Needs of homeless veterans: 5 years of the CHALENG Survey 2012–16

Needs of homeless veterans: 5 years of the CHALENG Survey 2012–16 Abstract Background National surveys of homeless veterans have been conducted for over a decade, but there has been no examination of changes in the needs of homeless veterans. Methods Annual surveys of convenience samples of homeless veterans conducted for Project Community Homelessness Assessment, Local Education and Networking Groups (CHALENG) from 2012 (n = 6859), 2013 (n = 7741), 2014 (n = 7126), 2015 (n = 3765) and 2016 (n = 3191) were analyzed. CHALENG surveys collected background information about respondents and their ratings of unmet needs of homeless veterans. Results Across years, the majority of respondents were males, white, 45–60 years old, Army veterans, lived in urban areas, had no dependent children, and were enrolled in VA healthcare. Over time, the proportion of respondents who were over 60, female, and white increased. There was little change in reported unmet needs with the highest rated unmet needs related to credit counseling, utility assistance, furniture and housewares, dental care and disability income. Among subsamples of veterans with specialized needs, the top three reported unmet needs were housing for registered sex offenders, legal assistance for evictions/foreclosures, and legal assistance for child support. Conclusions Several intractable unmet needs of homeless veterans have persisted in contemporary time. housing, social determinants, socioeconomics factors Populations experiencing homelessness have a range of housing, healthcare, and social needs. Assessment and updated knowledge of these needs are important to providing the comprehensive interdisciplinary care that is often needed to serve these populations.1,2 Homelessness among US veterans is of great public concern and homeless veterans represent an important group in need of assistance from the perspectives of public health, federal policy and society at large. In general, US veterans have been overrepresented in the country’s homeless adult population; in 2016, it was estimated that veterans constituted 9.2% of homeless adults3 while only constituting 7.4% of all adults.4 Perhaps more importantly, homeless veterans also symbolically represent a failure of the government to care for those who have served our military and country. The Department of Veterans Affairs (VA) has spent significant amounts of money on its homeless programs since the 1980s but more recently, beginning in 2009, VA embarked on a federal initiative to end veteran homelessness and spent over 1 billion dollars annually for programs and services for homeless veterans.5,6 As a result, the most recent 2017 Annual Homeless Assessment Report reported that homelessness among veterans has declined by 45% since 2009, with a Point-In-Time (PIT) count of 75 609 veterans in 2009 to 40 056 veterans in 2016 who experienced homelessness on a single night in January 2017.7 While considerable progress has been made, many veterans continue to struggle with homelessness, health problems and other social issues which may not be captured in PIT counts and other homeless metrics. For example, one national study found that ~11% of veterans who exit VA’s supported housing program return to homelessness after 1 year; and among exiters, 10% are evicted.8 Other studies have found that homeless veterans experience various other problems beyond housing, such as substance abuse, income insecurity, money mismanagement, criminal justice involvement, poor social integration and civil legal problems.9–11 Project Community Homelessness Assessment, Local Education and Networking Groups (CHALENG) was launched by the VA in 1993 in response to Public Law 102-405 to enhance continuum of services for homeless veterans provided by VA healthcare facilities and community service agencies. Project CHALENG conducts a national survey to assess the needs of homeless veterans annually and has been conducting the survey for over two decades now.12 The CHALENG survey was designed to be an ongoing assessment process that describes the needs of homeless veterans and identifies the barriers they face to successful recovery. Since 2011, when VA determined the CHALENG report was no longer due to Congress, brief reports detailing the results of the CHALENG survey have been issued annually. Since 2011, there has been no formal examination of survey results over time, which can provide information on contemporary changes and trends in the needs of homeless veterans. Thus, in this study, we compiled 5 years of CHALENG survey data available since the 2011 report and examined changes in the characteristics of respondents and their ratings on unmet needs. There have been various demographic changes in the general veteran population which the VA has tracked and developed services for accordingly.13 The VA remains dedicated to addressing veteran homelessness and understanding the consistent and changing needs of homeless veterans may be important in these efforts. Methods The CHALENG survey is the only ongoing comprehensive national effort to request input from homeless veterans, VA staff, community partnership agencies, and local, state and federal government representatives about the needs of homeless veterans. The results help VA identify interventions needed to effectively assist homeless veterans. For this study, 5 years of data from the CHALENG survey conducted 2012–16 were obtained and merged for analysis. The veteran component of the survey was the focus of this study. Survey data from 2012 to 2016 were selected because they are contemporary and to allow comparability of responses between years. While the CHALENG survey has been conducted since 1993, there have been various changes made to the survey over time. For example, the veteran component was introduced in 2007, data on the gender of respondents were collected beginning in 2011, and there have been various changes in items and scoring that have occurred prior to 2012. The CHALENG survey is distributed annually by VA staff and the survey asks respondents to rank 63 pre-identified homelessness veterans’ needs (five related specifically to female veterans). The survey is distributed at multiple times throughout the year to homeless and at-risk veterans at Stand Downs, VA homeless assessment centers, at homeless programs such as the Domiciliary Care for Homeless Veterans, Healthcare for Homeless Veterans, Grant and Per Diem, and Housing and Urban-Veterans Affairs Supportive Housing (HUD-VASH) program, CHALENG meetings, and other veteran-driven events throughout the nation. Hard copies of the survey are distributed to individuals at all VA homeless program sites nationwide and the survey is anonymous. In addition, there is a website where individuals can complete the survey online. Completed surveys are accumulated throughout the year from sites. The number of respondents to the CHALENG survey have decreased from 2012 to 2016 and this may be due to various reasons, including the transition to online data collection, because the CHALENG report is no longer congressionally required, and because the VA Homeless Program Office has developed additional data sources over the years. Analysis of the data from the CHALENG surveys has been approved by the VA Homeless Program Office and the institutional review board at VA Connecticut Healthcare System. In 2012, 6859 veterans (11.3% relative to PIT count that year) completed the CHALENG survey. In 2013, 7741 veterans (13.9% relative to PIT count) completed the CHALENG survey. In 2014, 7216 (14.5% relative to PIT count) completed the survey. In 2015, 3765 (7.9% relative to PIT count) completed the survey and in 2016, 3191 (8.1% relative to PIT count) completed the CHALENG survey. Measures The veteran CHALENG survey was identical from the years 2012 to 2016. The CHALENG survey first asked respondents for background information about their sociodemographic characteristics and housing (i.e. current housing situation, history of homelessness). Then respondents were provided a list of 63 pre-identified needs in six categories: housing, treatment, income/benefits, legal assistance, education/job services and community partnership. Respondents were asked to rate each of these needs on a scale from 1 (Unmet) to 4 (Met) or 5 (N/A) based on the extent to which they believed the needs of homeless veterans in their community area were met. A copy of the CHALENG survey is available upon request from the authors. Data analysis Annual CHALENG survey data from 2012 to 2016 were merged for analysis and each year was treated as a separate sample. Analyses proceeded in three phases. First, analysis of variance was conducted to compare the sociodemographic and housing characteristics of samples between years. Second, preliminary analysis revealed substantial variability in the number of respondents across items. Hence, we identified 28 items that had the most respondents (i.e. the majority of samples responded to these items) and examined change in ratings of these items. Other items were excluded because many respondents did not respond to them. We could identify no specific pattern with missing data beyond the fact that some items were too specific to be applicable to all respondents (e.g. parent education, tuberculosis testing and treatment, discharge upgrade). Analysis of covariance was conducted to compare ratings of the 28 main items between years; background differences between years were entered as covariates. Fisher’s Least Significant Difference (LSD) test was used for post-hoc pairwise comparisons between years. These analyses of covariance were repeated with respondents by their housing status which was categorized as literally homeless, transiently homeless (e.g. in transitional housing) or in permanent housing (subsidized and unsubsidized). Finally, we wanted to examine the highest rated unmet needs of homeless veterans regardless of the number of respondents. Therefore, we conducted descriptive analyses on all 63 items and identified the top five rated unmet needs rated every year. Of the top five rated unmet needs, we also calculated the proportion of respondents who indicated the need was ‘unmet’ (i.e. rating of 1). Results Table 1 shows the sociodemographic, geographic, household, military and housing characteristics of respondents from years 2012 to 2016. Sample sizes for each year are shown in the Table and there is a footnote in the Table indicating the PIT counts of homeless veterans for every year of the survey. Across years, the majority of respondents were male, white, 45–60 years old, Army veterans, lived in urban areas, had no dependent children, and were enrolled in VA healthcare. Respondents were geographically diverse with most coming from the Midwest, Southeast, and Northeast regions of the USA. Across year, over 10% of respondents had a history of chronic homelessness and the majority were currently residing in transitional housing, Section 8 housing, or were literally homeless. Table 1 Background characteristics of homeless respondents Year 2012a Year 2013 Year 2014 Year 2015 Year 2016 Test of difference N = 6859 N = 7741 N = 7126 N = 3765 N = 3191 Age  <25 years 100 (1.5%) 77 (1.0%) 77 (1.1%) 33 (0.9%) 21 (0.7%) 235.31***  25–34 years 573 (8.4%) 623 (8.0%) 644 (9.2%) 347 (9.4%) 246 (7.8%)  35–44 years 806 (11.8%) 867 (11.2%) 803 (11.5%) 445 (12.1%) 363 (11.5%)  45–60 years 4369 (63.7%) 4848 (62.6%) 4209 (60.1%) 2118 (57.7%) 1708 (54.1%)  61+ years 1011 (14.7%) 1326 (17.1%) 1272 (18.2%) 729 (19.9%) 822 (26.0%) Gender  Male 6297 (91.8%) 7023 (90.7%) 6388 (89.6%) 3337 (88.6%) 2820 (88.4%) 47.34***  Female 562 (8.2%) 718 (9.3%) 738 (10.4%) 428 (11.4%) 371 (11.6%) Race/Ethnicityb  White 3392 (49.6%) 3679 (47.6%) 3339 (49.5%) 1718 (48.5%) 1637 (53.3%) 161.30***  Black 2747 (40.2%) 3205 (41.5%) 2612 (38.7%) 1291 (36.4%) 1106 (36.0%)  Hispanic 283 (4.1%) 353 (4.6%) 464 (6.9%) 272 (7.7%) 178 (5.8%)  Other 414 (6.1%) 484 (6.3%) 337 (5.0%) 262 (7.4%) 149 (4.9%) Service branch  Army 3644 (53.1%) 4080 (52.7%) 3668 (51.5%) 2012 (53.4%) 1690 (53.0%) 33.16*  Navy 1391 (20.3%) 1529 (19.8%) 1468 (20.6%) 744 (19.8%) 618 (19.4%)  Marine Corps 842 (12.3%) 984 (12.7%) 865 (12.1%) 505 (13.4%) 418 (13.1%)  Air Force 781 (11.4%) 897 (11.6%) 855 (12.0%) 393 (10.4%) 373 (11.7%)  Coast Guard 60 (0.9%) 75 (1.0%) 58 (0.8%) 32 (0.8%) 27 (0.8%)  National Guard/Reserve 141 (2.1%) 176 (2.3%) 212 (3.0%) 79 (2.1%) 65 (2.0%) Region  Westc 809 (14.6%) 898 (13.9%) 776 (13.3%) 273 (7.7%) 142 (4.9%) 1122.35***  Midwest 1094 (19.7%) 1555 (24.1%) 1270 (21.8%) 1437 (40.8%) 888 (30.5%)  Southwest 528 (9.5%) 564 (8.8%) 479 (8.2%) 107 (3.0%) 246 (8.5%)  Southeast 2529 (45.5%) 2805 (43.5%) 2578 (44.2%) 1415 (40.2%) 1046 (35.9%)  Northeast 594 (10.7%) 622 (9.7%) 724 (12.4%) 292 (20.2%) 589 (20.2%) Live in rural or frontier community 1400 (20.4%) 1314 (17.0%) 1339 (20.3%) 815 (22.6%) 534 (17.4%) 68.94*** Number of dependents  0 6110 (89.1%) 6800 (87.8%) 5919 (85.6%) 3106 (85.4%) 2729 (87.1%) 55.43***  1 358 (5.2%) 447 (5.8%) 463 (6.7%) 245 (6.7%) 189 (6.0%)  2–3 298 (4.3%) 398 (5.1%) 416 (6.0%) 234 (6.4%) 166 (5.3%)  >4 93 (1.4%) 96 (1.2%) 114 (1.6%) 52 (1.4%) 50 (1.6%) History of chronic homelessnessd 793 (11.6%) 1152 (14.9%) 1120 (15.7%) 679 (18.0%) 426 (13.4%) 98.29*** Current housing  Literally homeless 1300 (19.0%) 1826 (23.6%) 2044 (28.7%) 1072 (28.5%) 798 (25.0%) 845.02***  Emergency housing 486 (7.1%) 416 (5.4%) 385 (5.4%) 206 (5.5%) 199 (6.2%)  Transitional housing 2836 (41.3%) 2692 (34.8%) 1944 (27.3%) 1065 (28.3%) 843 (26.4%)  Section 8 housing 1665 (24.3%) 1740 (22.5%) 1415 (19.9%) 774 (20.6%) 868 (27.2%)  Independent housing 572 (8.3%) 1067 (13.8%) 1338 (18.8%) 648 (17.2%) 483 (15.1%) Enrolled in VA healthcare benefits 6382 (93.0%) 7.042 (91.0%) 6257 (89.6%) 3319 (90.9%) 2898 (91.4%) 69.68*** Year 2012a Year 2013 Year 2014 Year 2015 Year 2016 Test of difference N = 6859 N = 7741 N = 7126 N = 3765 N = 3191 Age  <25 years 100 (1.5%) 77 (1.0%) 77 (1.1%) 33 (0.9%) 21 (0.7%) 235.31***  25–34 years 573 (8.4%) 623 (8.0%) 644 (9.2%) 347 (9.4%) 246 (7.8%)  35–44 years 806 (11.8%) 867 (11.2%) 803 (11.5%) 445 (12.1%) 363 (11.5%)  45–60 years 4369 (63.7%) 4848 (62.6%) 4209 (60.1%) 2118 (57.7%) 1708 (54.1%)  61+ years 1011 (14.7%) 1326 (17.1%) 1272 (18.2%) 729 (19.9%) 822 (26.0%) Gender  Male 6297 (91.8%) 7023 (90.7%) 6388 (89.6%) 3337 (88.6%) 2820 (88.4%) 47.34***  Female 562 (8.2%) 718 (9.3%) 738 (10.4%) 428 (11.4%) 371 (11.6%) Race/Ethnicityb  White 3392 (49.6%) 3679 (47.6%) 3339 (49.5%) 1718 (48.5%) 1637 (53.3%) 161.30***  Black 2747 (40.2%) 3205 (41.5%) 2612 (38.7%) 1291 (36.4%) 1106 (36.0%)  Hispanic 283 (4.1%) 353 (4.6%) 464 (6.9%) 272 (7.7%) 178 (5.8%)  Other 414 (6.1%) 484 (6.3%) 337 (5.0%) 262 (7.4%) 149 (4.9%) Service branch  Army 3644 (53.1%) 4080 (52.7%) 3668 (51.5%) 2012 (53.4%) 1690 (53.0%) 33.16*  Navy 1391 (20.3%) 1529 (19.8%) 1468 (20.6%) 744 (19.8%) 618 (19.4%)  Marine Corps 842 (12.3%) 984 (12.7%) 865 (12.1%) 505 (13.4%) 418 (13.1%)  Air Force 781 (11.4%) 897 (11.6%) 855 (12.0%) 393 (10.4%) 373 (11.7%)  Coast Guard 60 (0.9%) 75 (1.0%) 58 (0.8%) 32 (0.8%) 27 (0.8%)  National Guard/Reserve 141 (2.1%) 176 (2.3%) 212 (3.0%) 79 (2.1%) 65 (2.0%) Region  Westc 809 (14.6%) 898 (13.9%) 776 (13.3%) 273 (7.7%) 142 (4.9%) 1122.35***  Midwest 1094 (19.7%) 1555 (24.1%) 1270 (21.8%) 1437 (40.8%) 888 (30.5%)  Southwest 528 (9.5%) 564 (8.8%) 479 (8.2%) 107 (3.0%) 246 (8.5%)  Southeast 2529 (45.5%) 2805 (43.5%) 2578 (44.2%) 1415 (40.2%) 1046 (35.9%)  Northeast 594 (10.7%) 622 (9.7%) 724 (12.4%) 292 (20.2%) 589 (20.2%) Live in rural or frontier community 1400 (20.4%) 1314 (17.0%) 1339 (20.3%) 815 (22.6%) 534 (17.4%) 68.94*** Number of dependents  0 6110 (89.1%) 6800 (87.8%) 5919 (85.6%) 3106 (85.4%) 2729 (87.1%) 55.43***  1 358 (5.2%) 447 (5.8%) 463 (6.7%) 245 (6.7%) 189 (6.0%)  2–3 298 (4.3%) 398 (5.1%) 416 (6.0%) 234 (6.4%) 166 (5.3%)  >4 93 (1.4%) 96 (1.2%) 114 (1.6%) 52 (1.4%) 50 (1.6%) History of chronic homelessnessd 793 (11.6%) 1152 (14.9%) 1120 (15.7%) 679 (18.0%) 426 (13.4%) 98.29*** Current housing  Literally homeless 1300 (19.0%) 1826 (23.6%) 2044 (28.7%) 1072 (28.5%) 798 (25.0%) 845.02***  Emergency housing 486 (7.1%) 416 (5.4%) 385 (5.4%) 206 (5.5%) 199 (6.2%)  Transitional housing 2836 (41.3%) 2692 (34.8%) 1944 (27.3%) 1065 (28.3%) 843 (26.4%)  Section 8 housing 1665 (24.3%) 1740 (22.5%) 1415 (19.9%) 774 (20.6%) 868 (27.2%)  Independent housing 572 (8.3%) 1067 (13.8%) 1338 (18.8%) 648 (17.2%) 483 (15.1%) Enrolled in VA healthcare benefits 6382 (93.0%) 7.042 (91.0%) 6257 (89.6%) 3319 (90.9%) 2898 (91.4%) 69.68*** *P < 0.05, **P < 0.01, ***P < 0.001. aPoint-in-time counts of the number of homeless veterans on a given night annually are as follows: 60 579 homeless veterans in 2012; 55 619 homeless veterans in 2013; 49 689 in 2014; 47 725 in 2015; and 39 471 in 2016. bRace and ethnicity were assessed differently between years so respondents were categorized based on a combination of mutually exclusive race/ethnicity categories. Respondents in the Hispanic category included those who were White Hispanic or Black Hispanic. cOklahoma was categorized as in the West region because of the way VA network areas are organized. dChronic homelessness was defined as being homeless for longer than 1 year and/or having more than four or more episodes of homelessness in the past 3 years. Table 1 Background characteristics of homeless respondents Year 2012a Year 2013 Year 2014 Year 2015 Year 2016 Test of difference N = 6859 N = 7741 N = 7126 N = 3765 N = 3191 Age  <25 years 100 (1.5%) 77 (1.0%) 77 (1.1%) 33 (0.9%) 21 (0.7%) 235.31***  25–34 years 573 (8.4%) 623 (8.0%) 644 (9.2%) 347 (9.4%) 246 (7.8%)  35–44 years 806 (11.8%) 867 (11.2%) 803 (11.5%) 445 (12.1%) 363 (11.5%)  45–60 years 4369 (63.7%) 4848 (62.6%) 4209 (60.1%) 2118 (57.7%) 1708 (54.1%)  61+ years 1011 (14.7%) 1326 (17.1%) 1272 (18.2%) 729 (19.9%) 822 (26.0%) Gender  Male 6297 (91.8%) 7023 (90.7%) 6388 (89.6%) 3337 (88.6%) 2820 (88.4%) 47.34***  Female 562 (8.2%) 718 (9.3%) 738 (10.4%) 428 (11.4%) 371 (11.6%) Race/Ethnicityb  White 3392 (49.6%) 3679 (47.6%) 3339 (49.5%) 1718 (48.5%) 1637 (53.3%) 161.30***  Black 2747 (40.2%) 3205 (41.5%) 2612 (38.7%) 1291 (36.4%) 1106 (36.0%)  Hispanic 283 (4.1%) 353 (4.6%) 464 (6.9%) 272 (7.7%) 178 (5.8%)  Other 414 (6.1%) 484 (6.3%) 337 (5.0%) 262 (7.4%) 149 (4.9%) Service branch  Army 3644 (53.1%) 4080 (52.7%) 3668 (51.5%) 2012 (53.4%) 1690 (53.0%) 33.16*  Navy 1391 (20.3%) 1529 (19.8%) 1468 (20.6%) 744 (19.8%) 618 (19.4%)  Marine Corps 842 (12.3%) 984 (12.7%) 865 (12.1%) 505 (13.4%) 418 (13.1%)  Air Force 781 (11.4%) 897 (11.6%) 855 (12.0%) 393 (10.4%) 373 (11.7%)  Coast Guard 60 (0.9%) 75 (1.0%) 58 (0.8%) 32 (0.8%) 27 (0.8%)  National Guard/Reserve 141 (2.1%) 176 (2.3%) 212 (3.0%) 79 (2.1%) 65 (2.0%) Region  Westc 809 (14.6%) 898 (13.9%) 776 (13.3%) 273 (7.7%) 142 (4.9%) 1122.35***  Midwest 1094 (19.7%) 1555 (24.1%) 1270 (21.8%) 1437 (40.8%) 888 (30.5%)  Southwest 528 (9.5%) 564 (8.8%) 479 (8.2%) 107 (3.0%) 246 (8.5%)  Southeast 2529 (45.5%) 2805 (43.5%) 2578 (44.2%) 1415 (40.2%) 1046 (35.9%)  Northeast 594 (10.7%) 622 (9.7%) 724 (12.4%) 292 (20.2%) 589 (20.2%) Live in rural or frontier community 1400 (20.4%) 1314 (17.0%) 1339 (20.3%) 815 (22.6%) 534 (17.4%) 68.94*** Number of dependents  0 6110 (89.1%) 6800 (87.8%) 5919 (85.6%) 3106 (85.4%) 2729 (87.1%) 55.43***  1 358 (5.2%) 447 (5.8%) 463 (6.7%) 245 (6.7%) 189 (6.0%)  2–3 298 (4.3%) 398 (5.1%) 416 (6.0%) 234 (6.4%) 166 (5.3%)  >4 93 (1.4%) 96 (1.2%) 114 (1.6%) 52 (1.4%) 50 (1.6%) History of chronic homelessnessd 793 (11.6%) 1152 (14.9%) 1120 (15.7%) 679 (18.0%) 426 (13.4%) 98.29*** Current housing  Literally homeless 1300 (19.0%) 1826 (23.6%) 2044 (28.7%) 1072 (28.5%) 798 (25.0%) 845.02***  Emergency housing 486 (7.1%) 416 (5.4%) 385 (5.4%) 206 (5.5%) 199 (6.2%)  Transitional housing 2836 (41.3%) 2692 (34.8%) 1944 (27.3%) 1065 (28.3%) 843 (26.4%)  Section 8 housing 1665 (24.3%) 1740 (22.5%) 1415 (19.9%) 774 (20.6%) 868 (27.2%)  Independent housing 572 (8.3%) 1067 (13.8%) 1338 (18.8%) 648 (17.2%) 483 (15.1%) Enrolled in VA healthcare benefits 6382 (93.0%) 7.042 (91.0%) 6257 (89.6%) 3319 (90.9%) 2898 (91.4%) 69.68*** Year 2012a Year 2013 Year 2014 Year 2015 Year 2016 Test of difference N = 6859 N = 7741 N = 7126 N = 3765 N = 3191 Age  <25 years 100 (1.5%) 77 (1.0%) 77 (1.1%) 33 (0.9%) 21 (0.7%) 235.31***  25–34 years 573 (8.4%) 623 (8.0%) 644 (9.2%) 347 (9.4%) 246 (7.8%)  35–44 years 806 (11.8%) 867 (11.2%) 803 (11.5%) 445 (12.1%) 363 (11.5%)  45–60 years 4369 (63.7%) 4848 (62.6%) 4209 (60.1%) 2118 (57.7%) 1708 (54.1%)  61+ years 1011 (14.7%) 1326 (17.1%) 1272 (18.2%) 729 (19.9%) 822 (26.0%) Gender  Male 6297 (91.8%) 7023 (90.7%) 6388 (89.6%) 3337 (88.6%) 2820 (88.4%) 47.34***  Female 562 (8.2%) 718 (9.3%) 738 (10.4%) 428 (11.4%) 371 (11.6%) Race/Ethnicityb  White 3392 (49.6%) 3679 (47.6%) 3339 (49.5%) 1718 (48.5%) 1637 (53.3%) 161.30***  Black 2747 (40.2%) 3205 (41.5%) 2612 (38.7%) 1291 (36.4%) 1106 (36.0%)  Hispanic 283 (4.1%) 353 (4.6%) 464 (6.9%) 272 (7.7%) 178 (5.8%)  Other 414 (6.1%) 484 (6.3%) 337 (5.0%) 262 (7.4%) 149 (4.9%) Service branch  Army 3644 (53.1%) 4080 (52.7%) 3668 (51.5%) 2012 (53.4%) 1690 (53.0%) 33.16*  Navy 1391 (20.3%) 1529 (19.8%) 1468 (20.6%) 744 (19.8%) 618 (19.4%)  Marine Corps 842 (12.3%) 984 (12.7%) 865 (12.1%) 505 (13.4%) 418 (13.1%)  Air Force 781 (11.4%) 897 (11.6%) 855 (12.0%) 393 (10.4%) 373 (11.7%)  Coast Guard 60 (0.9%) 75 (1.0%) 58 (0.8%) 32 (0.8%) 27 (0.8%)  National Guard/Reserve 141 (2.1%) 176 (2.3%) 212 (3.0%) 79 (2.1%) 65 (2.0%) Region  Westc 809 (14.6%) 898 (13.9%) 776 (13.3%) 273 (7.7%) 142 (4.9%) 1122.35***  Midwest 1094 (19.7%) 1555 (24.1%) 1270 (21.8%) 1437 (40.8%) 888 (30.5%)  Southwest 528 (9.5%) 564 (8.8%) 479 (8.2%) 107 (3.0%) 246 (8.5%)  Southeast 2529 (45.5%) 2805 (43.5%) 2578 (44.2%) 1415 (40.2%) 1046 (35.9%)  Northeast 594 (10.7%) 622 (9.7%) 724 (12.4%) 292 (20.2%) 589 (20.2%) Live in rural or frontier community 1400 (20.4%) 1314 (17.0%) 1339 (20.3%) 815 (22.6%) 534 (17.4%) 68.94*** Number of dependents  0 6110 (89.1%) 6800 (87.8%) 5919 (85.6%) 3106 (85.4%) 2729 (87.1%) 55.43***  1 358 (5.2%) 447 (5.8%) 463 (6.7%) 245 (6.7%) 189 (6.0%)  2–3 298 (4.3%) 398 (5.1%) 416 (6.0%) 234 (6.4%) 166 (5.3%)  >4 93 (1.4%) 96 (1.2%) 114 (1.6%) 52 (1.4%) 50 (1.6%) History of chronic homelessnessd 793 (11.6%) 1152 (14.9%) 1120 (15.7%) 679 (18.0%) 426 (13.4%) 98.29*** Current housing  Literally homeless 1300 (19.0%) 1826 (23.6%) 2044 (28.7%) 1072 (28.5%) 798 (25.0%) 845.02***  Emergency housing 486 (7.1%) 416 (5.4%) 385 (5.4%) 206 (5.5%) 199 (6.2%)  Transitional housing 2836 (41.3%) 2692 (34.8%) 1944 (27.3%) 1065 (28.3%) 843 (26.4%)  Section 8 housing 1665 (24.3%) 1740 (22.5%) 1415 (19.9%) 774 (20.6%) 868 (27.2%)  Independent housing 572 (8.3%) 1067 (13.8%) 1338 (18.8%) 648 (17.2%) 483 (15.1%) Enrolled in VA healthcare benefits 6382 (93.0%) 7.042 (91.0%) 6257 (89.6%) 3319 (90.9%) 2898 (91.4%) 69.68*** *P < 0.05, **P < 0.01, ***P < 0.001. aPoint-in-time counts of the number of homeless veterans on a given night annually are as follows: 60 579 homeless veterans in 2012; 55 619 homeless veterans in 2013; 49 689 in 2014; 47 725 in 2015; and 39 471 in 2016. bRace and ethnicity were assessed differently between years so respondents were categorized based on a combination of mutually exclusive race/ethnicity categories. Respondents in the Hispanic category included those who were White Hispanic or Black Hispanic. cOklahoma was categorized as in the West region because of the way VA network areas are organized. dChronic homelessness was defined as being homeless for longer than 1 year and/or having more than four or more episodes of homelessness in the past 3 years. Between the years, there were various significant differences in age, gender, race/ethnicity, service branch, geographic region, number of dependents, enrollment in VA healthcare and homeless histories between respondents. There were few consistent patterns in these differences across years, except the proportion of respondents who were over 60, female, and white have steadily increased every year. The sample size of respondents also has decreased every year. Table 2 presents the general rated needs of respondents (i.e. identified 28 items with most respondents) for each year from 2012 to 2016. Across years, the highest unmet needs (based on lowest scores) were related to credit counseling, utility assistance, furniture and housewares, dental care, and Supplementary Security Income/Social Security Disability Insurance (SSI/SSDI). Examination of change years revealed significant differences in reported needs between years, but most of these changes were small. Some of the relatively larger differences observed in reported needs (based on F-tests) were related to case management, food, emergency shelter and medical services. Overall, across years, there was a general pattern of greater reported unmet needs across categories over time (i.e. lower scores with increasing years). Table 2 Change in rated general needs of homeless respondent between years 2012 and 2016 2012 2013 2014 2015 2016 Multivariable test of differenceb,c Pairwise comparisons N = 6312a N = 6721 N = 6117 N = 3539 N = 2978 F= Housing Emergency shelter 3.3 (1.0)d 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.1) 38.11 1 > 2 > 5 > 3,4 Transitional housing 3.2 (1.1) 3.1 (1.1) 2.8 (1.3) 2.8 (1.2) 3.0 (1.2) 20.91 1 > 2 > 4 > 3; 1 > 5 > 3 Permanent housing 2.7 (1.3) 2.6 (1.3) 2.4 (1.3) 2.5 (1.3) 2.7 (1.3) 14.10 1,5 > 2,4 > 3 Furniture and housewares 2.5 (1.3) 2.4 (1.3) 2.3 (1.3) 2.4 (1.3) 2.6 (1.3) 11.86 5 > 1,2 > 3; 4 > 2 > 3 Healthcare services Medical services 3.7 (0.7) 3.6 (0.8) 3.5 (0.9) 3.4 (0.9) 3.5 (0.8) 35.46 1 > 2 > 3,4,5 Mental health services 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 25.02 1 > 2 > 3,4,5 Substance abuse treatment 3.6 (0.9) 3.4 (1.0) 3.3 (1.1) 3.3 (1.1) 3.3 (1.1) 26.77 1 > 2 > 3,4,5 Dental care 2.6 (1.3) 2.5 (1.3) 2.4 (1.3) 2.4 (1.3) 2.4 (1.3) 8.92 1,2,4 > 3; 1 > 5 Eye care 3.2 (1.2) 3.2 (1.2) 3.0 (1.2) 3.0 (1.2) 3.2 (1.1) 6.60 1,2 > 5 > 4 > 3 Personal hygiene 3.6 (0.9) 3.5 (0.9) 3.3 (1.1) 3.3 (1.1) 3.4 (1.0) 22.73 1 > 2 > 3,4,5 Medication management 3.6 (0.8) 3.5 (0.9) 3.4 (1.0) 3.3 (1.1) 3.4 (1.0) 29.69 1 > 2 > 3,4,5 Health and wellness 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 27.90 1 > 2 > 3,4,5 Case management 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 40.02 1 > 2 > 5 > 3,4 Basic needs VA disability/pension 2.8 (1.3) 2.8 (1.3) 2.6 (1.3) 2.7 (1.3) 2.8 (1.3) 8.16 1 > 4 > 3; 2,5 > 3 SSI/SSDIe 2.7 (1.4) 2.6 (1.4) 2.5 (1.4) 2.5 (1.4) 2.7 (1.3) 7.51 1,5 > 2 > 3; 1,5 > 4 Money management 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.7 (1.2) 19.24 1 > 2 > 3; 1 > 4,5 Food 3.5 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.1) 39.98 1 > 2 > 3,4,5 Clothing 3.3 (1.0) 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.2) 29.48 1 > 2 > 3,5; 1 > 4 Credit counseling 2.6 (1.3) 2.4 (1.3) 2.3 (1.3) 2.2 (1.3) 2.2 (1.2) 8.00 1 > 2 > 3; 1 > 4,5 Social networking 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.6 (1.3) 15.06 1 > 2 > 3 > 4,5 Utility assistance 2.5 (1.3) 2.4 (1.3) 1.2 (1.3) 2.4 (1.3) 2.5 (1.3) 8.74 5 > 2,1 > 3; 4 > 2 > 3 Transportation 3.0 (1.2) 2.9 (1.2) 2.7 (1.3) 2.7 (1.3) 2.9 (1.2) 15.11 1 > 2 > 3; 1 > 4,5 Education 3.0 (1.2) 3.0 (1.2) 2.8 (1.2) 2.8 (1.2) 2.8 (1.2) 11.08 1,2 > 3,4,5 Employment 2.8 (1.2) 2.6 (1.2) 2.5 (1.2) 2.5 (1.2) 2.7 (1.2) 17.74 1 > 2,4 > 3; 5 > 4 > 3 Spiritual 3.2 (1.1) 3.1 (1.2) 2.9 (1.3) 2.9 (1.2) 2.9 (1.2) 29.78 1 > 2 > 3,4,5 Positive perception of services Accessibility of VA services 3.4 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.0) 45.21 1 > 2 > 5 > 3; 1 > 2 > 4 VA coordination of services 3.5 (0.9) 3.4 (0.9) 3.1 (1.1) 3.1 (1.1) 3.3 (1.0) 49.06 1 > 2 > 5 > 3; 1 > 2 > 4 Community agencies’ awareness of veterans’ needs 3.2 (1.0) 3.1 (1.1) 3.0 (1.1) 3.0 (1.1) 3.1 (1.1) 20.49 1 > 2 > 4 > 3; 1 > 5 > 3 2012 2013 2014 2015 2016 Multivariable test of differenceb,c Pairwise comparisons N = 6312a N = 6721 N = 6117 N = 3539 N = 2978 F= Housing Emergency shelter 3.3 (1.0)d 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.1) 38.11 1 > 2 > 5 > 3,4 Transitional housing 3.2 (1.1) 3.1 (1.1) 2.8 (1.3) 2.8 (1.2) 3.0 (1.2) 20.91 1 > 2 > 4 > 3; 1 > 5 > 3 Permanent housing 2.7 (1.3) 2.6 (1.3) 2.4 (1.3) 2.5 (1.3) 2.7 (1.3) 14.10 1,5 > 2,4 > 3 Furniture and housewares 2.5 (1.3) 2.4 (1.3) 2.3 (1.3) 2.4 (1.3) 2.6 (1.3) 11.86 5 > 1,2 > 3; 4 > 2 > 3 Healthcare services Medical services 3.7 (0.7) 3.6 (0.8) 3.5 (0.9) 3.4 (0.9) 3.5 (0.8) 35.46 1 > 2 > 3,4,5 Mental health services 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 25.02 1 > 2 > 3,4,5 Substance abuse treatment 3.6 (0.9) 3.4 (1.0) 3.3 (1.1) 3.3 (1.1) 3.3 (1.1) 26.77 1 > 2 > 3,4,5 Dental care 2.6 (1.3) 2.5 (1.3) 2.4 (1.3) 2.4 (1.3) 2.4 (1.3) 8.92 1,2,4 > 3; 1 > 5 Eye care 3.2 (1.2) 3.2 (1.2) 3.0 (1.2) 3.0 (1.2) 3.2 (1.1) 6.60 1,2 > 5 > 4 > 3 Personal hygiene 3.6 (0.9) 3.5 (0.9) 3.3 (1.1) 3.3 (1.1) 3.4 (1.0) 22.73 1 > 2 > 3,4,5 Medication management 3.6 (0.8) 3.5 (0.9) 3.4 (1.0) 3.3 (1.1) 3.4 (1.0) 29.69 1 > 2 > 3,4,5 Health and wellness 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 27.90 1 > 2 > 3,4,5 Case management 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 40.02 1 > 2 > 5 > 3,4 Basic needs VA disability/pension 2.8 (1.3) 2.8 (1.3) 2.6 (1.3) 2.7 (1.3) 2.8 (1.3) 8.16 1 > 4 > 3; 2,5 > 3 SSI/SSDIe 2.7 (1.4) 2.6 (1.4) 2.5 (1.4) 2.5 (1.4) 2.7 (1.3) 7.51 1,5 > 2 > 3; 1,5 > 4 Money management 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.7 (1.2) 19.24 1 > 2 > 3; 1 > 4,5 Food 3.5 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.1) 39.98 1 > 2 > 3,4,5 Clothing 3.3 (1.0) 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.2) 29.48 1 > 2 > 3,5; 1 > 4 Credit counseling 2.6 (1.3) 2.4 (1.3) 2.3 (1.3) 2.2 (1.3) 2.2 (1.2) 8.00 1 > 2 > 3; 1 > 4,5 Social networking 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.6 (1.3) 15.06 1 > 2 > 3 > 4,5 Utility assistance 2.5 (1.3) 2.4 (1.3) 1.2 (1.3) 2.4 (1.3) 2.5 (1.3) 8.74 5 > 2,1 > 3; 4 > 2 > 3 Transportation 3.0 (1.2) 2.9 (1.2) 2.7 (1.3) 2.7 (1.3) 2.9 (1.2) 15.11 1 > 2 > 3; 1 > 4,5 Education 3.0 (1.2) 3.0 (1.2) 2.8 (1.2) 2.8 (1.2) 2.8 (1.2) 11.08 1,2 > 3,4,5 Employment 2.8 (1.2) 2.6 (1.2) 2.5 (1.2) 2.5 (1.2) 2.7 (1.2) 17.74 1 > 2,4 > 3; 5 > 4 > 3 Spiritual 3.2 (1.1) 3.1 (1.2) 2.9 (1.3) 2.9 (1.2) 2.9 (1.2) 29.78 1 > 2 > 3,4,5 Positive perception of services Accessibility of VA services 3.4 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.0) 45.21 1 > 2 > 5 > 3; 1 > 2 > 4 VA coordination of services 3.5 (0.9) 3.4 (0.9) 3.1 (1.1) 3.1 (1.1) 3.3 (1.0) 49.06 1 > 2 > 5 > 3; 1 > 2 > 4 Community agencies’ awareness of veterans’ needs 3.2 (1.0) 3.1 (1.1) 3.0 (1.1) 3.0 (1.1) 3.1 (1.1) 20.49 1 > 2 > 4 > 3; 1 > 5 > 3 *P < 0.05, **P < 0.01, ***P < 0.001. aSample sizes ranged in 2012 from 3285 to 6312; in 2013 from 3477 to 6721; in 2014 from 3351 to 6117; in 2015 from 2014 to 3539; in 2016 from 1719 to 2978. bTests of differences controlled for background differences between respondents. cAll test statistics presented were statistically significant at P < 0.01 level. dHigher scores reflect greater reported needs being met. For items in the Positive Perceptions of Services category, higher scores reflect more positive perceptions. eSSI = supplemental security income; SSDI = social security disability income. Table 2 Change in rated general needs of homeless respondent between years 2012 and 2016 2012 2013 2014 2015 2016 Multivariable test of differenceb,c Pairwise comparisons N = 6312a N = 6721 N = 6117 N = 3539 N = 2978 F= Housing Emergency shelter 3.3 (1.0)d 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.1) 38.11 1 > 2 > 5 > 3,4 Transitional housing 3.2 (1.1) 3.1 (1.1) 2.8 (1.3) 2.8 (1.2) 3.0 (1.2) 20.91 1 > 2 > 4 > 3; 1 > 5 > 3 Permanent housing 2.7 (1.3) 2.6 (1.3) 2.4 (1.3) 2.5 (1.3) 2.7 (1.3) 14.10 1,5 > 2,4 > 3 Furniture and housewares 2.5 (1.3) 2.4 (1.3) 2.3 (1.3) 2.4 (1.3) 2.6 (1.3) 11.86 5 > 1,2 > 3; 4 > 2 > 3 Healthcare services Medical services 3.7 (0.7) 3.6 (0.8) 3.5 (0.9) 3.4 (0.9) 3.5 (0.8) 35.46 1 > 2 > 3,4,5 Mental health services 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 25.02 1 > 2 > 3,4,5 Substance abuse treatment 3.6 (0.9) 3.4 (1.0) 3.3 (1.1) 3.3 (1.1) 3.3 (1.1) 26.77 1 > 2 > 3,4,5 Dental care 2.6 (1.3) 2.5 (1.3) 2.4 (1.3) 2.4 (1.3) 2.4 (1.3) 8.92 1,2,4 > 3; 1 > 5 Eye care 3.2 (1.2) 3.2 (1.2) 3.0 (1.2) 3.0 (1.2) 3.2 (1.1) 6.60 1,2 > 5 > 4 > 3 Personal hygiene 3.6 (0.9) 3.5 (0.9) 3.3 (1.1) 3.3 (1.1) 3.4 (1.0) 22.73 1 > 2 > 3,4,5 Medication management 3.6 (0.8) 3.5 (0.9) 3.4 (1.0) 3.3 (1.1) 3.4 (1.0) 29.69 1 > 2 > 3,4,5 Health and wellness 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 27.90 1 > 2 > 3,4,5 Case management 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 40.02 1 > 2 > 5 > 3,4 Basic needs VA disability/pension 2.8 (1.3) 2.8 (1.3) 2.6 (1.3) 2.7 (1.3) 2.8 (1.3) 8.16 1 > 4 > 3; 2,5 > 3 SSI/SSDIe 2.7 (1.4) 2.6 (1.4) 2.5 (1.4) 2.5 (1.4) 2.7 (1.3) 7.51 1,5 > 2 > 3; 1,5 > 4 Money management 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.7 (1.2) 19.24 1 > 2 > 3; 1 > 4,5 Food 3.5 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.1) 39.98 1 > 2 > 3,4,5 Clothing 3.3 (1.0) 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.2) 29.48 1 > 2 > 3,5; 1 > 4 Credit counseling 2.6 (1.3) 2.4 (1.3) 2.3 (1.3) 2.2 (1.3) 2.2 (1.2) 8.00 1 > 2 > 3; 1 > 4,5 Social networking 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.6 (1.3) 15.06 1 > 2 > 3 > 4,5 Utility assistance 2.5 (1.3) 2.4 (1.3) 1.2 (1.3) 2.4 (1.3) 2.5 (1.3) 8.74 5 > 2,1 > 3; 4 > 2 > 3 Transportation 3.0 (1.2) 2.9 (1.2) 2.7 (1.3) 2.7 (1.3) 2.9 (1.2) 15.11 1 > 2 > 3; 1 > 4,5 Education 3.0 (1.2) 3.0 (1.2) 2.8 (1.2) 2.8 (1.2) 2.8 (1.2) 11.08 1,2 > 3,4,5 Employment 2.8 (1.2) 2.6 (1.2) 2.5 (1.2) 2.5 (1.2) 2.7 (1.2) 17.74 1 > 2,4 > 3; 5 > 4 > 3 Spiritual 3.2 (1.1) 3.1 (1.2) 2.9 (1.3) 2.9 (1.2) 2.9 (1.2) 29.78 1 > 2 > 3,4,5 Positive perception of services Accessibility of VA services 3.4 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.0) 45.21 1 > 2 > 5 > 3; 1 > 2 > 4 VA coordination of services 3.5 (0.9) 3.4 (0.9) 3.1 (1.1) 3.1 (1.1) 3.3 (1.0) 49.06 1 > 2 > 5 > 3; 1 > 2 > 4 Community agencies’ awareness of veterans’ needs 3.2 (1.0) 3.1 (1.1) 3.0 (1.1) 3.0 (1.1) 3.1 (1.1) 20.49 1 > 2 > 4 > 3; 1 > 5 > 3 2012 2013 2014 2015 2016 Multivariable test of differenceb,c Pairwise comparisons N = 6312a N = 6721 N = 6117 N = 3539 N = 2978 F= Housing Emergency shelter 3.3 (1.0)d 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.1) 38.11 1 > 2 > 5 > 3,4 Transitional housing 3.2 (1.1) 3.1 (1.1) 2.8 (1.3) 2.8 (1.2) 3.0 (1.2) 20.91 1 > 2 > 4 > 3; 1 > 5 > 3 Permanent housing 2.7 (1.3) 2.6 (1.3) 2.4 (1.3) 2.5 (1.3) 2.7 (1.3) 14.10 1,5 > 2,4 > 3 Furniture and housewares 2.5 (1.3) 2.4 (1.3) 2.3 (1.3) 2.4 (1.3) 2.6 (1.3) 11.86 5 > 1,2 > 3; 4 > 2 > 3 Healthcare services Medical services 3.7 (0.7) 3.6 (0.8) 3.5 (0.9) 3.4 (0.9) 3.5 (0.8) 35.46 1 > 2 > 3,4,5 Mental health services 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 25.02 1 > 2 > 3,4,5 Substance abuse treatment 3.6 (0.9) 3.4 (1.0) 3.3 (1.1) 3.3 (1.1) 3.3 (1.1) 26.77 1 > 2 > 3,4,5 Dental care 2.6 (1.3) 2.5 (1.3) 2.4 (1.3) 2.4 (1.3) 2.4 (1.3) 8.92 1,2,4 > 3; 1 > 5 Eye care 3.2 (1.2) 3.2 (1.2) 3.0 (1.2) 3.0 (1.2) 3.2 (1.1) 6.60 1,2 > 5 > 4 > 3 Personal hygiene 3.6 (0.9) 3.5 (0.9) 3.3 (1.1) 3.3 (1.1) 3.4 (1.0) 22.73 1 > 2 > 3,4,5 Medication management 3.6 (0.8) 3.5 (0.9) 3.4 (1.0) 3.3 (1.1) 3.4 (1.0) 29.69 1 > 2 > 3,4,5 Health and wellness 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 27.90 1 > 2 > 3,4,5 Case management 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 40.02 1 > 2 > 5 > 3,4 Basic needs VA disability/pension 2.8 (1.3) 2.8 (1.3) 2.6 (1.3) 2.7 (1.3) 2.8 (1.3) 8.16 1 > 4 > 3; 2,5 > 3 SSI/SSDIe 2.7 (1.4) 2.6 (1.4) 2.5 (1.4) 2.5 (1.4) 2.7 (1.3) 7.51 1,5 > 2 > 3; 1,5 > 4 Money management 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.7 (1.2) 19.24 1 > 2 > 3; 1 > 4,5 Food 3.5 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.1) 39.98 1 > 2 > 3,4,5 Clothing 3.3 (1.0) 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.2) 29.48 1 > 2 > 3,5; 1 > 4 Credit counseling 2.6 (1.3) 2.4 (1.3) 2.3 (1.3) 2.2 (1.3) 2.2 (1.2) 8.00 1 > 2 > 3; 1 > 4,5 Social networking 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.6 (1.3) 15.06 1 > 2 > 3 > 4,5 Utility assistance 2.5 (1.3) 2.4 (1.3) 1.2 (1.3) 2.4 (1.3) 2.5 (1.3) 8.74 5 > 2,1 > 3; 4 > 2 > 3 Transportation 3.0 (1.2) 2.9 (1.2) 2.7 (1.3) 2.7 (1.3) 2.9 (1.2) 15.11 1 > 2 > 3; 1 > 4,5 Education 3.0 (1.2) 3.0 (1.2) 2.8 (1.2) 2.8 (1.2) 2.8 (1.2) 11.08 1,2 > 3,4,5 Employment 2.8 (1.2) 2.6 (1.2) 2.5 (1.2) 2.5 (1.2) 2.7 (1.2) 17.74 1 > 2,4 > 3; 5 > 4 > 3 Spiritual 3.2 (1.1) 3.1 (1.2) 2.9 (1.3) 2.9 (1.2) 2.9 (1.2) 29.78 1 > 2 > 3,4,5 Positive perception of services Accessibility of VA services 3.4 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.0) 45.21 1 > 2 > 5 > 3; 1 > 2 > 4 VA coordination of services 3.5 (0.9) 3.4 (0.9) 3.1 (1.1) 3.1 (1.1) 3.3 (1.0) 49.06 1 > 2 > 5 > 3; 1 > 2 > 4 Community agencies’ awareness of veterans’ needs 3.2 (1.0) 3.1 (1.1) 3.0 (1.1) 3.0 (1.1) 3.1 (1.1) 20.49 1 > 2 > 4 > 3; 1 > 5 > 3 *P < 0.05, **P < 0.01, ***P < 0.001. aSample sizes ranged in 2012 from 3285 to 6312; in 2013 from 3477 to 6721; in 2014 from 3351 to 6117; in 2015 from 2014 to 3539; in 2016 from 1719 to 2978. bTests of differences controlled for background differences between respondents. cAll test statistics presented were statistically significant at P < 0.01 level. dHigher scores reflect greater reported needs being met. For items in the Positive Perceptions of Services category, higher scores reflect more positive perceptions. eSSI = supplemental security income; SSDI = social security disability income. Table 3 shows changes in these general reported needs of respondents by housing status. Similar to the total sample, changes in reported unmet needs across categories were quite small. There were notable increases in unmet needs observed for emergency shelters among respondents who were literally homeless, and unmet needs for case management and permanent housing among respondents in permanent housing. Accessibility and coordination of VA services also showed notably poorer scores among respondents who were literally homeless and respondents who were in permanent housing. Table 3 Change in needs of respondents by current housing status between years 2012 and 2016a Literally homeless Transiently homeless In permanent housing F=b F= F= Housing Emergency shelter 29.91↓ 4.56↓ 20.42↓ Transitional housing 15.52↓ 2.70ns 16.59↓ Permanent housing 7.18↓ 1.87ns 41.73↓ Furniture and housewares 6.24↓ 4.25↑ 18.38↓ Healthcare services Medical services 13.08↓ 7.48↓ 20.92↓ Mental health services 11.34↓ 5.08↓ 17.26↓ Substance abuse treatment 8.53↓ 10.72↓ 14.75↓ Dental care 4.95↓ 9.12↓ 1.70ns Eye care 4.69↓ 0.87ns 8.37↑ Personal hygiene 14.25↓ 10.81↓ 5.13↓ Medication management 12.19↓ 6.17↓ 16.79↓ Health and wellness 12.34↓ 6.64↓ 16.26↓ Case management 16.43↓ 6.41↓ 35.72↓ Basic needs VA disability/pension 3.94↓ 2.28ns 6.57↓ SSI/SSDIc 5.25↓ 2.12ns 8.71↓ Money management 8.17↓ 4.39↓ 19.79↓ Food 17.13↓ 14.36↓ 20.26↓ Clothing 16.50↓ 6.21↓ 19.26↓ Credit counseling 10.88↓ 0.96ns 5.42↓ Social networking 9.48↓ 4.92↓ 8.41↓ Utility assistance 6.20↑ 3.66↑ 12.94↓ Transportation 9.96↓ 3.38↓ 9.05↓ Education 6.68↓ 2.50ns 7.59↓ Employment 11.01↓ 2.28ns 15.38↓ Spiritual 17.86↓ 6.90↓ 15.47↓ Positive perception of services Accessibility of VA services 30.37↓ 5.39↓ 31.42↓ VA coordination of services 32.44↓ 5.67↓ 37.04↓ Community agencies’ awareness of veterans’ needs 16.63↓ 1.58ns 20.84↓ Literally homeless Transiently homeless In permanent housing F=b F= F= Housing Emergency shelter 29.91↓ 4.56↓ 20.42↓ Transitional housing 15.52↓ 2.70ns 16.59↓ Permanent housing 7.18↓ 1.87ns 41.73↓ Furniture and housewares 6.24↓ 4.25↑ 18.38↓ Healthcare services Medical services 13.08↓ 7.48↓ 20.92↓ Mental health services 11.34↓ 5.08↓ 17.26↓ Substance abuse treatment 8.53↓ 10.72↓ 14.75↓ Dental care 4.95↓ 9.12↓ 1.70ns Eye care 4.69↓ 0.87ns 8.37↑ Personal hygiene 14.25↓ 10.81↓ 5.13↓ Medication management 12.19↓ 6.17↓ 16.79↓ Health and wellness 12.34↓ 6.64↓ 16.26↓ Case management 16.43↓ 6.41↓ 35.72↓ Basic needs VA disability/pension 3.94↓ 2.28ns 6.57↓ SSI/SSDIc 5.25↓ 2.12ns 8.71↓ Money management 8.17↓ 4.39↓ 19.79↓ Food 17.13↓ 14.36↓ 20.26↓ Clothing 16.50↓ 6.21↓ 19.26↓ Credit counseling 10.88↓ 0.96ns 5.42↓ Social networking 9.48↓ 4.92↓ 8.41↓ Utility assistance 6.20↑ 3.66↑ 12.94↓ Transportation 9.96↓ 3.38↓ 9.05↓ Education 6.68↓ 2.50ns 7.59↓ Employment 11.01↓ 2.28ns 15.38↓ Spiritual 17.86↓ 6.90↓ 15.47↓ Positive perception of services Accessibility of VA services 30.37↓ 5.39↓ 31.42↓ VA coordination of services 32.44↓ 5.67↓ 37.04↓ Community agencies’ awareness of veterans’ needs 16.63↓ 1.58ns 20.84↓ aAll test statistics presented controlled for background differences between respondents. All test statistics were statistically significant at the P < 0.01 level unless denoted with footnote of ns. bTests of differences controlled for background differences between respondents. cSSI = Supplemental Security Income; SSDI = Social Security Disability Income; ↓ = Decreasing scores; ↑ = Increasing scores. Table 3 Change in needs of respondents by current housing status between years 2012 and 2016a Literally homeless Transiently homeless In permanent housing F=b F= F= Housing Emergency shelter 29.91↓ 4.56↓ 20.42↓ Transitional housing 15.52↓ 2.70ns 16.59↓ Permanent housing 7.18↓ 1.87ns 41.73↓ Furniture and housewares 6.24↓ 4.25↑ 18.38↓ Healthcare services Medical services 13.08↓ 7.48↓ 20.92↓ Mental health services 11.34↓ 5.08↓ 17.26↓ Substance abuse treatment 8.53↓ 10.72↓ 14.75↓ Dental care 4.95↓ 9.12↓ 1.70ns Eye care 4.69↓ 0.87ns 8.37↑ Personal hygiene 14.25↓ 10.81↓ 5.13↓ Medication management 12.19↓ 6.17↓ 16.79↓ Health and wellness 12.34↓ 6.64↓ 16.26↓ Case management 16.43↓ 6.41↓ 35.72↓ Basic needs VA disability/pension 3.94↓ 2.28ns 6.57↓ SSI/SSDIc 5.25↓ 2.12ns 8.71↓ Money management 8.17↓ 4.39↓ 19.79↓ Food 17.13↓ 14.36↓ 20.26↓ Clothing 16.50↓ 6.21↓ 19.26↓ Credit counseling 10.88↓ 0.96ns 5.42↓ Social networking 9.48↓ 4.92↓ 8.41↓ Utility assistance 6.20↑ 3.66↑ 12.94↓ Transportation 9.96↓ 3.38↓ 9.05↓ Education 6.68↓ 2.50ns 7.59↓ Employment 11.01↓ 2.28ns 15.38↓ Spiritual 17.86↓ 6.90↓ 15.47↓ Positive perception of services Accessibility of VA services 30.37↓ 5.39↓ 31.42↓ VA coordination of services 32.44↓ 5.67↓ 37.04↓ Community agencies’ awareness of veterans’ needs 16.63↓ 1.58ns 20.84↓ Literally homeless Transiently homeless In permanent housing F=b F= F= Housing Emergency shelter 29.91↓ 4.56↓ 20.42↓ Transitional housing 15.52↓ 2.70ns 16.59↓ Permanent housing 7.18↓ 1.87ns 41.73↓ Furniture and housewares 6.24↓ 4.25↑ 18.38↓ Healthcare services Medical services 13.08↓ 7.48↓ 20.92↓ Mental health services 11.34↓ 5.08↓ 17.26↓ Substance abuse treatment 8.53↓ 10.72↓ 14.75↓ Dental care 4.95↓ 9.12↓ 1.70ns Eye care 4.69↓ 0.87ns 8.37↑ Personal hygiene 14.25↓ 10.81↓ 5.13↓ Medication management 12.19↓ 6.17↓ 16.79↓ Health and wellness 12.34↓ 6.64↓ 16.26↓ Case management 16.43↓ 6.41↓ 35.72↓ Basic needs VA disability/pension 3.94↓ 2.28ns 6.57↓ SSI/SSDIc 5.25↓ 2.12ns 8.71↓ Money management 8.17↓ 4.39↓ 19.79↓ Food 17.13↓ 14.36↓ 20.26↓ Clothing 16.50↓ 6.21↓ 19.26↓ Credit counseling 10.88↓ 0.96ns 5.42↓ Social networking 9.48↓ 4.92↓ 8.41↓ Utility assistance 6.20↑ 3.66↑ 12.94↓ Transportation 9.96↓ 3.38↓ 9.05↓ Education 6.68↓ 2.50ns 7.59↓ Employment 11.01↓ 2.28ns 15.38↓ Spiritual 17.86↓ 6.90↓ 15.47↓ Positive perception of services Accessibility of VA services 30.37↓ 5.39↓ 31.42↓ VA coordination of services 32.44↓ 5.67↓ 37.04↓ Community agencies’ awareness of veterans’ needs 16.63↓ 1.58ns 20.84↓ aAll test statistics presented controlled for background differences between respondents. All test statistics were statistically significant at the P < 0.01 level unless denoted with footnote of ns. bTests of differences controlled for background differences between respondents. cSSI = Supplemental Security Income; SSDI = Social Security Disability Income; ↓ = Decreasing scores; ↑ = Increasing scores. As shown in Table 4, we then examined the higher reported unmet needs across all 62 items including specialized categories in which much smaller numbers of respondents responded to. Across years 2012–16, need for legal assistance for evictions and foreclosures was reported as one of the top unmet needs in all 5 years; housing for registered sex offenders was one of the top reported unmet needs in four of the 5 years; legal assistance for child support was a commonly reported unmet need that was also reported in 4 of the 5 years; and child care was reported in three of the 5 years. Table 4 Top five reported unmet needs among homeless respondents by year Year 2012 N = 6859 Year 2013 N = 7741 Year 2014 N = 7126 Year 2015 N = 3765 Year 2016 N = 3191 μ (sd) % μ (sd) % μ (sd) % μ (sd) % μ (sd) % Registered sex offender housing (n = 1024) 1.9 (1.2) 60.6 Legal assistance for eviction and foreclosure (n = 2072) 1.8 (1.2) 62.6 Legal assistance for eviction and foreclosure (n = 2287) 1.7 (1.1) 66.9 Legal assistance for eviction and foreclosure (n = 1427) 1.9 (1.2) 61.9 Registered sex offender housing (n = 644) 1.8 (1.2) 65.8 Legal assistance for eviction and foreclosure (n = 1782) 2.0 (1.2) 56.3 Registered sex offender housing (n = 1324) 1.8 (1.2) 65.0 Registered sex offender housing (n = 1317) 1.8 (1.2) 65.6 Welfare payments (n = 1384) 2.0 (1.3) 56.6 Legal assistance for eviction and foreclosure (n = 1094) 1.8 (1.2) 63.0 Legal assistance for child support (n = 1683) 2.1 (1.3) 52.7 Legal assistance for child support (n = 1769) 1.9 (1.2) 59.1 Legal assistance for child support (n = 1822) 1.8 (1.2) 62.7 Registered sex offender housing (n = 799) 2.0 (1.2) 56.1 Legal assistance for child support (n = 846) 1.9 (1.2) 69.8 Child care (n = 1350) 2.2 (1.3) 51.0 Financial guardship (n = 1878) 2.0 (1.2) 55.1 Child care (n = 1580) 1.9 (1.2) 60.6 Legal assistance for outstanding warrants and fines (n = 1271) 2.1 (1.3) 54.4 Child care (n = 745) 2.0 (1.2) 56.4 Assisted living for elderly (n = 1389) 2.2 (1.3) 49.4 Child care 2.0 (1.3) 54.3 Financial guardship (n = 1854) 1.9 (1.2) 59.3 Legal assistance for child support (n = 1146) 2.1 (1.3) 53.4 Financial guardianship (n = 860) 2.0 (1.2) 55.9 Year 2012 N = 6859 Year 2013 N = 7741 Year 2014 N = 7126 Year 2015 N = 3765 Year 2016 N = 3191 μ (sd) % μ (sd) % μ (sd) % μ (sd) % μ (sd) % Registered sex offender housing (n = 1024) 1.9 (1.2) 60.6 Legal assistance for eviction and foreclosure (n = 2072) 1.8 (1.2) 62.6 Legal assistance for eviction and foreclosure (n = 2287) 1.7 (1.1) 66.9 Legal assistance for eviction and foreclosure (n = 1427) 1.9 (1.2) 61.9 Registered sex offender housing (n = 644) 1.8 (1.2) 65.8 Legal assistance for eviction and foreclosure (n = 1782) 2.0 (1.2) 56.3 Registered sex offender housing (n = 1324) 1.8 (1.2) 65.0 Registered sex offender housing (n = 1317) 1.8 (1.2) 65.6 Welfare payments (n = 1384) 2.0 (1.3) 56.6 Legal assistance for eviction and foreclosure (n = 1094) 1.8 (1.2) 63.0 Legal assistance for child support (n = 1683) 2.1 (1.3) 52.7 Legal assistance for child support (n = 1769) 1.9 (1.2) 59.1 Legal assistance for child support (n = 1822) 1.8 (1.2) 62.7 Registered sex offender housing (n = 799) 2.0 (1.2) 56.1 Legal assistance for child support (n = 846) 1.9 (1.2) 69.8 Child care (n = 1350) 2.2 (1.3) 51.0 Financial guardship (n = 1878) 2.0 (1.2) 55.1 Child care (n = 1580) 1.9 (1.2) 60.6 Legal assistance for outstanding warrants and fines (n = 1271) 2.1 (1.3) 54.4 Child care (n = 745) 2.0 (1.2) 56.4 Assisted living for elderly (n = 1389) 2.2 (1.3) 49.4 Child care 2.0 (1.3) 54.3 Financial guardship (n = 1854) 1.9 (1.2) 59.3 Legal assistance for child support (n = 1146) 2.1 (1.3) 53.4 Financial guardianship (n = 860) 2.0 (1.2) 55.9 Table 4 Top five reported unmet needs among homeless respondents by year Year 2012 N = 6859 Year 2013 N = 7741 Year 2014 N = 7126 Year 2015 N = 3765 Year 2016 N = 3191 μ (sd) % μ (sd) % μ (sd) % μ (sd) % μ (sd) % Registered sex offender housing (n = 1024) 1.9 (1.2) 60.6 Legal assistance for eviction and foreclosure (n = 2072) 1.8 (1.2) 62.6 Legal assistance for eviction and foreclosure (n = 2287) 1.7 (1.1) 66.9 Legal assistance for eviction and foreclosure (n = 1427) 1.9 (1.2) 61.9 Registered sex offender housing (n = 644) 1.8 (1.2) 65.8 Legal assistance for eviction and foreclosure (n = 1782) 2.0 (1.2) 56.3 Registered sex offender housing (n = 1324) 1.8 (1.2) 65.0 Registered sex offender housing (n = 1317) 1.8 (1.2) 65.6 Welfare payments (n = 1384) 2.0 (1.3) 56.6 Legal assistance for eviction and foreclosure (n = 1094) 1.8 (1.2) 63.0 Legal assistance for child support (n = 1683) 2.1 (1.3) 52.7 Legal assistance for child support (n = 1769) 1.9 (1.2) 59.1 Legal assistance for child support (n = 1822) 1.8 (1.2) 62.7 Registered sex offender housing (n = 799) 2.0 (1.2) 56.1 Legal assistance for child support (n = 846) 1.9 (1.2) 69.8 Child care (n = 1350) 2.2 (1.3) 51.0 Financial guardship (n = 1878) 2.0 (1.2) 55.1 Child care (n = 1580) 1.9 (1.2) 60.6 Legal assistance for outstanding warrants and fines (n = 1271) 2.1 (1.3) 54.4 Child care (n = 745) 2.0 (1.2) 56.4 Assisted living for elderly (n = 1389) 2.2 (1.3) 49.4 Child care 2.0 (1.3) 54.3 Financial guardship (n = 1854) 1.9 (1.2) 59.3 Legal assistance for child support (n = 1146) 2.1 (1.3) 53.4 Financial guardianship (n = 860) 2.0 (1.2) 55.9 Year 2012 N = 6859 Year 2013 N = 7741 Year 2014 N = 7126 Year 2015 N = 3765 Year 2016 N = 3191 μ (sd) % μ (sd) % μ (sd) % μ (sd) % μ (sd) % Registered sex offender housing (n = 1024) 1.9 (1.2) 60.6 Legal assistance for eviction and foreclosure (n = 2072) 1.8 (1.2) 62.6 Legal assistance for eviction and foreclosure (n = 2287) 1.7 (1.1) 66.9 Legal assistance for eviction and foreclosure (n = 1427) 1.9 (1.2) 61.9 Registered sex offender housing (n = 644) 1.8 (1.2) 65.8 Legal assistance for eviction and foreclosure (n = 1782) 2.0 (1.2) 56.3 Registered sex offender housing (n = 1324) 1.8 (1.2) 65.0 Registered sex offender housing (n = 1317) 1.8 (1.2) 65.6 Welfare payments (n = 1384) 2.0 (1.3) 56.6 Legal assistance for eviction and foreclosure (n = 1094) 1.8 (1.2) 63.0 Legal assistance for child support (n = 1683) 2.1 (1.3) 52.7 Legal assistance for child support (n = 1769) 1.9 (1.2) 59.1 Legal assistance for child support (n = 1822) 1.8 (1.2) 62.7 Registered sex offender housing (n = 799) 2.0 (1.2) 56.1 Legal assistance for child support (n = 846) 1.9 (1.2) 69.8 Child care (n = 1350) 2.2 (1.3) 51.0 Financial guardship (n = 1878) 2.0 (1.2) 55.1 Child care (n = 1580) 1.9 (1.2) 60.6 Legal assistance for outstanding warrants and fines (n = 1271) 2.1 (1.3) 54.4 Child care (n = 745) 2.0 (1.2) 56.4 Assisted living for elderly (n = 1389) 2.2 (1.3) 49.4 Child care 2.0 (1.3) 54.3 Financial guardship (n = 1854) 1.9 (1.2) 59.3 Legal assistance for child support (n = 1146) 2.1 (1.3) 53.4 Financial guardianship (n = 860) 2.0 (1.2) 55.9 Discussion Main finding of this study Using national annual surveys of homeless veterans over a recent 5-year period, we found little change in reported unmet needs of homeless veterans. There were slight increases in unmet needs related to case management, food, emergency shelter and medical services. But overall, the consistent ratings of needs over a multi-year period provide us with confidence that the items that were rated reflect true unmet needs. Across the 5 years, the highest rated unmet needs that affected the most respondents were related to credit, utilities, furniture, dental care and disability income. These findings are interesting since housing was not on this list and these ratings are entirely based on the perspective of homeless veterans themselves, which may be different than that of providers as studies of housing preferences have found.14 The federal government has dedicated tremendous resources and funds to provide transitional and permanent supported housing in the past decade through the federal initiative to end veteran homelessness. These findings suggest housing is less of an issue now given these efforts, and so homeless veterans have begun to identify other needs beyond obtaining housing and some of these needs may pertain to sustaining housing and improving social functioning. What is already known on this topic Homeless veterans have comprehensive healthcare and social needs, and their well-being is a major public health concern. The federal government along with communities across the country have dedicated various programs and services to address their needs. Previous studies have found that a substantial proportion of veterans who receive supported housing continue to struggle with staying housed and experience other problems that interfere with their ability to sustain housing.8–11 What this study adds Our analyses indicate that there several areas that homeless veterans consistently report difficulties in, which were related to housing such as income security, healthcare, and utilities and furniture. While VA continues to offer many comprehensive services for homeless veterans, scores on accessibility and coordination of VA services seemed to have been rated poorer over time, especially among veterans who are literally homeless and veterans in permanent housing. Overall though, the sociodemographic characteristics of samples have changed over time (i.e. increasing number of aging, female and white veterans), but their needs have largely remain unchanged suggesting most homeless veterans regardless of their background have these unmet needs which deserve attention. In addition to these general needs, there were several unmet specialized needs that were rated even higher but they were rated by only a minority of respondents presumably because the items were only relevant to them. Among these specialized needs, we found that legal assistance for civil legal problems, especially evictions/foreclosures and child support were two of the highest rated unmet needs of homeless veterans. This need for civil legal assistance has also been found among other homeless populations.15 The VA has no statutory authority to provide direct legal assistance to veterans, however, there is an increasing movement within VA medical centers to develop medical–legal partnerships with outside legal providers to assist veterans.16 Many of these VA medical–legal partnerships focus on serving veterans who are homeless and/or have severe mental illness with civil legal problems.17 One recent study of VA medical–legal partnerships in two states has found that these partnerships can improve housing and mental health outcomes.18 While the full medical–legal partnership model is not widespread across the country, pro-bono legal clinics that are housed on VA campuses have experienced growth, with 158 pro-bono clinics operating across the country.19 Our survey findings suggest many veterans would benefit from services provided through medical–legal partnerships and expanding these partnerships may help address veteran homelessness. In addition to the need for legal assistance, housing for registered sex offenders was also a highly rated unmet need. While there are varying state law and local ordinances concerning housing restrictions for registered sex offenders, many respondents reported it as a major problem across states. Housing for sex offenders has been a difficult problem for many decades and various studies have highlighted this problem and there are few effective solutions that have been developed.20–22 There is nearly no research on veterans who are registered sex offenders and it is unknown whether they face unique challenges compared to other registered sex offenders. New solutions and approaches are needed to help homeless veterans with past offenses obtain safe, stable housing and successfully integrate in their communities. Limitations of this study While attempts are made every year to distribute the CHALENG survey as widely as possible, the survey used convenience samples and the sample sizes declined over time. Samples could not be determined to be representative of the homeless veteran population and sampling was geographically uneven since some regions recruited more respondents than others. There was also no way for us to determine if respondents in 1 year were respondents in any other year of the survey. This study intended to provide a broad contemporary picture of the needs of homeless veterans, and further analyses are needed to examine these needs by various sociodemographic groups (i.e. age, gender). Survey items were based on self-report and respondents may have varying subjective opinions about the extent to which a need is ‘met’. Moreover, the CHALENG survey asked respondents to rate a list of preconceived items, but some respondents may have other unmet needs that were not on the list and thus would not have been captured in this study. Future designers of the CHALENG survey should consider including a few open-ended questions, which may be more easily facilitated through an online survey platform. These limitations notwithstanding, the results provide a broad, contemporary national overview of the self-reported needs of homeless veterans over an extended period of time. The findings also highlight numerous areas that may need further attention and intervention as the country continues striving to address veteran homelessness. References 1 Gelberg L , Andersen RM , Leake BD . The behavioral model for vulnerable populations: application to the medical care use and outcomes for homeless people . Health Serv Res 2000 ; 34 : 1273 – 302 . Google Scholar PubMed 2 Baggett TP , O’Connell JJ , Singer DE et al. . The unmet health care needs of homeless adults: a national study . Am J Public Health 2010 ; 100 : 1326 – 33 . Google Scholar CrossRef Search ADS PubMed 3 U. S. Department of Housing and Urban Development . The 2016 Annual Homeless Assessment Report (AHAR) to Congress. Washington, DC: U.S. Department of Housing and Urban Development, 2016 . 4 U.S. Census Bureau . S2101 Veteran Status: 2016 American Community Survey 1-Year Estimates. Washington, DC: U.S. Census Bureau; 2016 . Available from: https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_16_1YR_S2101&prodType=table (15 October 2017). 5 United States Department of Veterans Affairs . Secretary Shinseki Details Plans to End Homelessness for Veterans. In: Affairs PaI, editor. 2009 . 6 Tsai J , O’Toole T , Kearney LK . Homelessness as a public mental health and social problem: new knowledge and solutions . Psychol Serv 2017 ; 14 : 113 – 7 . Google Scholar CrossRef Search ADS PubMed 7 U.S. Department of Housing and Urban Development . The 2017 Annual Homeless Assessment Report (AHAR) to Congress: Part 1 Point-in-Time Estimates of Homelessness. Washington, DC: U.S. Department of Housing and Urban Development, Office of Community Planning and Development, 2017 . 8 Cusack M , Montgomery AE . The role of eviction in veterans’ homelessness recidivism . J Soc Distress Homeless 2017 ; 26 : 58 – 64 . Google Scholar CrossRef Search ADS 9 Tsai J , Rosenheck RA . Does housing chronically homeless adults lead to social integration? Psychiatr Serv 2012 ; 63 : 427 – 34 . Google Scholar CrossRef Search ADS PubMed 10 Tsai J , Kasprow WJ , Rosenheck RA . Alcohol and drug use disorders among homeless veterans: prevalence and association with supported housing outcomes . Addict Behav 2014 ; 39 : 455 – 60 . Google Scholar CrossRef Search ADS PubMed 11 Tsai J , Rosenheck RA , Kasprow WJ et al. . Homelessness in a national sample of incarcerated veterans in state and federal prisons. Administration and Policy in Mental Health and Mental . Health Serv Res 2014 ; 41 : 360 – 7 . 12 Kuhn JH , Nakashima J . The Seventeenth Annual Progress Report: Community Homelessness Assessment, Local Education And Networking Group (CHALENG) for Veterans Fiscal Year (FY) 2010): Services for Homeless Veterans Assessment and Coordination. Washington, DC: U.S. Department of Veterans Affairs, 2011 . 13 Tsai J , Rosenheck RA . US veterans’ use of VA Mental Health Services And Disability Compensation increased from 2001 to 2010 . Health Aff 2016 ; 35 : 966 – 73 . Google Scholar CrossRef Search ADS 14 Piat M , Lesage A , Boyer R et al. . Housing for persons with serious mental illness: consumer and service provider preferences . Psychiatr Serv 2008 ; 59 : 1011 – 7 . Google Scholar CrossRef Search ADS PubMed 15 Tsai J , Jenkins D , Lawton E . Civil legal services and medical-legal partnerships needed by the homeless population: a national survey . Am J Public Health 2017 ; 107 : 398 – 401 . Google Scholar CrossRef Search ADS PubMed 16 Tsai J , Middleton M , Retkin R et al. . Partnerships between healthcare and legal providers in the Veterans Health Administration . Psychiatr Serv 2017 ; 68 : 321 – 3 . Google Scholar CrossRef Search ADS PubMed 17 Wong CF , Tsai J , Klee A et al. . Helping veterans with mental illness overcome civil legal issues: collaboration between a veterans affairs psychosocial rehabilitation center and a nonprofit legal center . Psychol Serv 2013 ; 10 : 73 . Google Scholar CrossRef Search ADS PubMed 18 Tsai J , Middleton M , Villegas J et al. . Medical-legal partnerships at veterans affairs medical centers improved housing and psychosocial outcomes for vets . Health Aff 2017 ; 36 : 2195 – 203 . Google Scholar CrossRef Search ADS 19 U.S. Department of Veterans Affairs . Legal Help for Veterans. Washington, DC: U.S. Department of Veterans Affairs, Office of General Counsel; 2017 [updated August 9, 2017; cited 2017 December 6]. https://www.va.gov/OGC/LegalServices.asp. 20 Levenson JS , D’Amora DA , Hern AL . Megan’s law and its impact on community re‐entry for sex offenders . Behav Sci Law 2007 ; 25 : 587 – 602 . Google Scholar CrossRef Search ADS PubMed 21 Mustaine EE , Tewksbury R , Connor DP et al. . Criminal justice officials’ views of sex offenders, sex offender registration, community notification, and residency restrictions . Justice Syst J 2015 ; 36 : 63 – 85 . Google Scholar CrossRef Search ADS 22 Huebner BM , Kras KR , Rydberg J et al. . The effect and implications of sex offender residence restrictions . Criminol Public Policy 2014 ; 13 : 139 – 68 . Google Scholar CrossRef Search ADS Published by Oxford University Press on behalf of Faculty of Public Health 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Public Health Oxford University Press

Needs of homeless veterans: 5 years of the CHALENG Survey 2012–16

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Oxford University Press
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Published by Oxford University Press on behalf of Faculty of Public Health 2018.
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1741-3842
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1741-3850
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10.1093/pubmed/fdy076
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Abstract

Abstract Background National surveys of homeless veterans have been conducted for over a decade, but there has been no examination of changes in the needs of homeless veterans. Methods Annual surveys of convenience samples of homeless veterans conducted for Project Community Homelessness Assessment, Local Education and Networking Groups (CHALENG) from 2012 (n = 6859), 2013 (n = 7741), 2014 (n = 7126), 2015 (n = 3765) and 2016 (n = 3191) were analyzed. CHALENG surveys collected background information about respondents and their ratings of unmet needs of homeless veterans. Results Across years, the majority of respondents were males, white, 45–60 years old, Army veterans, lived in urban areas, had no dependent children, and were enrolled in VA healthcare. Over time, the proportion of respondents who were over 60, female, and white increased. There was little change in reported unmet needs with the highest rated unmet needs related to credit counseling, utility assistance, furniture and housewares, dental care and disability income. Among subsamples of veterans with specialized needs, the top three reported unmet needs were housing for registered sex offenders, legal assistance for evictions/foreclosures, and legal assistance for child support. Conclusions Several intractable unmet needs of homeless veterans have persisted in contemporary time. housing, social determinants, socioeconomics factors Populations experiencing homelessness have a range of housing, healthcare, and social needs. Assessment and updated knowledge of these needs are important to providing the comprehensive interdisciplinary care that is often needed to serve these populations.1,2 Homelessness among US veterans is of great public concern and homeless veterans represent an important group in need of assistance from the perspectives of public health, federal policy and society at large. In general, US veterans have been overrepresented in the country’s homeless adult population; in 2016, it was estimated that veterans constituted 9.2% of homeless adults3 while only constituting 7.4% of all adults.4 Perhaps more importantly, homeless veterans also symbolically represent a failure of the government to care for those who have served our military and country. The Department of Veterans Affairs (VA) has spent significant amounts of money on its homeless programs since the 1980s but more recently, beginning in 2009, VA embarked on a federal initiative to end veteran homelessness and spent over 1 billion dollars annually for programs and services for homeless veterans.5,6 As a result, the most recent 2017 Annual Homeless Assessment Report reported that homelessness among veterans has declined by 45% since 2009, with a Point-In-Time (PIT) count of 75 609 veterans in 2009 to 40 056 veterans in 2016 who experienced homelessness on a single night in January 2017.7 While considerable progress has been made, many veterans continue to struggle with homelessness, health problems and other social issues which may not be captured in PIT counts and other homeless metrics. For example, one national study found that ~11% of veterans who exit VA’s supported housing program return to homelessness after 1 year; and among exiters, 10% are evicted.8 Other studies have found that homeless veterans experience various other problems beyond housing, such as substance abuse, income insecurity, money mismanagement, criminal justice involvement, poor social integration and civil legal problems.9–11 Project Community Homelessness Assessment, Local Education and Networking Groups (CHALENG) was launched by the VA in 1993 in response to Public Law 102-405 to enhance continuum of services for homeless veterans provided by VA healthcare facilities and community service agencies. Project CHALENG conducts a national survey to assess the needs of homeless veterans annually and has been conducting the survey for over two decades now.12 The CHALENG survey was designed to be an ongoing assessment process that describes the needs of homeless veterans and identifies the barriers they face to successful recovery. Since 2011, when VA determined the CHALENG report was no longer due to Congress, brief reports detailing the results of the CHALENG survey have been issued annually. Since 2011, there has been no formal examination of survey results over time, which can provide information on contemporary changes and trends in the needs of homeless veterans. Thus, in this study, we compiled 5 years of CHALENG survey data available since the 2011 report and examined changes in the characteristics of respondents and their ratings on unmet needs. There have been various demographic changes in the general veteran population which the VA has tracked and developed services for accordingly.13 The VA remains dedicated to addressing veteran homelessness and understanding the consistent and changing needs of homeless veterans may be important in these efforts. Methods The CHALENG survey is the only ongoing comprehensive national effort to request input from homeless veterans, VA staff, community partnership agencies, and local, state and federal government representatives about the needs of homeless veterans. The results help VA identify interventions needed to effectively assist homeless veterans. For this study, 5 years of data from the CHALENG survey conducted 2012–16 were obtained and merged for analysis. The veteran component of the survey was the focus of this study. Survey data from 2012 to 2016 were selected because they are contemporary and to allow comparability of responses between years. While the CHALENG survey has been conducted since 1993, there have been various changes made to the survey over time. For example, the veteran component was introduced in 2007, data on the gender of respondents were collected beginning in 2011, and there have been various changes in items and scoring that have occurred prior to 2012. The CHALENG survey is distributed annually by VA staff and the survey asks respondents to rank 63 pre-identified homelessness veterans’ needs (five related specifically to female veterans). The survey is distributed at multiple times throughout the year to homeless and at-risk veterans at Stand Downs, VA homeless assessment centers, at homeless programs such as the Domiciliary Care for Homeless Veterans, Healthcare for Homeless Veterans, Grant and Per Diem, and Housing and Urban-Veterans Affairs Supportive Housing (HUD-VASH) program, CHALENG meetings, and other veteran-driven events throughout the nation. Hard copies of the survey are distributed to individuals at all VA homeless program sites nationwide and the survey is anonymous. In addition, there is a website where individuals can complete the survey online. Completed surveys are accumulated throughout the year from sites. The number of respondents to the CHALENG survey have decreased from 2012 to 2016 and this may be due to various reasons, including the transition to online data collection, because the CHALENG report is no longer congressionally required, and because the VA Homeless Program Office has developed additional data sources over the years. Analysis of the data from the CHALENG surveys has been approved by the VA Homeless Program Office and the institutional review board at VA Connecticut Healthcare System. In 2012, 6859 veterans (11.3% relative to PIT count that year) completed the CHALENG survey. In 2013, 7741 veterans (13.9% relative to PIT count) completed the CHALENG survey. In 2014, 7216 (14.5% relative to PIT count) completed the survey. In 2015, 3765 (7.9% relative to PIT count) completed the survey and in 2016, 3191 (8.1% relative to PIT count) completed the CHALENG survey. Measures The veteran CHALENG survey was identical from the years 2012 to 2016. The CHALENG survey first asked respondents for background information about their sociodemographic characteristics and housing (i.e. current housing situation, history of homelessness). Then respondents were provided a list of 63 pre-identified needs in six categories: housing, treatment, income/benefits, legal assistance, education/job services and community partnership. Respondents were asked to rate each of these needs on a scale from 1 (Unmet) to 4 (Met) or 5 (N/A) based on the extent to which they believed the needs of homeless veterans in their community area were met. A copy of the CHALENG survey is available upon request from the authors. Data analysis Annual CHALENG survey data from 2012 to 2016 were merged for analysis and each year was treated as a separate sample. Analyses proceeded in three phases. First, analysis of variance was conducted to compare the sociodemographic and housing characteristics of samples between years. Second, preliminary analysis revealed substantial variability in the number of respondents across items. Hence, we identified 28 items that had the most respondents (i.e. the majority of samples responded to these items) and examined change in ratings of these items. Other items were excluded because many respondents did not respond to them. We could identify no specific pattern with missing data beyond the fact that some items were too specific to be applicable to all respondents (e.g. parent education, tuberculosis testing and treatment, discharge upgrade). Analysis of covariance was conducted to compare ratings of the 28 main items between years; background differences between years were entered as covariates. Fisher’s Least Significant Difference (LSD) test was used for post-hoc pairwise comparisons between years. These analyses of covariance were repeated with respondents by their housing status which was categorized as literally homeless, transiently homeless (e.g. in transitional housing) or in permanent housing (subsidized and unsubsidized). Finally, we wanted to examine the highest rated unmet needs of homeless veterans regardless of the number of respondents. Therefore, we conducted descriptive analyses on all 63 items and identified the top five rated unmet needs rated every year. Of the top five rated unmet needs, we also calculated the proportion of respondents who indicated the need was ‘unmet’ (i.e. rating of 1). Results Table 1 shows the sociodemographic, geographic, household, military and housing characteristics of respondents from years 2012 to 2016. Sample sizes for each year are shown in the Table and there is a footnote in the Table indicating the PIT counts of homeless veterans for every year of the survey. Across years, the majority of respondents were male, white, 45–60 years old, Army veterans, lived in urban areas, had no dependent children, and were enrolled in VA healthcare. Respondents were geographically diverse with most coming from the Midwest, Southeast, and Northeast regions of the USA. Across year, over 10% of respondents had a history of chronic homelessness and the majority were currently residing in transitional housing, Section 8 housing, or were literally homeless. Table 1 Background characteristics of homeless respondents Year 2012a Year 2013 Year 2014 Year 2015 Year 2016 Test of difference N = 6859 N = 7741 N = 7126 N = 3765 N = 3191 Age  <25 years 100 (1.5%) 77 (1.0%) 77 (1.1%) 33 (0.9%) 21 (0.7%) 235.31***  25–34 years 573 (8.4%) 623 (8.0%) 644 (9.2%) 347 (9.4%) 246 (7.8%)  35–44 years 806 (11.8%) 867 (11.2%) 803 (11.5%) 445 (12.1%) 363 (11.5%)  45–60 years 4369 (63.7%) 4848 (62.6%) 4209 (60.1%) 2118 (57.7%) 1708 (54.1%)  61+ years 1011 (14.7%) 1326 (17.1%) 1272 (18.2%) 729 (19.9%) 822 (26.0%) Gender  Male 6297 (91.8%) 7023 (90.7%) 6388 (89.6%) 3337 (88.6%) 2820 (88.4%) 47.34***  Female 562 (8.2%) 718 (9.3%) 738 (10.4%) 428 (11.4%) 371 (11.6%) Race/Ethnicityb  White 3392 (49.6%) 3679 (47.6%) 3339 (49.5%) 1718 (48.5%) 1637 (53.3%) 161.30***  Black 2747 (40.2%) 3205 (41.5%) 2612 (38.7%) 1291 (36.4%) 1106 (36.0%)  Hispanic 283 (4.1%) 353 (4.6%) 464 (6.9%) 272 (7.7%) 178 (5.8%)  Other 414 (6.1%) 484 (6.3%) 337 (5.0%) 262 (7.4%) 149 (4.9%) Service branch  Army 3644 (53.1%) 4080 (52.7%) 3668 (51.5%) 2012 (53.4%) 1690 (53.0%) 33.16*  Navy 1391 (20.3%) 1529 (19.8%) 1468 (20.6%) 744 (19.8%) 618 (19.4%)  Marine Corps 842 (12.3%) 984 (12.7%) 865 (12.1%) 505 (13.4%) 418 (13.1%)  Air Force 781 (11.4%) 897 (11.6%) 855 (12.0%) 393 (10.4%) 373 (11.7%)  Coast Guard 60 (0.9%) 75 (1.0%) 58 (0.8%) 32 (0.8%) 27 (0.8%)  National Guard/Reserve 141 (2.1%) 176 (2.3%) 212 (3.0%) 79 (2.1%) 65 (2.0%) Region  Westc 809 (14.6%) 898 (13.9%) 776 (13.3%) 273 (7.7%) 142 (4.9%) 1122.35***  Midwest 1094 (19.7%) 1555 (24.1%) 1270 (21.8%) 1437 (40.8%) 888 (30.5%)  Southwest 528 (9.5%) 564 (8.8%) 479 (8.2%) 107 (3.0%) 246 (8.5%)  Southeast 2529 (45.5%) 2805 (43.5%) 2578 (44.2%) 1415 (40.2%) 1046 (35.9%)  Northeast 594 (10.7%) 622 (9.7%) 724 (12.4%) 292 (20.2%) 589 (20.2%) Live in rural or frontier community 1400 (20.4%) 1314 (17.0%) 1339 (20.3%) 815 (22.6%) 534 (17.4%) 68.94*** Number of dependents  0 6110 (89.1%) 6800 (87.8%) 5919 (85.6%) 3106 (85.4%) 2729 (87.1%) 55.43***  1 358 (5.2%) 447 (5.8%) 463 (6.7%) 245 (6.7%) 189 (6.0%)  2–3 298 (4.3%) 398 (5.1%) 416 (6.0%) 234 (6.4%) 166 (5.3%)  >4 93 (1.4%) 96 (1.2%) 114 (1.6%) 52 (1.4%) 50 (1.6%) History of chronic homelessnessd 793 (11.6%) 1152 (14.9%) 1120 (15.7%) 679 (18.0%) 426 (13.4%) 98.29*** Current housing  Literally homeless 1300 (19.0%) 1826 (23.6%) 2044 (28.7%) 1072 (28.5%) 798 (25.0%) 845.02***  Emergency housing 486 (7.1%) 416 (5.4%) 385 (5.4%) 206 (5.5%) 199 (6.2%)  Transitional housing 2836 (41.3%) 2692 (34.8%) 1944 (27.3%) 1065 (28.3%) 843 (26.4%)  Section 8 housing 1665 (24.3%) 1740 (22.5%) 1415 (19.9%) 774 (20.6%) 868 (27.2%)  Independent housing 572 (8.3%) 1067 (13.8%) 1338 (18.8%) 648 (17.2%) 483 (15.1%) Enrolled in VA healthcare benefits 6382 (93.0%) 7.042 (91.0%) 6257 (89.6%) 3319 (90.9%) 2898 (91.4%) 69.68*** Year 2012a Year 2013 Year 2014 Year 2015 Year 2016 Test of difference N = 6859 N = 7741 N = 7126 N = 3765 N = 3191 Age  <25 years 100 (1.5%) 77 (1.0%) 77 (1.1%) 33 (0.9%) 21 (0.7%) 235.31***  25–34 years 573 (8.4%) 623 (8.0%) 644 (9.2%) 347 (9.4%) 246 (7.8%)  35–44 years 806 (11.8%) 867 (11.2%) 803 (11.5%) 445 (12.1%) 363 (11.5%)  45–60 years 4369 (63.7%) 4848 (62.6%) 4209 (60.1%) 2118 (57.7%) 1708 (54.1%)  61+ years 1011 (14.7%) 1326 (17.1%) 1272 (18.2%) 729 (19.9%) 822 (26.0%) Gender  Male 6297 (91.8%) 7023 (90.7%) 6388 (89.6%) 3337 (88.6%) 2820 (88.4%) 47.34***  Female 562 (8.2%) 718 (9.3%) 738 (10.4%) 428 (11.4%) 371 (11.6%) Race/Ethnicityb  White 3392 (49.6%) 3679 (47.6%) 3339 (49.5%) 1718 (48.5%) 1637 (53.3%) 161.30***  Black 2747 (40.2%) 3205 (41.5%) 2612 (38.7%) 1291 (36.4%) 1106 (36.0%)  Hispanic 283 (4.1%) 353 (4.6%) 464 (6.9%) 272 (7.7%) 178 (5.8%)  Other 414 (6.1%) 484 (6.3%) 337 (5.0%) 262 (7.4%) 149 (4.9%) Service branch  Army 3644 (53.1%) 4080 (52.7%) 3668 (51.5%) 2012 (53.4%) 1690 (53.0%) 33.16*  Navy 1391 (20.3%) 1529 (19.8%) 1468 (20.6%) 744 (19.8%) 618 (19.4%)  Marine Corps 842 (12.3%) 984 (12.7%) 865 (12.1%) 505 (13.4%) 418 (13.1%)  Air Force 781 (11.4%) 897 (11.6%) 855 (12.0%) 393 (10.4%) 373 (11.7%)  Coast Guard 60 (0.9%) 75 (1.0%) 58 (0.8%) 32 (0.8%) 27 (0.8%)  National Guard/Reserve 141 (2.1%) 176 (2.3%) 212 (3.0%) 79 (2.1%) 65 (2.0%) Region  Westc 809 (14.6%) 898 (13.9%) 776 (13.3%) 273 (7.7%) 142 (4.9%) 1122.35***  Midwest 1094 (19.7%) 1555 (24.1%) 1270 (21.8%) 1437 (40.8%) 888 (30.5%)  Southwest 528 (9.5%) 564 (8.8%) 479 (8.2%) 107 (3.0%) 246 (8.5%)  Southeast 2529 (45.5%) 2805 (43.5%) 2578 (44.2%) 1415 (40.2%) 1046 (35.9%)  Northeast 594 (10.7%) 622 (9.7%) 724 (12.4%) 292 (20.2%) 589 (20.2%) Live in rural or frontier community 1400 (20.4%) 1314 (17.0%) 1339 (20.3%) 815 (22.6%) 534 (17.4%) 68.94*** Number of dependents  0 6110 (89.1%) 6800 (87.8%) 5919 (85.6%) 3106 (85.4%) 2729 (87.1%) 55.43***  1 358 (5.2%) 447 (5.8%) 463 (6.7%) 245 (6.7%) 189 (6.0%)  2–3 298 (4.3%) 398 (5.1%) 416 (6.0%) 234 (6.4%) 166 (5.3%)  >4 93 (1.4%) 96 (1.2%) 114 (1.6%) 52 (1.4%) 50 (1.6%) History of chronic homelessnessd 793 (11.6%) 1152 (14.9%) 1120 (15.7%) 679 (18.0%) 426 (13.4%) 98.29*** Current housing  Literally homeless 1300 (19.0%) 1826 (23.6%) 2044 (28.7%) 1072 (28.5%) 798 (25.0%) 845.02***  Emergency housing 486 (7.1%) 416 (5.4%) 385 (5.4%) 206 (5.5%) 199 (6.2%)  Transitional housing 2836 (41.3%) 2692 (34.8%) 1944 (27.3%) 1065 (28.3%) 843 (26.4%)  Section 8 housing 1665 (24.3%) 1740 (22.5%) 1415 (19.9%) 774 (20.6%) 868 (27.2%)  Independent housing 572 (8.3%) 1067 (13.8%) 1338 (18.8%) 648 (17.2%) 483 (15.1%) Enrolled in VA healthcare benefits 6382 (93.0%) 7.042 (91.0%) 6257 (89.6%) 3319 (90.9%) 2898 (91.4%) 69.68*** *P < 0.05, **P < 0.01, ***P < 0.001. aPoint-in-time counts of the number of homeless veterans on a given night annually are as follows: 60 579 homeless veterans in 2012; 55 619 homeless veterans in 2013; 49 689 in 2014; 47 725 in 2015; and 39 471 in 2016. bRace and ethnicity were assessed differently between years so respondents were categorized based on a combination of mutually exclusive race/ethnicity categories. Respondents in the Hispanic category included those who were White Hispanic or Black Hispanic. cOklahoma was categorized as in the West region because of the way VA network areas are organized. dChronic homelessness was defined as being homeless for longer than 1 year and/or having more than four or more episodes of homelessness in the past 3 years. Table 1 Background characteristics of homeless respondents Year 2012a Year 2013 Year 2014 Year 2015 Year 2016 Test of difference N = 6859 N = 7741 N = 7126 N = 3765 N = 3191 Age  <25 years 100 (1.5%) 77 (1.0%) 77 (1.1%) 33 (0.9%) 21 (0.7%) 235.31***  25–34 years 573 (8.4%) 623 (8.0%) 644 (9.2%) 347 (9.4%) 246 (7.8%)  35–44 years 806 (11.8%) 867 (11.2%) 803 (11.5%) 445 (12.1%) 363 (11.5%)  45–60 years 4369 (63.7%) 4848 (62.6%) 4209 (60.1%) 2118 (57.7%) 1708 (54.1%)  61+ years 1011 (14.7%) 1326 (17.1%) 1272 (18.2%) 729 (19.9%) 822 (26.0%) Gender  Male 6297 (91.8%) 7023 (90.7%) 6388 (89.6%) 3337 (88.6%) 2820 (88.4%) 47.34***  Female 562 (8.2%) 718 (9.3%) 738 (10.4%) 428 (11.4%) 371 (11.6%) Race/Ethnicityb  White 3392 (49.6%) 3679 (47.6%) 3339 (49.5%) 1718 (48.5%) 1637 (53.3%) 161.30***  Black 2747 (40.2%) 3205 (41.5%) 2612 (38.7%) 1291 (36.4%) 1106 (36.0%)  Hispanic 283 (4.1%) 353 (4.6%) 464 (6.9%) 272 (7.7%) 178 (5.8%)  Other 414 (6.1%) 484 (6.3%) 337 (5.0%) 262 (7.4%) 149 (4.9%) Service branch  Army 3644 (53.1%) 4080 (52.7%) 3668 (51.5%) 2012 (53.4%) 1690 (53.0%) 33.16*  Navy 1391 (20.3%) 1529 (19.8%) 1468 (20.6%) 744 (19.8%) 618 (19.4%)  Marine Corps 842 (12.3%) 984 (12.7%) 865 (12.1%) 505 (13.4%) 418 (13.1%)  Air Force 781 (11.4%) 897 (11.6%) 855 (12.0%) 393 (10.4%) 373 (11.7%)  Coast Guard 60 (0.9%) 75 (1.0%) 58 (0.8%) 32 (0.8%) 27 (0.8%)  National Guard/Reserve 141 (2.1%) 176 (2.3%) 212 (3.0%) 79 (2.1%) 65 (2.0%) Region  Westc 809 (14.6%) 898 (13.9%) 776 (13.3%) 273 (7.7%) 142 (4.9%) 1122.35***  Midwest 1094 (19.7%) 1555 (24.1%) 1270 (21.8%) 1437 (40.8%) 888 (30.5%)  Southwest 528 (9.5%) 564 (8.8%) 479 (8.2%) 107 (3.0%) 246 (8.5%)  Southeast 2529 (45.5%) 2805 (43.5%) 2578 (44.2%) 1415 (40.2%) 1046 (35.9%)  Northeast 594 (10.7%) 622 (9.7%) 724 (12.4%) 292 (20.2%) 589 (20.2%) Live in rural or frontier community 1400 (20.4%) 1314 (17.0%) 1339 (20.3%) 815 (22.6%) 534 (17.4%) 68.94*** Number of dependents  0 6110 (89.1%) 6800 (87.8%) 5919 (85.6%) 3106 (85.4%) 2729 (87.1%) 55.43***  1 358 (5.2%) 447 (5.8%) 463 (6.7%) 245 (6.7%) 189 (6.0%)  2–3 298 (4.3%) 398 (5.1%) 416 (6.0%) 234 (6.4%) 166 (5.3%)  >4 93 (1.4%) 96 (1.2%) 114 (1.6%) 52 (1.4%) 50 (1.6%) History of chronic homelessnessd 793 (11.6%) 1152 (14.9%) 1120 (15.7%) 679 (18.0%) 426 (13.4%) 98.29*** Current housing  Literally homeless 1300 (19.0%) 1826 (23.6%) 2044 (28.7%) 1072 (28.5%) 798 (25.0%) 845.02***  Emergency housing 486 (7.1%) 416 (5.4%) 385 (5.4%) 206 (5.5%) 199 (6.2%)  Transitional housing 2836 (41.3%) 2692 (34.8%) 1944 (27.3%) 1065 (28.3%) 843 (26.4%)  Section 8 housing 1665 (24.3%) 1740 (22.5%) 1415 (19.9%) 774 (20.6%) 868 (27.2%)  Independent housing 572 (8.3%) 1067 (13.8%) 1338 (18.8%) 648 (17.2%) 483 (15.1%) Enrolled in VA healthcare benefits 6382 (93.0%) 7.042 (91.0%) 6257 (89.6%) 3319 (90.9%) 2898 (91.4%) 69.68*** Year 2012a Year 2013 Year 2014 Year 2015 Year 2016 Test of difference N = 6859 N = 7741 N = 7126 N = 3765 N = 3191 Age  <25 years 100 (1.5%) 77 (1.0%) 77 (1.1%) 33 (0.9%) 21 (0.7%) 235.31***  25–34 years 573 (8.4%) 623 (8.0%) 644 (9.2%) 347 (9.4%) 246 (7.8%)  35–44 years 806 (11.8%) 867 (11.2%) 803 (11.5%) 445 (12.1%) 363 (11.5%)  45–60 years 4369 (63.7%) 4848 (62.6%) 4209 (60.1%) 2118 (57.7%) 1708 (54.1%)  61+ years 1011 (14.7%) 1326 (17.1%) 1272 (18.2%) 729 (19.9%) 822 (26.0%) Gender  Male 6297 (91.8%) 7023 (90.7%) 6388 (89.6%) 3337 (88.6%) 2820 (88.4%) 47.34***  Female 562 (8.2%) 718 (9.3%) 738 (10.4%) 428 (11.4%) 371 (11.6%) Race/Ethnicityb  White 3392 (49.6%) 3679 (47.6%) 3339 (49.5%) 1718 (48.5%) 1637 (53.3%) 161.30***  Black 2747 (40.2%) 3205 (41.5%) 2612 (38.7%) 1291 (36.4%) 1106 (36.0%)  Hispanic 283 (4.1%) 353 (4.6%) 464 (6.9%) 272 (7.7%) 178 (5.8%)  Other 414 (6.1%) 484 (6.3%) 337 (5.0%) 262 (7.4%) 149 (4.9%) Service branch  Army 3644 (53.1%) 4080 (52.7%) 3668 (51.5%) 2012 (53.4%) 1690 (53.0%) 33.16*  Navy 1391 (20.3%) 1529 (19.8%) 1468 (20.6%) 744 (19.8%) 618 (19.4%)  Marine Corps 842 (12.3%) 984 (12.7%) 865 (12.1%) 505 (13.4%) 418 (13.1%)  Air Force 781 (11.4%) 897 (11.6%) 855 (12.0%) 393 (10.4%) 373 (11.7%)  Coast Guard 60 (0.9%) 75 (1.0%) 58 (0.8%) 32 (0.8%) 27 (0.8%)  National Guard/Reserve 141 (2.1%) 176 (2.3%) 212 (3.0%) 79 (2.1%) 65 (2.0%) Region  Westc 809 (14.6%) 898 (13.9%) 776 (13.3%) 273 (7.7%) 142 (4.9%) 1122.35***  Midwest 1094 (19.7%) 1555 (24.1%) 1270 (21.8%) 1437 (40.8%) 888 (30.5%)  Southwest 528 (9.5%) 564 (8.8%) 479 (8.2%) 107 (3.0%) 246 (8.5%)  Southeast 2529 (45.5%) 2805 (43.5%) 2578 (44.2%) 1415 (40.2%) 1046 (35.9%)  Northeast 594 (10.7%) 622 (9.7%) 724 (12.4%) 292 (20.2%) 589 (20.2%) Live in rural or frontier community 1400 (20.4%) 1314 (17.0%) 1339 (20.3%) 815 (22.6%) 534 (17.4%) 68.94*** Number of dependents  0 6110 (89.1%) 6800 (87.8%) 5919 (85.6%) 3106 (85.4%) 2729 (87.1%) 55.43***  1 358 (5.2%) 447 (5.8%) 463 (6.7%) 245 (6.7%) 189 (6.0%)  2–3 298 (4.3%) 398 (5.1%) 416 (6.0%) 234 (6.4%) 166 (5.3%)  >4 93 (1.4%) 96 (1.2%) 114 (1.6%) 52 (1.4%) 50 (1.6%) History of chronic homelessnessd 793 (11.6%) 1152 (14.9%) 1120 (15.7%) 679 (18.0%) 426 (13.4%) 98.29*** Current housing  Literally homeless 1300 (19.0%) 1826 (23.6%) 2044 (28.7%) 1072 (28.5%) 798 (25.0%) 845.02***  Emergency housing 486 (7.1%) 416 (5.4%) 385 (5.4%) 206 (5.5%) 199 (6.2%)  Transitional housing 2836 (41.3%) 2692 (34.8%) 1944 (27.3%) 1065 (28.3%) 843 (26.4%)  Section 8 housing 1665 (24.3%) 1740 (22.5%) 1415 (19.9%) 774 (20.6%) 868 (27.2%)  Independent housing 572 (8.3%) 1067 (13.8%) 1338 (18.8%) 648 (17.2%) 483 (15.1%) Enrolled in VA healthcare benefits 6382 (93.0%) 7.042 (91.0%) 6257 (89.6%) 3319 (90.9%) 2898 (91.4%) 69.68*** *P < 0.05, **P < 0.01, ***P < 0.001. aPoint-in-time counts of the number of homeless veterans on a given night annually are as follows: 60 579 homeless veterans in 2012; 55 619 homeless veterans in 2013; 49 689 in 2014; 47 725 in 2015; and 39 471 in 2016. bRace and ethnicity were assessed differently between years so respondents were categorized based on a combination of mutually exclusive race/ethnicity categories. Respondents in the Hispanic category included those who were White Hispanic or Black Hispanic. cOklahoma was categorized as in the West region because of the way VA network areas are organized. dChronic homelessness was defined as being homeless for longer than 1 year and/or having more than four or more episodes of homelessness in the past 3 years. Between the years, there were various significant differences in age, gender, race/ethnicity, service branch, geographic region, number of dependents, enrollment in VA healthcare and homeless histories between respondents. There were few consistent patterns in these differences across years, except the proportion of respondents who were over 60, female, and white have steadily increased every year. The sample size of respondents also has decreased every year. Table 2 presents the general rated needs of respondents (i.e. identified 28 items with most respondents) for each year from 2012 to 2016. Across years, the highest unmet needs (based on lowest scores) were related to credit counseling, utility assistance, furniture and housewares, dental care, and Supplementary Security Income/Social Security Disability Insurance (SSI/SSDI). Examination of change years revealed significant differences in reported needs between years, but most of these changes were small. Some of the relatively larger differences observed in reported needs (based on F-tests) were related to case management, food, emergency shelter and medical services. Overall, across years, there was a general pattern of greater reported unmet needs across categories over time (i.e. lower scores with increasing years). Table 2 Change in rated general needs of homeless respondent between years 2012 and 2016 2012 2013 2014 2015 2016 Multivariable test of differenceb,c Pairwise comparisons N = 6312a N = 6721 N = 6117 N = 3539 N = 2978 F= Housing Emergency shelter 3.3 (1.0)d 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.1) 38.11 1 > 2 > 5 > 3,4 Transitional housing 3.2 (1.1) 3.1 (1.1) 2.8 (1.3) 2.8 (1.2) 3.0 (1.2) 20.91 1 > 2 > 4 > 3; 1 > 5 > 3 Permanent housing 2.7 (1.3) 2.6 (1.3) 2.4 (1.3) 2.5 (1.3) 2.7 (1.3) 14.10 1,5 > 2,4 > 3 Furniture and housewares 2.5 (1.3) 2.4 (1.3) 2.3 (1.3) 2.4 (1.3) 2.6 (1.3) 11.86 5 > 1,2 > 3; 4 > 2 > 3 Healthcare services Medical services 3.7 (0.7) 3.6 (0.8) 3.5 (0.9) 3.4 (0.9) 3.5 (0.8) 35.46 1 > 2 > 3,4,5 Mental health services 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 25.02 1 > 2 > 3,4,5 Substance abuse treatment 3.6 (0.9) 3.4 (1.0) 3.3 (1.1) 3.3 (1.1) 3.3 (1.1) 26.77 1 > 2 > 3,4,5 Dental care 2.6 (1.3) 2.5 (1.3) 2.4 (1.3) 2.4 (1.3) 2.4 (1.3) 8.92 1,2,4 > 3; 1 > 5 Eye care 3.2 (1.2) 3.2 (1.2) 3.0 (1.2) 3.0 (1.2) 3.2 (1.1) 6.60 1,2 > 5 > 4 > 3 Personal hygiene 3.6 (0.9) 3.5 (0.9) 3.3 (1.1) 3.3 (1.1) 3.4 (1.0) 22.73 1 > 2 > 3,4,5 Medication management 3.6 (0.8) 3.5 (0.9) 3.4 (1.0) 3.3 (1.1) 3.4 (1.0) 29.69 1 > 2 > 3,4,5 Health and wellness 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 27.90 1 > 2 > 3,4,5 Case management 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 40.02 1 > 2 > 5 > 3,4 Basic needs VA disability/pension 2.8 (1.3) 2.8 (1.3) 2.6 (1.3) 2.7 (1.3) 2.8 (1.3) 8.16 1 > 4 > 3; 2,5 > 3 SSI/SSDIe 2.7 (1.4) 2.6 (1.4) 2.5 (1.4) 2.5 (1.4) 2.7 (1.3) 7.51 1,5 > 2 > 3; 1,5 > 4 Money management 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.7 (1.2) 19.24 1 > 2 > 3; 1 > 4,5 Food 3.5 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.1) 39.98 1 > 2 > 3,4,5 Clothing 3.3 (1.0) 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.2) 29.48 1 > 2 > 3,5; 1 > 4 Credit counseling 2.6 (1.3) 2.4 (1.3) 2.3 (1.3) 2.2 (1.3) 2.2 (1.2) 8.00 1 > 2 > 3; 1 > 4,5 Social networking 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.6 (1.3) 15.06 1 > 2 > 3 > 4,5 Utility assistance 2.5 (1.3) 2.4 (1.3) 1.2 (1.3) 2.4 (1.3) 2.5 (1.3) 8.74 5 > 2,1 > 3; 4 > 2 > 3 Transportation 3.0 (1.2) 2.9 (1.2) 2.7 (1.3) 2.7 (1.3) 2.9 (1.2) 15.11 1 > 2 > 3; 1 > 4,5 Education 3.0 (1.2) 3.0 (1.2) 2.8 (1.2) 2.8 (1.2) 2.8 (1.2) 11.08 1,2 > 3,4,5 Employment 2.8 (1.2) 2.6 (1.2) 2.5 (1.2) 2.5 (1.2) 2.7 (1.2) 17.74 1 > 2,4 > 3; 5 > 4 > 3 Spiritual 3.2 (1.1) 3.1 (1.2) 2.9 (1.3) 2.9 (1.2) 2.9 (1.2) 29.78 1 > 2 > 3,4,5 Positive perception of services Accessibility of VA services 3.4 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.0) 45.21 1 > 2 > 5 > 3; 1 > 2 > 4 VA coordination of services 3.5 (0.9) 3.4 (0.9) 3.1 (1.1) 3.1 (1.1) 3.3 (1.0) 49.06 1 > 2 > 5 > 3; 1 > 2 > 4 Community agencies’ awareness of veterans’ needs 3.2 (1.0) 3.1 (1.1) 3.0 (1.1) 3.0 (1.1) 3.1 (1.1) 20.49 1 > 2 > 4 > 3; 1 > 5 > 3 2012 2013 2014 2015 2016 Multivariable test of differenceb,c Pairwise comparisons N = 6312a N = 6721 N = 6117 N = 3539 N = 2978 F= Housing Emergency shelter 3.3 (1.0)d 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.1) 38.11 1 > 2 > 5 > 3,4 Transitional housing 3.2 (1.1) 3.1 (1.1) 2.8 (1.3) 2.8 (1.2) 3.0 (1.2) 20.91 1 > 2 > 4 > 3; 1 > 5 > 3 Permanent housing 2.7 (1.3) 2.6 (1.3) 2.4 (1.3) 2.5 (1.3) 2.7 (1.3) 14.10 1,5 > 2,4 > 3 Furniture and housewares 2.5 (1.3) 2.4 (1.3) 2.3 (1.3) 2.4 (1.3) 2.6 (1.3) 11.86 5 > 1,2 > 3; 4 > 2 > 3 Healthcare services Medical services 3.7 (0.7) 3.6 (0.8) 3.5 (0.9) 3.4 (0.9) 3.5 (0.8) 35.46 1 > 2 > 3,4,5 Mental health services 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 25.02 1 > 2 > 3,4,5 Substance abuse treatment 3.6 (0.9) 3.4 (1.0) 3.3 (1.1) 3.3 (1.1) 3.3 (1.1) 26.77 1 > 2 > 3,4,5 Dental care 2.6 (1.3) 2.5 (1.3) 2.4 (1.3) 2.4 (1.3) 2.4 (1.3) 8.92 1,2,4 > 3; 1 > 5 Eye care 3.2 (1.2) 3.2 (1.2) 3.0 (1.2) 3.0 (1.2) 3.2 (1.1) 6.60 1,2 > 5 > 4 > 3 Personal hygiene 3.6 (0.9) 3.5 (0.9) 3.3 (1.1) 3.3 (1.1) 3.4 (1.0) 22.73 1 > 2 > 3,4,5 Medication management 3.6 (0.8) 3.5 (0.9) 3.4 (1.0) 3.3 (1.1) 3.4 (1.0) 29.69 1 > 2 > 3,4,5 Health and wellness 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 27.90 1 > 2 > 3,4,5 Case management 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 40.02 1 > 2 > 5 > 3,4 Basic needs VA disability/pension 2.8 (1.3) 2.8 (1.3) 2.6 (1.3) 2.7 (1.3) 2.8 (1.3) 8.16 1 > 4 > 3; 2,5 > 3 SSI/SSDIe 2.7 (1.4) 2.6 (1.4) 2.5 (1.4) 2.5 (1.4) 2.7 (1.3) 7.51 1,5 > 2 > 3; 1,5 > 4 Money management 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.7 (1.2) 19.24 1 > 2 > 3; 1 > 4,5 Food 3.5 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.1) 39.98 1 > 2 > 3,4,5 Clothing 3.3 (1.0) 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.2) 29.48 1 > 2 > 3,5; 1 > 4 Credit counseling 2.6 (1.3) 2.4 (1.3) 2.3 (1.3) 2.2 (1.3) 2.2 (1.2) 8.00 1 > 2 > 3; 1 > 4,5 Social networking 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.6 (1.3) 15.06 1 > 2 > 3 > 4,5 Utility assistance 2.5 (1.3) 2.4 (1.3) 1.2 (1.3) 2.4 (1.3) 2.5 (1.3) 8.74 5 > 2,1 > 3; 4 > 2 > 3 Transportation 3.0 (1.2) 2.9 (1.2) 2.7 (1.3) 2.7 (1.3) 2.9 (1.2) 15.11 1 > 2 > 3; 1 > 4,5 Education 3.0 (1.2) 3.0 (1.2) 2.8 (1.2) 2.8 (1.2) 2.8 (1.2) 11.08 1,2 > 3,4,5 Employment 2.8 (1.2) 2.6 (1.2) 2.5 (1.2) 2.5 (1.2) 2.7 (1.2) 17.74 1 > 2,4 > 3; 5 > 4 > 3 Spiritual 3.2 (1.1) 3.1 (1.2) 2.9 (1.3) 2.9 (1.2) 2.9 (1.2) 29.78 1 > 2 > 3,4,5 Positive perception of services Accessibility of VA services 3.4 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.0) 45.21 1 > 2 > 5 > 3; 1 > 2 > 4 VA coordination of services 3.5 (0.9) 3.4 (0.9) 3.1 (1.1) 3.1 (1.1) 3.3 (1.0) 49.06 1 > 2 > 5 > 3; 1 > 2 > 4 Community agencies’ awareness of veterans’ needs 3.2 (1.0) 3.1 (1.1) 3.0 (1.1) 3.0 (1.1) 3.1 (1.1) 20.49 1 > 2 > 4 > 3; 1 > 5 > 3 *P < 0.05, **P < 0.01, ***P < 0.001. aSample sizes ranged in 2012 from 3285 to 6312; in 2013 from 3477 to 6721; in 2014 from 3351 to 6117; in 2015 from 2014 to 3539; in 2016 from 1719 to 2978. bTests of differences controlled for background differences between respondents. cAll test statistics presented were statistically significant at P < 0.01 level. dHigher scores reflect greater reported needs being met. For items in the Positive Perceptions of Services category, higher scores reflect more positive perceptions. eSSI = supplemental security income; SSDI = social security disability income. Table 2 Change in rated general needs of homeless respondent between years 2012 and 2016 2012 2013 2014 2015 2016 Multivariable test of differenceb,c Pairwise comparisons N = 6312a N = 6721 N = 6117 N = 3539 N = 2978 F= Housing Emergency shelter 3.3 (1.0)d 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.1) 38.11 1 > 2 > 5 > 3,4 Transitional housing 3.2 (1.1) 3.1 (1.1) 2.8 (1.3) 2.8 (1.2) 3.0 (1.2) 20.91 1 > 2 > 4 > 3; 1 > 5 > 3 Permanent housing 2.7 (1.3) 2.6 (1.3) 2.4 (1.3) 2.5 (1.3) 2.7 (1.3) 14.10 1,5 > 2,4 > 3 Furniture and housewares 2.5 (1.3) 2.4 (1.3) 2.3 (1.3) 2.4 (1.3) 2.6 (1.3) 11.86 5 > 1,2 > 3; 4 > 2 > 3 Healthcare services Medical services 3.7 (0.7) 3.6 (0.8) 3.5 (0.9) 3.4 (0.9) 3.5 (0.8) 35.46 1 > 2 > 3,4,5 Mental health services 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 25.02 1 > 2 > 3,4,5 Substance abuse treatment 3.6 (0.9) 3.4 (1.0) 3.3 (1.1) 3.3 (1.1) 3.3 (1.1) 26.77 1 > 2 > 3,4,5 Dental care 2.6 (1.3) 2.5 (1.3) 2.4 (1.3) 2.4 (1.3) 2.4 (1.3) 8.92 1,2,4 > 3; 1 > 5 Eye care 3.2 (1.2) 3.2 (1.2) 3.0 (1.2) 3.0 (1.2) 3.2 (1.1) 6.60 1,2 > 5 > 4 > 3 Personal hygiene 3.6 (0.9) 3.5 (0.9) 3.3 (1.1) 3.3 (1.1) 3.4 (1.0) 22.73 1 > 2 > 3,4,5 Medication management 3.6 (0.8) 3.5 (0.9) 3.4 (1.0) 3.3 (1.1) 3.4 (1.0) 29.69 1 > 2 > 3,4,5 Health and wellness 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 27.90 1 > 2 > 3,4,5 Case management 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 40.02 1 > 2 > 5 > 3,4 Basic needs VA disability/pension 2.8 (1.3) 2.8 (1.3) 2.6 (1.3) 2.7 (1.3) 2.8 (1.3) 8.16 1 > 4 > 3; 2,5 > 3 SSI/SSDIe 2.7 (1.4) 2.6 (1.4) 2.5 (1.4) 2.5 (1.4) 2.7 (1.3) 7.51 1,5 > 2 > 3; 1,5 > 4 Money management 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.7 (1.2) 19.24 1 > 2 > 3; 1 > 4,5 Food 3.5 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.1) 39.98 1 > 2 > 3,4,5 Clothing 3.3 (1.0) 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.2) 29.48 1 > 2 > 3,5; 1 > 4 Credit counseling 2.6 (1.3) 2.4 (1.3) 2.3 (1.3) 2.2 (1.3) 2.2 (1.2) 8.00 1 > 2 > 3; 1 > 4,5 Social networking 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.6 (1.3) 15.06 1 > 2 > 3 > 4,5 Utility assistance 2.5 (1.3) 2.4 (1.3) 1.2 (1.3) 2.4 (1.3) 2.5 (1.3) 8.74 5 > 2,1 > 3; 4 > 2 > 3 Transportation 3.0 (1.2) 2.9 (1.2) 2.7 (1.3) 2.7 (1.3) 2.9 (1.2) 15.11 1 > 2 > 3; 1 > 4,5 Education 3.0 (1.2) 3.0 (1.2) 2.8 (1.2) 2.8 (1.2) 2.8 (1.2) 11.08 1,2 > 3,4,5 Employment 2.8 (1.2) 2.6 (1.2) 2.5 (1.2) 2.5 (1.2) 2.7 (1.2) 17.74 1 > 2,4 > 3; 5 > 4 > 3 Spiritual 3.2 (1.1) 3.1 (1.2) 2.9 (1.3) 2.9 (1.2) 2.9 (1.2) 29.78 1 > 2 > 3,4,5 Positive perception of services Accessibility of VA services 3.4 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.0) 45.21 1 > 2 > 5 > 3; 1 > 2 > 4 VA coordination of services 3.5 (0.9) 3.4 (0.9) 3.1 (1.1) 3.1 (1.1) 3.3 (1.0) 49.06 1 > 2 > 5 > 3; 1 > 2 > 4 Community agencies’ awareness of veterans’ needs 3.2 (1.0) 3.1 (1.1) 3.0 (1.1) 3.0 (1.1) 3.1 (1.1) 20.49 1 > 2 > 4 > 3; 1 > 5 > 3 2012 2013 2014 2015 2016 Multivariable test of differenceb,c Pairwise comparisons N = 6312a N = 6721 N = 6117 N = 3539 N = 2978 F= Housing Emergency shelter 3.3 (1.0)d 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.1) 38.11 1 > 2 > 5 > 3,4 Transitional housing 3.2 (1.1) 3.1 (1.1) 2.8 (1.3) 2.8 (1.2) 3.0 (1.2) 20.91 1 > 2 > 4 > 3; 1 > 5 > 3 Permanent housing 2.7 (1.3) 2.6 (1.3) 2.4 (1.3) 2.5 (1.3) 2.7 (1.3) 14.10 1,5 > 2,4 > 3 Furniture and housewares 2.5 (1.3) 2.4 (1.3) 2.3 (1.3) 2.4 (1.3) 2.6 (1.3) 11.86 5 > 1,2 > 3; 4 > 2 > 3 Healthcare services Medical services 3.7 (0.7) 3.6 (0.8) 3.5 (0.9) 3.4 (0.9) 3.5 (0.8) 35.46 1 > 2 > 3,4,5 Mental health services 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 25.02 1 > 2 > 3,4,5 Substance abuse treatment 3.6 (0.9) 3.4 (1.0) 3.3 (1.1) 3.3 (1.1) 3.3 (1.1) 26.77 1 > 2 > 3,4,5 Dental care 2.6 (1.3) 2.5 (1.3) 2.4 (1.3) 2.4 (1.3) 2.4 (1.3) 8.92 1,2,4 > 3; 1 > 5 Eye care 3.2 (1.2) 3.2 (1.2) 3.0 (1.2) 3.0 (1.2) 3.2 (1.1) 6.60 1,2 > 5 > 4 > 3 Personal hygiene 3.6 (0.9) 3.5 (0.9) 3.3 (1.1) 3.3 (1.1) 3.4 (1.0) 22.73 1 > 2 > 3,4,5 Medication management 3.6 (0.8) 3.5 (0.9) 3.4 (1.0) 3.3 (1.1) 3.4 (1.0) 29.69 1 > 2 > 3,4,5 Health and wellness 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 27.90 1 > 2 > 3,4,5 Case management 3.5 (0.9) 3.4 (1.0) 3.2 (1.1) 3.2 (1.1) 3.3 (1.0) 40.02 1 > 2 > 5 > 3,4 Basic needs VA disability/pension 2.8 (1.3) 2.8 (1.3) 2.6 (1.3) 2.7 (1.3) 2.8 (1.3) 8.16 1 > 4 > 3; 2,5 > 3 SSI/SSDIe 2.7 (1.4) 2.6 (1.4) 2.5 (1.4) 2.5 (1.4) 2.7 (1.3) 7.51 1,5 > 2 > 3; 1,5 > 4 Money management 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.7 (1.2) 19.24 1 > 2 > 3; 1 > 4,5 Food 3.5 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.1) 39.98 1 > 2 > 3,4,5 Clothing 3.3 (1.0) 3.1 (1.1) 2.9 (1.2) 2.9 (1.2) 3.0 (1.2) 29.48 1 > 2 > 3,5; 1 > 4 Credit counseling 2.6 (1.3) 2.4 (1.3) 2.3 (1.3) 2.2 (1.3) 2.2 (1.2) 8.00 1 > 2 > 3; 1 > 4,5 Social networking 2.9 (1.2) 2.8 (1.2) 2.6 (1.3) 2.6 (1.3) 2.6 (1.3) 15.06 1 > 2 > 3 > 4,5 Utility assistance 2.5 (1.3) 2.4 (1.3) 1.2 (1.3) 2.4 (1.3) 2.5 (1.3) 8.74 5 > 2,1 > 3; 4 > 2 > 3 Transportation 3.0 (1.2) 2.9 (1.2) 2.7 (1.3) 2.7 (1.3) 2.9 (1.2) 15.11 1 > 2 > 3; 1 > 4,5 Education 3.0 (1.2) 3.0 (1.2) 2.8 (1.2) 2.8 (1.2) 2.8 (1.2) 11.08 1,2 > 3,4,5 Employment 2.8 (1.2) 2.6 (1.2) 2.5 (1.2) 2.5 (1.2) 2.7 (1.2) 17.74 1 > 2,4 > 3; 5 > 4 > 3 Spiritual 3.2 (1.1) 3.1 (1.2) 2.9 (1.3) 2.9 (1.2) 2.9 (1.2) 29.78 1 > 2 > 3,4,5 Positive perception of services Accessibility of VA services 3.4 (0.9) 3.3 (1.0) 3.1 (1.1) 3.1 (1.1) 3.2 (1.0) 45.21 1 > 2 > 5 > 3; 1 > 2 > 4 VA coordination of services 3.5 (0.9) 3.4 (0.9) 3.1 (1.1) 3.1 (1.1) 3.3 (1.0) 49.06 1 > 2 > 5 > 3; 1 > 2 > 4 Community agencies’ awareness of veterans’ needs 3.2 (1.0) 3.1 (1.1) 3.0 (1.1) 3.0 (1.1) 3.1 (1.1) 20.49 1 > 2 > 4 > 3; 1 > 5 > 3 *P < 0.05, **P < 0.01, ***P < 0.001. aSample sizes ranged in 2012 from 3285 to 6312; in 2013 from 3477 to 6721; in 2014 from 3351 to 6117; in 2015 from 2014 to 3539; in 2016 from 1719 to 2978. bTests of differences controlled for background differences between respondents. cAll test statistics presented were statistically significant at P < 0.01 level. dHigher scores reflect greater reported needs being met. For items in the Positive Perceptions of Services category, higher scores reflect more positive perceptions. eSSI = supplemental security income; SSDI = social security disability income. Table 3 shows changes in these general reported needs of respondents by housing status. Similar to the total sample, changes in reported unmet needs across categories were quite small. There were notable increases in unmet needs observed for emergency shelters among respondents who were literally homeless, and unmet needs for case management and permanent housing among respondents in permanent housing. Accessibility and coordination of VA services also showed notably poorer scores among respondents who were literally homeless and respondents who were in permanent housing. Table 3 Change in needs of respondents by current housing status between years 2012 and 2016a Literally homeless Transiently homeless In permanent housing F=b F= F= Housing Emergency shelter 29.91↓ 4.56↓ 20.42↓ Transitional housing 15.52↓ 2.70ns 16.59↓ Permanent housing 7.18↓ 1.87ns 41.73↓ Furniture and housewares 6.24↓ 4.25↑ 18.38↓ Healthcare services Medical services 13.08↓ 7.48↓ 20.92↓ Mental health services 11.34↓ 5.08↓ 17.26↓ Substance abuse treatment 8.53↓ 10.72↓ 14.75↓ Dental care 4.95↓ 9.12↓ 1.70ns Eye care 4.69↓ 0.87ns 8.37↑ Personal hygiene 14.25↓ 10.81↓ 5.13↓ Medication management 12.19↓ 6.17↓ 16.79↓ Health and wellness 12.34↓ 6.64↓ 16.26↓ Case management 16.43↓ 6.41↓ 35.72↓ Basic needs VA disability/pension 3.94↓ 2.28ns 6.57↓ SSI/SSDIc 5.25↓ 2.12ns 8.71↓ Money management 8.17↓ 4.39↓ 19.79↓ Food 17.13↓ 14.36↓ 20.26↓ Clothing 16.50↓ 6.21↓ 19.26↓ Credit counseling 10.88↓ 0.96ns 5.42↓ Social networking 9.48↓ 4.92↓ 8.41↓ Utility assistance 6.20↑ 3.66↑ 12.94↓ Transportation 9.96↓ 3.38↓ 9.05↓ Education 6.68↓ 2.50ns 7.59↓ Employment 11.01↓ 2.28ns 15.38↓ Spiritual 17.86↓ 6.90↓ 15.47↓ Positive perception of services Accessibility of VA services 30.37↓ 5.39↓ 31.42↓ VA coordination of services 32.44↓ 5.67↓ 37.04↓ Community agencies’ awareness of veterans’ needs 16.63↓ 1.58ns 20.84↓ Literally homeless Transiently homeless In permanent housing F=b F= F= Housing Emergency shelter 29.91↓ 4.56↓ 20.42↓ Transitional housing 15.52↓ 2.70ns 16.59↓ Permanent housing 7.18↓ 1.87ns 41.73↓ Furniture and housewares 6.24↓ 4.25↑ 18.38↓ Healthcare services Medical services 13.08↓ 7.48↓ 20.92↓ Mental health services 11.34↓ 5.08↓ 17.26↓ Substance abuse treatment 8.53↓ 10.72↓ 14.75↓ Dental care 4.95↓ 9.12↓ 1.70ns Eye care 4.69↓ 0.87ns 8.37↑ Personal hygiene 14.25↓ 10.81↓ 5.13↓ Medication management 12.19↓ 6.17↓ 16.79↓ Health and wellness 12.34↓ 6.64↓ 16.26↓ Case management 16.43↓ 6.41↓ 35.72↓ Basic needs VA disability/pension 3.94↓ 2.28ns 6.57↓ SSI/SSDIc 5.25↓ 2.12ns 8.71↓ Money management 8.17↓ 4.39↓ 19.79↓ Food 17.13↓ 14.36↓ 20.26↓ Clothing 16.50↓ 6.21↓ 19.26↓ Credit counseling 10.88↓ 0.96ns 5.42↓ Social networking 9.48↓ 4.92↓ 8.41↓ Utility assistance 6.20↑ 3.66↑ 12.94↓ Transportation 9.96↓ 3.38↓ 9.05↓ Education 6.68↓ 2.50ns 7.59↓ Employment 11.01↓ 2.28ns 15.38↓ Spiritual 17.86↓ 6.90↓ 15.47↓ Positive perception of services Accessibility of VA services 30.37↓ 5.39↓ 31.42↓ VA coordination of services 32.44↓ 5.67↓ 37.04↓ Community agencies’ awareness of veterans’ needs 16.63↓ 1.58ns 20.84↓ aAll test statistics presented controlled for background differences between respondents. All test statistics were statistically significant at the P < 0.01 level unless denoted with footnote of ns. bTests of differences controlled for background differences between respondents. cSSI = Supplemental Security Income; SSDI = Social Security Disability Income; ↓ = Decreasing scores; ↑ = Increasing scores. Table 3 Change in needs of respondents by current housing status between years 2012 and 2016a Literally homeless Transiently homeless In permanent housing F=b F= F= Housing Emergency shelter 29.91↓ 4.56↓ 20.42↓ Transitional housing 15.52↓ 2.70ns 16.59↓ Permanent housing 7.18↓ 1.87ns 41.73↓ Furniture and housewares 6.24↓ 4.25↑ 18.38↓ Healthcare services Medical services 13.08↓ 7.48↓ 20.92↓ Mental health services 11.34↓ 5.08↓ 17.26↓ Substance abuse treatment 8.53↓ 10.72↓ 14.75↓ Dental care 4.95↓ 9.12↓ 1.70ns Eye care 4.69↓ 0.87ns 8.37↑ Personal hygiene 14.25↓ 10.81↓ 5.13↓ Medication management 12.19↓ 6.17↓ 16.79↓ Health and wellness 12.34↓ 6.64↓ 16.26↓ Case management 16.43↓ 6.41↓ 35.72↓ Basic needs VA disability/pension 3.94↓ 2.28ns 6.57↓ SSI/SSDIc 5.25↓ 2.12ns 8.71↓ Money management 8.17↓ 4.39↓ 19.79↓ Food 17.13↓ 14.36↓ 20.26↓ Clothing 16.50↓ 6.21↓ 19.26↓ Credit counseling 10.88↓ 0.96ns 5.42↓ Social networking 9.48↓ 4.92↓ 8.41↓ Utility assistance 6.20↑ 3.66↑ 12.94↓ Transportation 9.96↓ 3.38↓ 9.05↓ Education 6.68↓ 2.50ns 7.59↓ Employment 11.01↓ 2.28ns 15.38↓ Spiritual 17.86↓ 6.90↓ 15.47↓ Positive perception of services Accessibility of VA services 30.37↓ 5.39↓ 31.42↓ VA coordination of services 32.44↓ 5.67↓ 37.04↓ Community agencies’ awareness of veterans’ needs 16.63↓ 1.58ns 20.84↓ Literally homeless Transiently homeless In permanent housing F=b F= F= Housing Emergency shelter 29.91↓ 4.56↓ 20.42↓ Transitional housing 15.52↓ 2.70ns 16.59↓ Permanent housing 7.18↓ 1.87ns 41.73↓ Furniture and housewares 6.24↓ 4.25↑ 18.38↓ Healthcare services Medical services 13.08↓ 7.48↓ 20.92↓ Mental health services 11.34↓ 5.08↓ 17.26↓ Substance abuse treatment 8.53↓ 10.72↓ 14.75↓ Dental care 4.95↓ 9.12↓ 1.70ns Eye care 4.69↓ 0.87ns 8.37↑ Personal hygiene 14.25↓ 10.81↓ 5.13↓ Medication management 12.19↓ 6.17↓ 16.79↓ Health and wellness 12.34↓ 6.64↓ 16.26↓ Case management 16.43↓ 6.41↓ 35.72↓ Basic needs VA disability/pension 3.94↓ 2.28ns 6.57↓ SSI/SSDIc 5.25↓ 2.12ns 8.71↓ Money management 8.17↓ 4.39↓ 19.79↓ Food 17.13↓ 14.36↓ 20.26↓ Clothing 16.50↓ 6.21↓ 19.26↓ Credit counseling 10.88↓ 0.96ns 5.42↓ Social networking 9.48↓ 4.92↓ 8.41↓ Utility assistance 6.20↑ 3.66↑ 12.94↓ Transportation 9.96↓ 3.38↓ 9.05↓ Education 6.68↓ 2.50ns 7.59↓ Employment 11.01↓ 2.28ns 15.38↓ Spiritual 17.86↓ 6.90↓ 15.47↓ Positive perception of services Accessibility of VA services 30.37↓ 5.39↓ 31.42↓ VA coordination of services 32.44↓ 5.67↓ 37.04↓ Community agencies’ awareness of veterans’ needs 16.63↓ 1.58ns 20.84↓ aAll test statistics presented controlled for background differences between respondents. All test statistics were statistically significant at the P < 0.01 level unless denoted with footnote of ns. bTests of differences controlled for background differences between respondents. cSSI = Supplemental Security Income; SSDI = Social Security Disability Income; ↓ = Decreasing scores; ↑ = Increasing scores. As shown in Table 4, we then examined the higher reported unmet needs across all 62 items including specialized categories in which much smaller numbers of respondents responded to. Across years 2012–16, need for legal assistance for evictions and foreclosures was reported as one of the top unmet needs in all 5 years; housing for registered sex offenders was one of the top reported unmet needs in four of the 5 years; legal assistance for child support was a commonly reported unmet need that was also reported in 4 of the 5 years; and child care was reported in three of the 5 years. Table 4 Top five reported unmet needs among homeless respondents by year Year 2012 N = 6859 Year 2013 N = 7741 Year 2014 N = 7126 Year 2015 N = 3765 Year 2016 N = 3191 μ (sd) % μ (sd) % μ (sd) % μ (sd) % μ (sd) % Registered sex offender housing (n = 1024) 1.9 (1.2) 60.6 Legal assistance for eviction and foreclosure (n = 2072) 1.8 (1.2) 62.6 Legal assistance for eviction and foreclosure (n = 2287) 1.7 (1.1) 66.9 Legal assistance for eviction and foreclosure (n = 1427) 1.9 (1.2) 61.9 Registered sex offender housing (n = 644) 1.8 (1.2) 65.8 Legal assistance for eviction and foreclosure (n = 1782) 2.0 (1.2) 56.3 Registered sex offender housing (n = 1324) 1.8 (1.2) 65.0 Registered sex offender housing (n = 1317) 1.8 (1.2) 65.6 Welfare payments (n = 1384) 2.0 (1.3) 56.6 Legal assistance for eviction and foreclosure (n = 1094) 1.8 (1.2) 63.0 Legal assistance for child support (n = 1683) 2.1 (1.3) 52.7 Legal assistance for child support (n = 1769) 1.9 (1.2) 59.1 Legal assistance for child support (n = 1822) 1.8 (1.2) 62.7 Registered sex offender housing (n = 799) 2.0 (1.2) 56.1 Legal assistance for child support (n = 846) 1.9 (1.2) 69.8 Child care (n = 1350) 2.2 (1.3) 51.0 Financial guardship (n = 1878) 2.0 (1.2) 55.1 Child care (n = 1580) 1.9 (1.2) 60.6 Legal assistance for outstanding warrants and fines (n = 1271) 2.1 (1.3) 54.4 Child care (n = 745) 2.0 (1.2) 56.4 Assisted living for elderly (n = 1389) 2.2 (1.3) 49.4 Child care 2.0 (1.3) 54.3 Financial guardship (n = 1854) 1.9 (1.2) 59.3 Legal assistance for child support (n = 1146) 2.1 (1.3) 53.4 Financial guardianship (n = 860) 2.0 (1.2) 55.9 Year 2012 N = 6859 Year 2013 N = 7741 Year 2014 N = 7126 Year 2015 N = 3765 Year 2016 N = 3191 μ (sd) % μ (sd) % μ (sd) % μ (sd) % μ (sd) % Registered sex offender housing (n = 1024) 1.9 (1.2) 60.6 Legal assistance for eviction and foreclosure (n = 2072) 1.8 (1.2) 62.6 Legal assistance for eviction and foreclosure (n = 2287) 1.7 (1.1) 66.9 Legal assistance for eviction and foreclosure (n = 1427) 1.9 (1.2) 61.9 Registered sex offender housing (n = 644) 1.8 (1.2) 65.8 Legal assistance for eviction and foreclosure (n = 1782) 2.0 (1.2) 56.3 Registered sex offender housing (n = 1324) 1.8 (1.2) 65.0 Registered sex offender housing (n = 1317) 1.8 (1.2) 65.6 Welfare payments (n = 1384) 2.0 (1.3) 56.6 Legal assistance for eviction and foreclosure (n = 1094) 1.8 (1.2) 63.0 Legal assistance for child support (n = 1683) 2.1 (1.3) 52.7 Legal assistance for child support (n = 1769) 1.9 (1.2) 59.1 Legal assistance for child support (n = 1822) 1.8 (1.2) 62.7 Registered sex offender housing (n = 799) 2.0 (1.2) 56.1 Legal assistance for child support (n = 846) 1.9 (1.2) 69.8 Child care (n = 1350) 2.2 (1.3) 51.0 Financial guardship (n = 1878) 2.0 (1.2) 55.1 Child care (n = 1580) 1.9 (1.2) 60.6 Legal assistance for outstanding warrants and fines (n = 1271) 2.1 (1.3) 54.4 Child care (n = 745) 2.0 (1.2) 56.4 Assisted living for elderly (n = 1389) 2.2 (1.3) 49.4 Child care 2.0 (1.3) 54.3 Financial guardship (n = 1854) 1.9 (1.2) 59.3 Legal assistance for child support (n = 1146) 2.1 (1.3) 53.4 Financial guardianship (n = 860) 2.0 (1.2) 55.9 Table 4 Top five reported unmet needs among homeless respondents by year Year 2012 N = 6859 Year 2013 N = 7741 Year 2014 N = 7126 Year 2015 N = 3765 Year 2016 N = 3191 μ (sd) % μ (sd) % μ (sd) % μ (sd) % μ (sd) % Registered sex offender housing (n = 1024) 1.9 (1.2) 60.6 Legal assistance for eviction and foreclosure (n = 2072) 1.8 (1.2) 62.6 Legal assistance for eviction and foreclosure (n = 2287) 1.7 (1.1) 66.9 Legal assistance for eviction and foreclosure (n = 1427) 1.9 (1.2) 61.9 Registered sex offender housing (n = 644) 1.8 (1.2) 65.8 Legal assistance for eviction and foreclosure (n = 1782) 2.0 (1.2) 56.3 Registered sex offender housing (n = 1324) 1.8 (1.2) 65.0 Registered sex offender housing (n = 1317) 1.8 (1.2) 65.6 Welfare payments (n = 1384) 2.0 (1.3) 56.6 Legal assistance for eviction and foreclosure (n = 1094) 1.8 (1.2) 63.0 Legal assistance for child support (n = 1683) 2.1 (1.3) 52.7 Legal assistance for child support (n = 1769) 1.9 (1.2) 59.1 Legal assistance for child support (n = 1822) 1.8 (1.2) 62.7 Registered sex offender housing (n = 799) 2.0 (1.2) 56.1 Legal assistance for child support (n = 846) 1.9 (1.2) 69.8 Child care (n = 1350) 2.2 (1.3) 51.0 Financial guardship (n = 1878) 2.0 (1.2) 55.1 Child care (n = 1580) 1.9 (1.2) 60.6 Legal assistance for outstanding warrants and fines (n = 1271) 2.1 (1.3) 54.4 Child care (n = 745) 2.0 (1.2) 56.4 Assisted living for elderly (n = 1389) 2.2 (1.3) 49.4 Child care 2.0 (1.3) 54.3 Financial guardship (n = 1854) 1.9 (1.2) 59.3 Legal assistance for child support (n = 1146) 2.1 (1.3) 53.4 Financial guardianship (n = 860) 2.0 (1.2) 55.9 Year 2012 N = 6859 Year 2013 N = 7741 Year 2014 N = 7126 Year 2015 N = 3765 Year 2016 N = 3191 μ (sd) % μ (sd) % μ (sd) % μ (sd) % μ (sd) % Registered sex offender housing (n = 1024) 1.9 (1.2) 60.6 Legal assistance for eviction and foreclosure (n = 2072) 1.8 (1.2) 62.6 Legal assistance for eviction and foreclosure (n = 2287) 1.7 (1.1) 66.9 Legal assistance for eviction and foreclosure (n = 1427) 1.9 (1.2) 61.9 Registered sex offender housing (n = 644) 1.8 (1.2) 65.8 Legal assistance for eviction and foreclosure (n = 1782) 2.0 (1.2) 56.3 Registered sex offender housing (n = 1324) 1.8 (1.2) 65.0 Registered sex offender housing (n = 1317) 1.8 (1.2) 65.6 Welfare payments (n = 1384) 2.0 (1.3) 56.6 Legal assistance for eviction and foreclosure (n = 1094) 1.8 (1.2) 63.0 Legal assistance for child support (n = 1683) 2.1 (1.3) 52.7 Legal assistance for child support (n = 1769) 1.9 (1.2) 59.1 Legal assistance for child support (n = 1822) 1.8 (1.2) 62.7 Registered sex offender housing (n = 799) 2.0 (1.2) 56.1 Legal assistance for child support (n = 846) 1.9 (1.2) 69.8 Child care (n = 1350) 2.2 (1.3) 51.0 Financial guardship (n = 1878) 2.0 (1.2) 55.1 Child care (n = 1580) 1.9 (1.2) 60.6 Legal assistance for outstanding warrants and fines (n = 1271) 2.1 (1.3) 54.4 Child care (n = 745) 2.0 (1.2) 56.4 Assisted living for elderly (n = 1389) 2.2 (1.3) 49.4 Child care 2.0 (1.3) 54.3 Financial guardship (n = 1854) 1.9 (1.2) 59.3 Legal assistance for child support (n = 1146) 2.1 (1.3) 53.4 Financial guardianship (n = 860) 2.0 (1.2) 55.9 Discussion Main finding of this study Using national annual surveys of homeless veterans over a recent 5-year period, we found little change in reported unmet needs of homeless veterans. There were slight increases in unmet needs related to case management, food, emergency shelter and medical services. But overall, the consistent ratings of needs over a multi-year period provide us with confidence that the items that were rated reflect true unmet needs. Across the 5 years, the highest rated unmet needs that affected the most respondents were related to credit, utilities, furniture, dental care and disability income. These findings are interesting since housing was not on this list and these ratings are entirely based on the perspective of homeless veterans themselves, which may be different than that of providers as studies of housing preferences have found.14 The federal government has dedicated tremendous resources and funds to provide transitional and permanent supported housing in the past decade through the federal initiative to end veteran homelessness. These findings suggest housing is less of an issue now given these efforts, and so homeless veterans have begun to identify other needs beyond obtaining housing and some of these needs may pertain to sustaining housing and improving social functioning. What is already known on this topic Homeless veterans have comprehensive healthcare and social needs, and their well-being is a major public health concern. The federal government along with communities across the country have dedicated various programs and services to address their needs. Previous studies have found that a substantial proportion of veterans who receive supported housing continue to struggle with staying housed and experience other problems that interfere with their ability to sustain housing.8–11 What this study adds Our analyses indicate that there several areas that homeless veterans consistently report difficulties in, which were related to housing such as income security, healthcare, and utilities and furniture. While VA continues to offer many comprehensive services for homeless veterans, scores on accessibility and coordination of VA services seemed to have been rated poorer over time, especially among veterans who are literally homeless and veterans in permanent housing. Overall though, the sociodemographic characteristics of samples have changed over time (i.e. increasing number of aging, female and white veterans), but their needs have largely remain unchanged suggesting most homeless veterans regardless of their background have these unmet needs which deserve attention. In addition to these general needs, there were several unmet specialized needs that were rated even higher but they were rated by only a minority of respondents presumably because the items were only relevant to them. Among these specialized needs, we found that legal assistance for civil legal problems, especially evictions/foreclosures and child support were two of the highest rated unmet needs of homeless veterans. This need for civil legal assistance has also been found among other homeless populations.15 The VA has no statutory authority to provide direct legal assistance to veterans, however, there is an increasing movement within VA medical centers to develop medical–legal partnerships with outside legal providers to assist veterans.16 Many of these VA medical–legal partnerships focus on serving veterans who are homeless and/or have severe mental illness with civil legal problems.17 One recent study of VA medical–legal partnerships in two states has found that these partnerships can improve housing and mental health outcomes.18 While the full medical–legal partnership model is not widespread across the country, pro-bono legal clinics that are housed on VA campuses have experienced growth, with 158 pro-bono clinics operating across the country.19 Our survey findings suggest many veterans would benefit from services provided through medical–legal partnerships and expanding these partnerships may help address veteran homelessness. In addition to the need for legal assistance, housing for registered sex offenders was also a highly rated unmet need. While there are varying state law and local ordinances concerning housing restrictions for registered sex offenders, many respondents reported it as a major problem across states. Housing for sex offenders has been a difficult problem for many decades and various studies have highlighted this problem and there are few effective solutions that have been developed.20–22 There is nearly no research on veterans who are registered sex offenders and it is unknown whether they face unique challenges compared to other registered sex offenders. New solutions and approaches are needed to help homeless veterans with past offenses obtain safe, stable housing and successfully integrate in their communities. Limitations of this study While attempts are made every year to distribute the CHALENG survey as widely as possible, the survey used convenience samples and the sample sizes declined over time. Samples could not be determined to be representative of the homeless veteran population and sampling was geographically uneven since some regions recruited more respondents than others. There was also no way for us to determine if respondents in 1 year were respondents in any other year of the survey. This study intended to provide a broad contemporary picture of the needs of homeless veterans, and further analyses are needed to examine these needs by various sociodemographic groups (i.e. age, gender). Survey items were based on self-report and respondents may have varying subjective opinions about the extent to which a need is ‘met’. Moreover, the CHALENG survey asked respondents to rate a list of preconceived items, but some respondents may have other unmet needs that were not on the list and thus would not have been captured in this study. Future designers of the CHALENG survey should consider including a few open-ended questions, which may be more easily facilitated through an online survey platform. These limitations notwithstanding, the results provide a broad, contemporary national overview of the self-reported needs of homeless veterans over an extended period of time. The findings also highlight numerous areas that may need further attention and intervention as the country continues striving to address veteran homelessness. References 1 Gelberg L , Andersen RM , Leake BD . The behavioral model for vulnerable populations: application to the medical care use and outcomes for homeless people . Health Serv Res 2000 ; 34 : 1273 – 302 . Google Scholar PubMed 2 Baggett TP , O’Connell JJ , Singer DE et al. . The unmet health care needs of homeless adults: a national study . Am J Public Health 2010 ; 100 : 1326 – 33 . Google Scholar CrossRef Search ADS PubMed 3 U. S. Department of Housing and Urban Development . The 2016 Annual Homeless Assessment Report (AHAR) to Congress. Washington, DC: U.S. Department of Housing and Urban Development, 2016 . 4 U.S. Census Bureau . S2101 Veteran Status: 2016 American Community Survey 1-Year Estimates. Washington, DC: U.S. Census Bureau; 2016 . Available from: https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_16_1YR_S2101&prodType=table (15 October 2017). 5 United States Department of Veterans Affairs . Secretary Shinseki Details Plans to End Homelessness for Veterans. In: Affairs PaI, editor. 2009 . 6 Tsai J , O’Toole T , Kearney LK . Homelessness as a public mental health and social problem: new knowledge and solutions . Psychol Serv 2017 ; 14 : 113 – 7 . Google Scholar CrossRef Search ADS PubMed 7 U.S. Department of Housing and Urban Development . The 2017 Annual Homeless Assessment Report (AHAR) to Congress: Part 1 Point-in-Time Estimates of Homelessness. Washington, DC: U.S. Department of Housing and Urban Development, Office of Community Planning and Development, 2017 . 8 Cusack M , Montgomery AE . The role of eviction in veterans’ homelessness recidivism . J Soc Distress Homeless 2017 ; 26 : 58 – 64 . Google Scholar CrossRef Search ADS 9 Tsai J , Rosenheck RA . Does housing chronically homeless adults lead to social integration? Psychiatr Serv 2012 ; 63 : 427 – 34 . Google Scholar CrossRef Search ADS PubMed 10 Tsai J , Kasprow WJ , Rosenheck RA . Alcohol and drug use disorders among homeless veterans: prevalence and association with supported housing outcomes . Addict Behav 2014 ; 39 : 455 – 60 . Google Scholar CrossRef Search ADS PubMed 11 Tsai J , Rosenheck RA , Kasprow WJ et al. . Homelessness in a national sample of incarcerated veterans in state and federal prisons. Administration and Policy in Mental Health and Mental . Health Serv Res 2014 ; 41 : 360 – 7 . 12 Kuhn JH , Nakashima J . The Seventeenth Annual Progress Report: Community Homelessness Assessment, Local Education And Networking Group (CHALENG) for Veterans Fiscal Year (FY) 2010): Services for Homeless Veterans Assessment and Coordination. Washington, DC: U.S. Department of Veterans Affairs, 2011 . 13 Tsai J , Rosenheck RA . US veterans’ use of VA Mental Health Services And Disability Compensation increased from 2001 to 2010 . Health Aff 2016 ; 35 : 966 – 73 . Google Scholar CrossRef Search ADS 14 Piat M , Lesage A , Boyer R et al. . Housing for persons with serious mental illness: consumer and service provider preferences . Psychiatr Serv 2008 ; 59 : 1011 – 7 . Google Scholar CrossRef Search ADS PubMed 15 Tsai J , Jenkins D , Lawton E . Civil legal services and medical-legal partnerships needed by the homeless population: a national survey . Am J Public Health 2017 ; 107 : 398 – 401 . Google Scholar CrossRef Search ADS PubMed 16 Tsai J , Middleton M , Retkin R et al. . Partnerships between healthcare and legal providers in the Veterans Health Administration . Psychiatr Serv 2017 ; 68 : 321 – 3 . Google Scholar CrossRef Search ADS PubMed 17 Wong CF , Tsai J , Klee A et al. . Helping veterans with mental illness overcome civil legal issues: collaboration between a veterans affairs psychosocial rehabilitation center and a nonprofit legal center . Psychol Serv 2013 ; 10 : 73 . Google Scholar CrossRef Search ADS PubMed 18 Tsai J , Middleton M , Villegas J et al. . Medical-legal partnerships at veterans affairs medical centers improved housing and psychosocial outcomes for vets . Health Aff 2017 ; 36 : 2195 – 203 . Google Scholar CrossRef Search ADS 19 U.S. Department of Veterans Affairs . Legal Help for Veterans. Washington, DC: U.S. Department of Veterans Affairs, Office of General Counsel; 2017 [updated August 9, 2017; cited 2017 December 6]. https://www.va.gov/OGC/LegalServices.asp. 20 Levenson JS , D’Amora DA , Hern AL . Megan’s law and its impact on community re‐entry for sex offenders . Behav Sci Law 2007 ; 25 : 587 – 602 . Google Scholar CrossRef Search ADS PubMed 21 Mustaine EE , Tewksbury R , Connor DP et al. . Criminal justice officials’ views of sex offenders, sex offender registration, community notification, and residency restrictions . Justice Syst J 2015 ; 36 : 63 – 85 . Google Scholar CrossRef Search ADS 22 Huebner BM , Kras KR , Rydberg J et al. . The effect and implications of sex offender residence restrictions . Criminol Public Policy 2014 ; 13 : 139 – 68 . Google Scholar CrossRef Search ADS Published by Oxford University Press on behalf of Faculty of Public Health 2018. This work is written by (a) US Government employee(s) and is in the public domain in the US.

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Journal of Public HealthOxford University Press

Published: May 3, 2018

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