Nearly one in three veterans experiencing housing insecurity require frequent, intensive medical care, and those with persistent needs are at significantly higher risk of suicidal thoughts. These findings, published in Medical Care, underscore the urgent need to address housing as a fundamental component of veteran healthcare.
The Veterans Health Administration (VHA) serves millions of veterans, a substantial number of whom face unstable housing situations. This instability doesn’t just create a social crisis; it dramatically increases demand on VA hospitals and emergency departments, according to a systematic review. Identifying veterans most likely to be readmitted is crucial for targeted interventions, leading to the development of “hotspotting” programs.
New Insights from a National Study
A recent article in Medical Care examined acute care utilization among housing-insecure veterans. Blonigen et al. analyzed data from the VHA Homeless Registry spanning 2018–2022 (n≈1.47 million) to pinpoint veterans meeting “hot spotter” criteria: at least one hospital admission or two or more emergency department (ED) visits within a single quarter. The study detailed patterns of care and contrasted those with ongoing versus temporary high acute care needs.
The analysis revealed that almost one-third of housing-insecure veterans met hot spotter criteria in at least one quarter. Strikingly, over half of those identified as high-utilizers met the criteria repeatedly, indicating a substantial group with chronic, recurring healthcare demands, not isolated incidents.
Complex Health Profiles
Clinical complexity was prevalent. Depression affected 58% of veterans, while 51% experienced substance use disorders. Veterans repeatedly flagged as hot spotters also carried a heavier burden of chronic conditions—averaging just over five—compared to those flagged only once, who averaged just over three.
Despite these complex needs, high acute care use didn’t necessarily indicate disengagement from the healthcare system. In fact, veterans with repeated hot spotter status utilized outpatient care more frequently. This likely reflects the relative accessibility of VA outpatient services and the intensity of their health needs. While medical hospitalizations outnumbered psychiatric hospitalizations by roughly two to one, mental health and substance use disorders remained central to their overall clinical picture.
A Concerning Link to Suicide Risk
Perhaps the most alarming finding was the correlation between repeated hot spotter status and suicide risk. Veterans flagged in more than one quarter had nearly double the documented suicidality compared to those flagged only once (23.7% vs. 11.7%). This suggests that sustained periods of high acute care use may signal profound psychological vulnerability, extending beyond medical instability.
Implications for Care and Policy
These findings demonstrate how housing insecurity profoundly shapes healthcare needs. The high rates of outpatient engagement among the hot spot group likely reflect the greater access veterans have to VA outpatient services compared to non-VA systems. However, even with access to primary care, these veterans require intensive management to prevent acute events.
The significant prevalence of mental health and substance use disorders underscores the inadequacy of medical care alone. Integrated behavioral health services are crucial to reducing reliance on crisis care. Prioritizing sustained access to mental health and addiction treatment, not just acute interventions, is essential.
National HUD-VASH program studies show that even housed veterans continue to utilize emergency and inpatient services at elevated rates compared to their independently housed peers, highlighting the lasting impact of past housing instability.
The Role of Respite Care and Coordination
Blonigen et al. suggest increasing coordination with medical respite programs following hospitalization. These programs provide a safe recovery environment and may reduce readmissions for individuals lacking stable housing.
Investing in post-acute care coordination and housing support aligns with “housing as healthcare” models gaining traction in Medicaid and public sector demonstrations. Effective care for housing-insecure patients requires a holistic approach encompassing clinical, social, and housing services.
- Nearly one-third of housing-insecure veterans are identified as “hot spotters” – frequent users of acute care services.
- Repeated hot spotter status is strongly linked to a higher prevalence of chronic conditions, mental health disorders, and substance use.
- Veterans flagged as hot spotters in multiple quarters exhibit nearly double the documented risk of suicidality.
- Addressing housing insecurity is critical for improving veteran health outcomes and reducing healthcare costs.
A robust body of research demonstrates the strong link between housing insecurity and acute care utilization. Systematic reviews reveal that people experiencing homelessness visit emergency departments at much higher rates than those who are housed and often rely on hospitals as their primary source of care. Screening for housing instability in acute care settings reveals that a significant proportion of ED patients are housing insecure and have complex clinical needs.
Research increasingly characterizes homelessness as an actionable social determinant of health. Reviews by Health Affairs and others emphasize that housing stability, affordability, and quality influence a wide range of health outcomes, including hospital admissions and ED use. Interventions that combine stable housing with care coordination and supportive services have reduced costly utilization in Medicaid and safety-net populations [pdf].
Within the veteran population, homelessness and housing instability are clearly tied to mental health burden and suicide risk. Prior studies report higher odds of suicidal ideation, attempts, and psychological distress among veterans with housing instability compared to those with stable housing. National VA data also show that veterans with a history of homelessness face elevated suicide risk even after accounting for other factors.
The hotspotting literature complements this evidence by demonstrating that a small subset of patients—those with housing instability, multimorbidity, and behavioral health disorders—account for a disproportionate share of acute care use [pdf]. Early super-utilizer research emphasized that frequent ED and inpatient use clusters in populations with complex health and social needs. In Medicaid and safety-net settings, identifying these patients for tailored interventions reduced downstream utilization [pdf].
This evidence reinforces a simple principle: housing insecurity is a predictable risk factor for acute care use. It also underscores the need for hotspotting programs linked to comprehensive interventions, including housing support, behavioral health integration, and post-acute care coordination. Programs like Supportive Services for Veteran Families, which rapidly re-house veterans and provide ongoing support, are a vital part of this continuum.
