dosage (< 20 mg daily) may be effective in systemic corticosteroid-naïve patients with active sarcoidosis.³

Adherence to this regimen by specialists (eg, pulmonologists, dermatologists, ophthalmologists, rheumatologists, and cardiologists) has not been established. This study sought to determine the starting dosages for prednisone prescribed at the Jesse Brown Department of Veterans Affairs Medical Center (JBVAMC) to patients with active sarcoidosis who were systemic corticosteroid-naïve.

Methods

Patient data were reviewed from the Computerized Patient Record System (CPRS) for individuals diagnosed with sarcoidosis who were corticosteroid-naïve and prescribed initial prednisone dosages by health care practitioners (HCPs) from several specialties between 2014 and 2023 at JBVAMC. This 200-bed acute care facility serves about 62,000 veterans who live in Illinois or Indiana. JBVAMC is affiliated with the University of Illinois College of Medicine at Chicago, Northwestern University Feinberg School of Medicine, and the University of Chicago Pritzker School of Medicine; many JBVAMC HCPs hold academic appointments with these medical schools.

Patient demographics, prescriber specialty, and daily starting dosage were recorded. The decision to initiate prednisone therapy and its dosage were at the discretion of HCPs who diagnosed active sarcoidosis based on compatible clinical and ancillary test findings as documented in CPRS.^2-4,6-10 Statistical analyses were conducted using a t test, and a threshold of P < .05 was considered statistically significant. This study was reviewed and determined to be exempt by the JBVAMC institutional review board.

Results

Sixty-eight patients who were systemic corticosteroid- naïve and had sarcoidosis were prescribed prednisone by HCPs at JBVAMC. Fifty-two were Black (76%), 62 were male (91%), and 53 were current or former smokers (78%). The mean (SD) age was 63 (11) years (Table 1). Forty patients (59%) had lung involvement, 6 had eye (9%), 6 had skin (9%), and 5 had musculoskeletal system (7%) involvement.

Pulmonologists predominantly prescribed initial dosage of 20 mg to 40 mg (median, 35 mg daily) (Figure). Other HCPs, including primary care, tended to prescribe prednisone < 20 mg (median, 17.5 mg; P < .05) (Table 2). The highest initial prednisone dosage was 80 mg daily, prescribed by a neurologist for a patient with neurosarcoidosis. Voortman et al recommend 20 to 40 mg prednisone daily for neurosarcoidosis.⁷ Both groups, pulmonologists and nonpulmonologists, had no significant differences in patient characteristics.

Discussion

Disparate prescription patterns of initial prednisone dosages were observed between pulmonologists and nonpulmonologists treating systemic corticosteroid-naïve patients with active sarcoidosis at JBVAMC. This study did not determine the underlying reasons for this phenomenon, nor its impact on patient outcomes.

Clinical practice guidelines have not been independently validated for each organ affected by sarcoidosis.^2-4,6-10 Variations in clinical practice for other specialties may account for the variable prednisone starting dosage selection. For example, among 6 patients with active ocular sarcoidosis treated by ophthalmologists, 4 were prescribed an initial prednisone dosage of ≥ 10 mg daily. The American Academy of Ophthalmology recommends an initial short-term course of prednisone at 1 to 1.5 mg/kg daily, tapered down to the lowest effective dosage.¹⁰

Limitations

This study used a small, single-center predominantly older Black male patient cohort. The generalizability of these observations is unknown. A larger, multicenter prospective study is warranted to further evaluate these initial observations.

Conclusions

HCPs treating patients who are systemic corticosteroid-naïve with active sarcoidosis for whom prednisone is indicated should adhere to current clinical practice guidelines by prescribing prednisone in the 20 to 40 mg daily range.

Sarcoidosis is a multiorgan granulomatous disorder of unknown etiology that impacts many US veterans.¹ At diagnosis, clinical manifestations vary and partially depend on the extent and severity of organ involvement, particularly of the lungs, heart, and eyes.^2,3 Sarcoidosis may lead to progressive organ dysfunction, long-term disability, and death.^1-3 Clinical practice guidelines recommend prednisone 20 to 40 mg daily or equivalent-prednisone dose followed by a slow tapering, as first-line pharmacotherapy for patients with active sarcoidosis who are naïve to systemic corticosteroids.^2-4

Use of prolonged, high-dosage prednisone (> 40 mg daily) is discouraged due to a high risk of corticosteroid-related adverse events and associated health care costs.^5,6 Research suggests that initial lower prednisone dosage (< 20 mg daily) may be effective in systemic corticosteroid-naïve patients with active sarcoidosis.³

Adherence to this regimen by specialists (eg, pulmonologists, dermatologists, ophthalmologists, rheumatologists, and cardiologists) has not been established. This study sought to determine the starting dosages for prednisone prescribed at the Jesse Brown Department of Veterans Affairs Medical Center (JBVAMC) to patients with active sarcoidosis who were systemic corticosteroid-naïve.

Methods

Patient data were reviewed from the Computerized Patient Record System (CPRS) for individuals diagnosed with sarcoidosis who were corticosteroid-naïve and prescribed initial prednisone dosages by health care practitioners (HCPs) from several specialties between 2014 and 2023 at JBVAMC. This 200-bed acute care facility serves about 62,000 veterans who live in Illinois or Indiana. JBVAMC is affiliated with the University of Illinois College of Medicine at Chicago, Northwestern University Feinberg School of Medicine, and the University of Chicago Pritzker School of Medicine; many JBVAMC HCPs hold academic appointments with these medical schools.

Patient demographics, prescriber specialty, and daily starting dosage were recorded. The decision to initiate prednisone therapy and its dosage were at the discretion of HCPs who diagnosed active sarcoidosis based on compatible clinical and ancillary test findings as documented in CPRS.^2-4,6-10 Statistical analyses were conducted using a t test, and a threshold of P < .05 was considered statistically significant. This study was reviewed and determined to be exempt by the JBVAMC institutional review board.

Results

Sixty-eight patients who were systemic corticosteroid- naïve and had sarcoidosis were prescribed prednisone by HCPs at JBVAMC. Fifty-two were Black (76%), 62 were male (91%), and 53 were current or former smokers (78%). The mean (SD) age was 63 (11) years (Table 1). Forty patients (59%) had lung involvement, 6 had eye (9%), 6 had skin (9%), and 5 had musculoskeletal system (7%) involvement.

Pulmonologists predominantly prescribed initial dosage of 20 mg to 40 mg (median, 35 mg daily) (Figure). Other HCPs, including primary care, tended to prescribe prednisone < 20 mg (median, 17.5 mg; P < .05) (Table 2). The highest initial prednisone dosage was 80 mg daily, prescribed by a neurologist for a patient with neurosarcoidosis. Voortman et al recommend 20 to 40 mg prednisone daily for neurosarcoidosis.⁷ Both groups, pulmonologists and nonpulmonologists, had no significant differences in patient characteristics.

Discussion

Disparate prescription patterns of initial prednisone dosages were observed between pulmonologists and nonpulmonologists treating systemic corticosteroid-naïve patients with active sarcoidosis at JBVAMC. This study did not determine the underlying reasons for this phenomenon, nor its impact on patient outcomes.

Clinical practice guidelines have not been independently validated for each organ affected by sarcoidosis.^2-4,6-10 Variations in clinical practice for other specialties may account for the variable prednisone starting dosage selection. For example, among 6 patients with active ocular sarcoidosis treated by ophthalmologists, 4 were prescribed an initial prednisone dosage of ≥ 10 mg daily. The American Academy of Ophthalmology recommends an initial short-term course of prednisone at 1 to 1.5 mg/kg daily, tapered down to the lowest effective dosage.¹⁰

Limitations

This study used a small, single-center predominantly older Black male patient cohort. The generalizability of these observations is unknown. A larger, multicenter prospective study is warranted to further evaluate these initial observations.

Conclusions

HCPs treating patients who are systemic corticosteroid-naïve with active sarcoidosis for whom prednisone is indicated should adhere to current clinical practice guidelines by prescribing prednisone in the 20 to 40 mg daily range.