Veterans experiencing housing insecurity face severe health risks. They have high rates of chronic disease, mental health disorders, and substance use. These conditions drive emergency department visits and hospitalizations far above population norms. Homelessness and unstable housing are powerful social determinants of acute care use. Addressing them is essential to improve outcomes and reduce costs.
The Veterans Health Administration (VHA) serves millions of veterans. A substantial subset experiences housing insecurity or homelessness. Increased acute care use among this group stresses VA hospitals and emergency departments. Predicting which veterans are at highest risk for repeat hospitalizations could guide interventions. “Hotspotting” programs aim to do just that.
New Evidence from a National VHA Hot Spotter Study
A new article in Medical Care examines acute care use among housing-insecure veterans. Blonigen et al. used VHA Homeless Registry data from 2018–2022 (n≈1.47 million) to identify veterans meeting “hot spotter” criteria. These criteria included ≥1 hospital admission or ≥2 emergency department (ED) visits in a quarter. They described care patterns and compared those with persistent versus transient acute care use.
In this national VHA cohort, nearly one in three housing-insecure veterans met hot spotter criteria in at least one quarter. More striking, more than half of those flagged met criteria in multiple quarters. This pattern points to a large subgroup with persistent or recurrent high acute care use, not just one-time crises.
Clinical complexity was the norm. Depression and substance use disorders were highly prevalent, affecting 58% and 51% of veterans, respectively. Veterans with repeated hot spotter flags also carried a heavier burden of chronic disease, averaging just over five chronic conditions compared with just over three among those flagged only once.
High acute care use did not reflect disengagement from the health system. In fact, veterans with repeated hot spotter status had greater outpatient care use. This likely reflects both the accessibility of VA outpatient services and the intensity of needs in this population. Medical hospitalizations outnumbered psychiatric hospitalizations by roughly two to one, yet mental health and substance use disorders remained central features of clinical complexity.
One of the most concerning findings involved suicide risk. Veterans flagged in more than one quarter had nearly double the documented suicidality compared with those flagged in only one quarter (23.7% vs. 11.7%). This suggests that repeated or sustained periods of high acute care use may mark times of exceptional psychological vulnerability, not just medical instability.
Implications for Providers, Policy, and Health Systems
These findings show how housing insecurity shapes healthcare needs in complex ways. Many veterans in the hot spot group had high outpatient engagement. This likely reflects the relative access veterans have to VA outpatient services compared with non-VA systems. Veterans can face fewer barriers to primary care, yet still need intensive management to prevent acute events.
The high burden of mental health and substance use disorders underscores that medical care alone is insufficient. Integrated behavioral health is crucial to reduce crisis care reliance. Systems should prioritize sustained access to mental health and addiction services, not just acute treatment episodes.
Veteran homelessness is associated with complex multimorbidity that goes well beyond typical outpatient models. National HUD-VASH program studies show that housed veterans still use emergency and inpatient services at high rates when compared to independently housed peers.
Respite Care and Care Coordination
It’s worth noting that Blonigen et al. suggest increasing coordination with medical respite programs after hospitalization. These programs can support recovery in a safe setting and may reduce return to acute care for individuals without stable housing.
Investing in post-acute care coordination and housing support could align with housing as health care models recognized in Medicaid and public sector demonstrations. Effective care for housing-insecure patients spans clinical, social, and housing services.
Why This Matters
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A robust literature shows that housing insecurity and homelessness are deeply linked to acute care use. Systematic reviews find that people experiencing homelessness visit emergency departments at much higher rates than housed peers and often rely on hospitals as their primary source of care. Programs that screen for housing instability in acute settings reveal that a meaningful share of ED patients are housing insecure and have complex clinical needs.
Research also characterizes homelessness as an actionable social determinant of health. Reviews by Health Affairs and others emphasize that housing stability, affordability, and quality influence a wide range of health outcomes, including hospital admissions and ED use. Interventions that tie stable housing to care coordination and supportive services have reduced costly utilization in Medicaid and safety-net populations [pdf].
Within the veteran population, homelessness and housing instability are clearly tied to mental health burden and suicide risk. Prior studies report higher odds of suicidal ideation, attempts, and psychological distress among veterans with housing instability compared to those with stable housing. National VA data also show that veterans with a history of homelessness face elevated suicide risk even after accounting for other factors.
The hotspotting literature complements this evidence by showing that a small subset of patients, with housing instability, multimorbidity, and behavioral health disorders, account for a disproportionate share of acute care use [pdf]. Early super-utilizer research emphasizes that frequent ED and inpatient use clusters in populations with complex health and social needs. In Medicaid and safety-net settings, identifying these patients for tailored interventions reduced downstream utilization [pdf].
From Prediction to Prevention
The Blonigen et al. study adds important nuance to these prior findings. It confirms at national scale what smaller studies have shown locally: that housing insecurity predicts persistent high utilization, not just isolated crises. It also shows that these veterans are engaged in outpatient care, suggesting that access alone does not prevent repeat acute visits without integrated support. And by linking repeated hot spotter status with documented suicidality, it signals that hotspotting can do more than forecast costs—it can highlight patients at heightened psychological risk.
Altogether, this evidence reinforces a simple principle: housing insecurity is an actionable predictor of acute care use and risk. It also reinforces the need for hotspotting programs that are tied to comprehensive interventions, including housing supports, behavioral health integration, and post-acute coordination. Programs like Supportive Services for Veteran Families, which rapidly re-house veterans and provide ongoing supports, are part of this continuum.
Ben King