Staff Perceptions of Homeless Veterans' Needs and ... - APA PsycNET

Journal of Rural Mental Health 2015, Vol. 39, No. 1, 46 –53

In the public domain http://dx.doi.org/10.1037/rmh0000024

Staff Perceptions of Homeless Veterans’ Needs and Available Services at Community-Based Outpatient Clinics Geri Adler

Lonique R. Pritchett

Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, Houston Texas; Houston VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas; and Baylor College of Medicine

Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, Houston Texas; Houston VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas

Michael R. Kauth and Juliette Mott Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, Houston Texas; Houston VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas; and Baylor College of Medicine This study surveyed staff at rural Veterans Affairs community-based outpatient clinics (CBOCs) about the unique characteristics and service needs of rural homeless veterans. Results reported are based on descriptive analyses of responses from 254 staff members from 30 CBOCs who reported coming into contact with homeless veterans. Substance use (57%), unemployment (53%), and mental illness (45%) were considered the primary causes of rural homelessness. Staff perceived that, compared with urban homeless veterans, rural homeless veterans have less access to needed services and, because of aspects of rural culture, are more self-reliant. Staff cited dental care, substance-use treatment, transportation, and job training as significant needs among the rural homeless population. In general, staff perceived that rural CBOCs had greater availability of health care services but that non-VA community programs had greater availability of nonhealthcare resources for rural veterans (e.g., job training, clothing). Keywords: homelessness, rural, veterans

This article was published Online First December 15, 2014. Geri Adler, Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, Houston Texas; Houston VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine; Lonique R. Pritchett, Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, Houston Texas; Houston VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas; Michael R. Kauth and Juliette Mott, Veterans Affairs South Central Mental Illness Research, Education, and Clinical Center, Houston Texas; Houston VA Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, Texas; Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine.

Juliette Mott is now affiliated with the Department of Veterans Affairs National Center for Posttraumatic Stress Disorder, White River Junction, VT. Lonique R. Pritchett is now affiliated with Social Work Service at the Michael E. DeBakey VA Medical Center, Houston, Texas. This work was partly supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, and the Houston VA Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety (CIN13-413) and the South Central Mental Illness Research, Education and Clinical Center. The views expressed are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the United States government, or Baylor College of Medicine. Correspondence concerning this article should be addressed to Geri Adler, Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety, (MEDVAMC 152), 2002 Holcombe Boulevard, Houston, TX 77030. E-mail: [email protected] 46

NEEDS OF HOMELESS RURAL VETERANS

Veterans represent more than 12% of the U.S. homeless population (Henry, Cortes, & Morris, 2013). Ending veteran homelessness is a major initiative for the Department of Veterans Affairs (VA; Office of the Secretary of the Department of Veterans Affairs, 2011), which has invested substantial resources in programs to prevent and end homelessness, including a national call center ensuring the homeless and at-risk round-theclock, no-cost access to trained counselors; housing and case-management services; compensated work therapy; and support for special outreach and benefits assistance counselors (Homeless Programs & Resources, 2013). Meeting the unique needs of veterans in rural areas presents additional challenges, including limited access to medical and behavioral health care, lack of affordable housing, and few transportation options (Robertson, Harris, Fritz, Noftsinger, & Fischer, 2007). Rural residents are also “at-risk” for becoming homeless including living in substandard, overcrowded, and/or cost-burdened housing (National Alliance to End Homelessness, 2010). Rural homeless veterans differ from their urban counterparts: they access Veterans Health Administration (VHA) health care at reduced rates, report poorer health status, and are more likely to have past or current alcohol dependence (Gordon, Haas, Luther, Hilton, & Goldstein, 2010). To improve access to health care services for rural veterans, the VA established communitybased outpatient clinics (CBOCs), which offer primary care and some mental health services (Zeiss & Karlin, 2008). CBOCs are staffed with a primary care physician, and most have at least one mental health provider, often a nurse, psychologist, or social worker (Panangala & Mendez, 2010). Over 800 CBOCs operate in conjunction with 157 VA medical centers (VAMCs) in the United States (Heisler, Panangala, Bagalman, 2013). Treatment programs for rural homeless veterans (e.g., Health Care for Homeless Veterans) are sometimes available at CBOCs. The VA also has funded pilot projects to improve homeless services in CBOCs. For example, one employed case managers at four CBOCs to identify and enroll homeless and at-risk veterans in the VA system, educate them on available health services, and foster partnerships among VA and community groups (Atlas Research, 2011).

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Failure to recognize and address serious health care and nonhealthcare (e.g., housing, job training) issues facing rural homeless can have substantial consequences. A first step to evaluating and improving VA care for this population is to identify what needs exist and how services are being delivered. Research in this area is sparse, probably because of the inherent challenges associated with locating and interviewing rural homeless veterans. In light of this challenge, the current study examined the needs of and services for homeless veterans through the perspective of rural CBOC staff who serve them. CBOC staff members are uniquely situated to provide rich perspectives in these domains given that they are not only knowledgeable about the services available to rural veterans, but also, as a result of their contact with rural homeless veterans, have firsthand knowledge of these veterans’ needs and the barriers to care. Thus, this exploratory investigation sought to better understand staff perceptions of the unique characteristics and health care and nonhealthcare needs of rural homeless and at-risk homeless veterans in the Southeastern and Southern United States. Additionally, we assessed staff perceptions regarding to what extent types of VA facilities (i.e., CBOCs, VAMCs) and non-VA community organizations address specific needs of homeless veterans. Method The study was approved by the local Institutional Review Board and VA Research and Development Committee. Setting Study sites included 30 CBOCs in Veterans Integrated Service Network (VISN) 16 and VISN 6. VISN 16 encompasses one of the most rural areas in the United States, extending from the Florida panhandle to eastern Texas, covering all or parts of eight states. VISN 6 spans North Carolina, Virginia, and West Virginia. Eligible CBOCs were associated with Alexandria, Biloxi, Durham, Houston, Jackson, Little Rock, Muskogee, Oklahoma City, or Shreveport VAMCs. All CBOCs were within geographic areas categorized as rural or highly rural, as defined by the three-category

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ADLER, PRITCHETT, KAUTH, AND MOTT

classification system developed by the VA Planning Systems Support Group in collaboration with the Census Bureau (Phibbs, Cowgill, & Fan, 2013). Staff Characteristics Facility-level leadership at each VAMC provided a point of contact and list of CBOC staff. To obtain broad, multidisciplinary perspectives on the needs of homeless rural veterans, we had no exclusion criteria. All identified staff (n ⫽ 529) received an e-mail linked to an online survey (through SurveyMonkey), inviting them to complete the survey within two weeks. Up to two electronic reminders were sent to nonrespondents. Survey answers were anonymous, and participation was voluntary. Measures An online survey was developed from a previous needs assessment of CBOC staff (Adler, Pritchett, & Kauth, 2013), then reviewed by experts in veteran homelessness. The final version queried staff perspectives on care for homeless veterans. The first item included a definition of homelessness (A veteran who lacks a fixed, adequate, and regular nighttime residence; McKinney-Vento Act, 2009) and asked, In your current position, do you come into contact with homeless veterans? Those answering yes answered several follow-up multiple-choice items assessing prevalence and characterization of homelessness among CBOC veterans, including two items assessing health care and nonhealthcare service needs of homeless veterans on a three-point Likert scale (no need, some need, significant need); two multiple-choice items assessing availability of services for homeless veterans at CBOCs, primary VA facilities, and community-based organizations; demographic items, including gender, race/ ethnicity, professional training, and rural background; and one item asking whether respondents believed homeless veterans in rural areas differed from those in urban areas. Those replying yes to this last question were directed to a free-response item (Please describe how you feel rural homeless veterans differ from urban homeless veterans).

Data Analyses All analyses were descriptive. We first present frequency statistics for survey items querying the prevalence and perceived causes of homelessness among rural veterans. We also present descriptive data regarding staff perceptions of homeless veterans’ needs, and which type of facilities (CBOC, primary VA facility, community organization), if any, provide services to address each need. We used qualitative content analysis to interpret responses to the open-ended item about differences in rural and urban homelessness. First, an initial rater reviewed data by reading all responses to get an overall sense of content and generate preliminary codes. Next, the rater assigned thematic codes to the data. A second rater reviewed the codes to ensure that all relevant information had been properly coded. Raters resolved disagreements through multiple discussions and arrived at a final code for each respondent. Interrelated codes were then merged into a set of representative themes and tallied (Saldaña, 2012). Results A total of 296 of 529 eligible staff (55.9%) responded to the survey between March and June, 2013. An initial screening question assessed staff contact with homeless veterans; staff who reported “no” contact with homeless veterans were instructed not to complete the remaining survey items; thus, only staff who reported contact with homeless veterans (n ⫽ 254, 86%) were included in analyses. Respondents were diverse with respect to professional training, including nurses (n ⫽ 93), social workers (n ⫽ 30), physicians (n ⫽ 21), administrative staff (n ⫽ 17), medical-support assistants (n ⫽ 16), psychologists (n ⫽ 10), other professionals (e.g., dieticians; n ⫽ 28), and unknown (n ⫽ 39). Respondents were predominately women (n ⫽ 171, 67.3%) and primarily identified as White (n ⫽ 142, 55.9%), fewer identified as African American (n ⫽ 41, 16.1%), American Indian (n ⫽ 12, 4.7%), Hispanic (n ⫽ 8, 3.1%), Asian (n ⫽ 7, 2.8%), other (n ⫽ 3, 1.2%), and unknown (n ⫽ 41, 16.1%). Seventyseven respondents (30.3%) were reared in the rural area served by their CBOC, 61 (24.0%)


were reared in another rural area, 80 (31.5%) were reared in an urban area, and 36 (14.2%) did not respond. On average, respondents had worked within the VHA for 8.5 (SD ⫽ 16.2) years. Characterization of Homelessness in CBOC Veterans On average each month, 156 staff (63%) had contact with one to two homeless veterans, and 37% (n ⫽ 91) had contact with at least three homeless veterans. Most perceived that homeless veterans were presenting to CBOCs via self-referral (n ⫽ 105, 46%), or that a veterans service organization representative (e.g., Vet Center, Disabled American Veterans, Veterans of Foreign Wars) service officer/representative (n ⫽ 71, 18%) referred them for care. When asked about the most common causes for homelessness among rural veterans, respondents most often identified substance use (n ⫽ 132, 57%), unemployment (n ⫽ 123, 53%), and mental illness (n ⫽ 104, 45%). Although most perceived the number of homeless veterans seen at their facility to be stable (n ⫽ 134, 57%), others (n ⫽ 83, 34%) perceived increasing numbers of homeless veterans being served by their CBOC. More than half of staff (n ⫽ 146, 57.5%) perceived differences between rural and urban homelessness (see Table 1). Two primary response domains emerged: access to care and

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rural culture. The most common theme within the first domain was that rural veterans have fewer resources than urban veterans, described by 53% of respondents. For example, one participant noted, “There are no established, local ongoing shelter programs or assistance; and all the people who could answer questions or provide support are at least 50 miles away (too far to walk, purchase fuel or drive in an unreliable vehicle).” The most common theme in the ruralculture domain was that rural veterans are more self-reliant (10% of respondents) and, therefore, less likely to seek services. For example, a social worker commented, “Rural homeless vets rely on themselves more; they hunt, fish, live in camper trailers without electricity or water.” Staff Perspectives on Homeless Veterans’ Needs and Services Table 2 presents significant areas of need for homeless rural veterans, identified by CBOC staff members, as well as staff perspectives as to what type of facility addresses these needs. Dental care was the most commonly identified health care need, recognized by more than 80%, followed by substance-use treatment (71%) and mental health care (63%). Only 7% reported that dental services were available in their CBOC. In contrast, respondents perceived an overall greater availability of mental health care, substance-use treatment, primary care ser-

Table 1 Themes Describing How Rural Homelessness Differs From Urban Homelessness Domain Access to care

Rural culture

Theme

n

%

Example

Fewer available resources

78

53.4

Lack of transportation

42

28.8

Limited access to health and other services Greater self-reliance

29

19.9

15

10.3

General sociocultural factors, including close social ties, voluntary social support, mistrust of outsiders

15

10.3

“I do not believe that rural homeless veterans have the needed resources readily available. I believe it to be much easier for urban homeless to get assistance than a rural veteran.” “Transportation is a huge need of rural veterans because there is no mass transit system here.” “VA services are available, but getting patients to it is impossible.” “More prone to think they just need to be tough and deal with their situation on their own.” “Rural veterans can get meals and overnight housing from neighbors and friends. They do little small jobs around someone’s house for a meal and a place to sleep.”

Note. Because of missing data, descriptive statistics are based on a sample size of 146 respondents. The table presents only those themes referenced by at least 10% of respondents.

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Table 2 Homeless Rural Veterans’ Needs and Availability of Services Addressing These Needs by Facility Type

Domain Healthcare Dental care Substance-use treatment Mental health care Vision care Primary care Infectious disease testing Non-healthcare Transportation Job training Clothing VA benefits Child care Non-VA benefits Food Legal assistance Food stamps Guardianship/PoA Integration after incarceration

Significant area of need n (%)

CBOC addresses need n (%)

VA facility addresses need n (%)

Community addresses need n (%)

188 (82.1) 162 (70.7) 143 (62.5) 133 (58.1) 123 (53.7) 105 (45.9)

15 (6.6) 108 (47.2) 198 (86.5) 65 (28.4) 203 (88.7) 129 (56.3)

77 (33.6) 96 (41.9) 32 (13.1) 90 (39.3) 29 (12.7) 62 (27.1)

63 (27.5) 42 (18.3) 34 (14.9) 45 (19.7) 33 (14.4) 53 (21.3)

152 (68.2) 149 (66.8) 145 (65.0) 116 (52.7) 109 (48.9) 91 (41.4) 90 (40.4) 81 (36.3) 77 (35.0) 68 (30.9) 68 (30.5)

49 (21.9) 7 (3.1) 15 (6.7) 117 (53.2) 1 (0.5) 25 (11.4) 5 (2.2) 7 (1.8) 25 (11.4) 67 (30.5) 16 (7.2)

54 (24.0) 60 (26.9) 26 (11.7) 91 (41.4) 2 (0.9) 16 (7.3) 8 (3.6) 60 (26.9) 12 (5.5) 41 (18.6) 41 (18.4)

79 (35.4) 85 (38.1) 123 (55.3) 57 (25.9) 42 (18.8) 121 (55.0) 171 (76.7) 85 (38.1) 134 (60.9) 60 (27.3) 32 (14.4)

Note. CBOC ⫽ Community-Based Outpatient Clinic; VA ⫽ Veterans Affairs; PoA ⫽ Power of Attorney. Because of missing data, descriptive statistics are based on a sample size of 229 staff.

vices, and infectious disease testing in their CBOC than in the primary VA facility or local community clinics. The most common nonhealthcare needs were transportation (68%), job training (67%), and clothing (65%). Staff reported that nonhealthcare services for homeless veterans were less readily available than health care services at their CBOC. Discrepancies in the availability of nonhealthcare services at different types of facilities (CBOCs, VAMCs, and community organizations/clinics) were most apparent for job training; staff believed that these services were more available at non-VA community clinics (38%) and primary VA facilities (27%) than at CBOCs (3%). Discrepancies were also apparent for legal services; although one third of respondents identified legal services as a significant need, less than 2% reported legal services available at their CBOC; in contrast, 27% reported that these services were available at the main VA facility. Community organizations were perceived to have greater service availability than CBOCs or VA facilities in eight of the 11 nonhealthcare domains: transportation, job

training, clothing, childcare, non-VA benefits, food, food stamps, and legal assistance. Discussion This study examined rural CBOC staff perceptions of rural homeless veterans. Substance use, unemployment, and mental illness were seen as primary causes of rural homelessness; and staff perceived rural homeless veterans as having less access to services and being more self-reliant than urban homeless veterans. Dental care, substance-use treatment, transportation, and job training were seen as significant needs by rural homeless veterans with CBOCs seen as providing more health care services and local community programs having more nonhealthcare services. CBOC staff perceived important differences between rural and urban homeless veterans. Qualitative coding of participant responses revealed two primary response domains: access to care and rural culture. Regarding access to care, CBOC staff perceived rural veterans facing several critical obstacles, with unavailable services and lack of transportation being most


frequently cited. Homeless veterans have complex health problems, as well as housing, financial, and job-related issues (Perl, 2013). CBOCs can address some of these, but without community programs to augment VA services challenges are still substantial. Scarce transportation options in rural areas exacerbate the situation (Shoup & Homa, 2010). With limited or no transportation, homeless veterans often cannot access medical appointments or obtain or sustain employment. Regarding the second domain, rural culture, respondents referenced several sociocultural characteristics distinguishing rural veterans from their urban counterparts. The most common related to general factors and self-reliance among rural veterans. These themes have been noted previously in research on rural-dwelling individuals; Post (2002) stated that small-town residents pride themselves on caring for their own and place a high value on individuality and self-sufficiency. Consistent with research showing rural communities characterized by close social ties and dependence on family and friends (Robertson et al., 2007), staff also viewed rural homeless veterans as more likely than urban veterans to receive support and help from individuals in the community. Together, these cultural characteristics may reduce or delay help-seeking of rural homeless and at-risk veterans. Understanding the community, building trust, developing cultural competency, and knowing formal and informal community resources are important to effective rural practice. Staff perceptions of causes of rural homelessness (e.g., substance abuse, lack of employment, mental illness) were largely consistent with results of empirical research of predictors of homelessness among veterans, which suggest that illicit drug use is the strongest predictor and that personality disorders and severe mental illness (schizophrenia or bipolar disorder) increase the risk (Edens, Kasprow, Tsai, & Rosenheck, 2011). Our findings departed from prior research in that CBOC staff did not explicitly identify poverty as a central cause of homelessness among rural veterans. Poverty is a well-established risk factor for homelessness (Robertson et al., 2007). Homelessness is concentrated in rural communities with persistent poverty, often agricultural communities or those that have relied on declining industries, such as mining, fishing, or forestry, or in economic-

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growth areas, which often result in increased taxes, housing, and living expenses (Post, 2002). Perhaps, because they work in health care, staff were more apt to identify medicalrelated reasons for homelessness than systemic factors, such as poverty. Staff perceived that CBOCs had greater availability than primary VAMCs and community agencies of most health care services for rural veterans, except for dental and vision care. This was unexpected, given that all VAMCs provide health care services related to mental health/substance use, primary care, and infectious diseases. This may reflect CBOC staff being more familiar with services at their own clinic than services at VAMCs. Respondents reported comparatively less availability of nonhealthcare services, such as childcare, legal aid, and job training, at CBOCs. Community agencies provide most services to address nonmental health needs. These results highlight the need for continued efforts to provide nonhealthcare services at CBOCs and for CBOCs to creatively partner with community groups. Ongoing efforts and initiatives to improve availability of these types of services include the Veteran’s Justice Outreach Program, which is a national initiative to provide outreach to veterans involved in justice systems (Homeless Veterans, 2014), and the Homeless Providers Grant and Per Diem, which funds community agencies providing services to homeless veterans to promote development and provision of supportive housing and other services. Such programs can improve veterans’ engagement in and access to beneficial programs and services. Results are limited to self-report data reflecting staff perceptions and, perhaps, bias, and may not accurately reflect actual needs and availability of services for rural veterans. Study respondents included solely CBOC employees. We selected this sample because these rural staff would, arguably, have the most direct exposure to rural homeless; however, staff from other VA and community facilities may have responded differently. Results may have limited generalizability, given that rural areas are diverse and unique in cultural and regional characteristics (Shamblin, Williams, & Bellaw, 2012). Most rural CBOC staff report encountering homeless veterans at their clinics. Meeting the

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needs of these homeless veterans is challenging because of lack of access to needed services and some aspects of rural culture. Providers perceive that CBOCs are able to meet some medical needs of their rural homeless veterans, especially primary and mental health care needs. Other significant needs, such as dental and vision care, and substance-use treatment are perceived as being unaddressed at rural CBOC facilities, as well as at nearby VAMCs. These facilities are also viewed as having limited ability to address nonhealthcare-related needs, such as transportation, job training, and clothing. Respondents indicated that non-VA community programs were comparatively better able to address these problems, although a paucity of resources remains. The current investigation highlights the need for additional community-based research that includes the perspectives of homeless veterans themselves, as well as community stakeholders, and an exploration of successful models of care. References Adler, G., Pritchett, L. R., & Kauth, M. R. (2013). Meeting the continuing education needs of rural mental health providers. Telemedicine and eHealth, 19, 852– 856. http://dx.doi.org/10.1089/ tmj.2013.0010 Atlas Research. (2011). Establishing homeless programs for veterans living in rural communities. Retrieved December 6, 2013 from http://atlasresearch .us/portfolio.php?all⫹y Edens, E. L., Kasprow, W., Tsai, J., & Rosenheck, R. A. (2011). Association of substance use and VA service-connected disability benefits with risk of homelessness among veterans. The American Journal on Addictions, 20, 412– 419. http://dx.doi .org/10.1111/j.1521-0391.2011.00166.x Gordon, A. J., Haas, G. L., Luther, J. F., Hilton, M. T., & Goldstein, G. (2010). Personal, medical and healthcare utilization among homeless veterans served by metropolitan and nonmetropolitan veteran facilities. Psychological Services, 7, 65– 74. http://dx.doi.org/10.1037/a0018479 Heisler, E. J., Panangala, S. V., & Bagalman, E. (2013). Health care for rural veterans: The example of federally qualified health centers (R43029). Washington, DC: Congressional Research Service. Retrieved September 16, 2014 from http://www .himss.org/files/himssorg/content/files/20130418crs-rpthealthcareruralveterans.pdf Henry, M., Cortes, A., & Morris, S. (2013). The 2013 annual homeless assessment report to Congress.

Washington, DC: U.S. Department of Housing and Urban Development. Retrieved September 8, 2014 from https://www.hudexchange.info/ resources/document/AHAR-2013-Part1.pdf Homeless Veterans Programs and Resources. Washington, DC: US Department of Veterans Affairs. Retrieved December 26, 2013 from http://www.va .gov/homeless/ McKinney-Vento Homeless Assistance Act as amended by S. 896, The Homeless Emergency Assistance & Rapid Transition to Housing (HEARTH) Act of 2009, Sec. 103 [42 USC 11302]. (2009). Retrieved May 14, 2014 from https://www.onecpd.info/resources/documents/ homelessassistanceactamendedbyhearth.pdf National Alliance to End Homelessness. (2010). Homelessness counts. Washington, DC: Author. Office of the Secretary of the Department of Veterans Affairs. (2011). Strategic plan refresh FY 2011– 2015. Retrieved January, 3, 2014 from www.va .gov/VA_2011-2015_Strategic_Plan_Refresh_wv .pdf.6 Panangala, S. V., & Mendez, B. H. P. (2010). Veterans Health Administration: Community-based outpatient clinics. Congressional Research Service 2010, R7-5700, R41044. Retrieved November 19, 2012 from http://assets.opencrs.com/rpts? R41044_20100128.pdf Perl, L. (2013). Veterans and homelessness. Washington, DC: Congressional Research Service. Retrieved September 8, 2014 from http://fas.org/sgp/ crs/misc/RL34024.pdf Phibbs, C. S., Cowgill, E. H., & Fan, A. Y. (2013). Guide to the PSSG enrollee file. Guidebook. VA Palo Alto. Menlo Park, CA: Health Economics Resource Center. Post, P. A. (2002). Hard to read: Rural homelessness & health care. Nashville, TN: National Health Care for the Homeless Council. Robertson, M., Harris, N., Fritz, N., Noftsinger, R., & Fischer, P. (2007). Rural homelessness. Presented at the 2007 National Symposium on Homelessness Research, Washington, DC. Retrieved March 1–2, 2007 from http://aspe.hhs.gov/hsp/homelessness/ symposium07/robertson/index/htm Saldaña, J. (2012). The coding manual for qualitative researchers. Thousand Oaks, CA: Sage. Shamblin, S. R., Williams, N. F., & Bellaw, J. R. (2012). Conceptualizing homelessness in rural Appalachia: Understanding contextual factors relevant to community mental health practice. Journal of Rural Mental Health, 36, 3–9. http://dx.doi.org/ 10.1037/h0095809 Shoup, L., & Homa, B. (2010). Principles for improving transportation options in rural and small town communities. White Paper for Transportation for America: Washington, DC.


U.S. Department of Veterans Affairs. (August 4, 2014). Homeless veterans. Retrieved December 17, 2013 from http://www.va.gov/homeless/vjo .asp Zeiss, A. M., & Karlin, B. E. (2008). Integrating mental health and primary care services in the Department of Veterans Affairs health care sys-

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tem. Journal of Clinical Psychology in Medical Settings, 15, 73–78. http://dx.doi.org/10.1007/ s10880-008-9100-4 Received January 17, 2014 Revision received September 16, 2014 Accepted September 16, 2014 䡲

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