UCLA

Substance use disorder (SUD) among the US Veterans has increased. SUD is also highly prevalent among the homeless and housing unstable Veterans. Despite the importance of primary care at the VA as the gateway to other services, the effect of SUD and housing instability on several areas of Veteran’s primary care experience has not been widely explored.Using a nationwide retrospective cohort of Veterans in primary care between 2019 and 2022, this dissertation examines telehealth use and attrition from primary care services among Veterans with and without SUD and housing instability. SUD and housing instability were identified through ICD-10 coding from VA administrative data. In Chapter Two, we compare patterns of Veteran telehealth and video use before and after the onset of COVID-19 by SUD diagnosis. In adjusted analyses, we find slightly higher rate of telehealth use and lower rates of video use among Veterans with SUD. In Chapter Three, we compare primary care attrition rates between Veterans with and without SUD between 2020 and 2022. We find a substantially lower attrition among higher users of VA primary care services, but a higher rate of attrition among patients with SUD. In Chapter Four, we examine the transitions of housing instability states among Veterans in primary care and the combined impact housing instability and SUD on telehealth use and attrition from primary care services. We find high rates of transition from homelessness but Veterans with SUD were more likely to remain homeless. We find higher rate of telehealth use and lower rate of video use among Veterans with SUD and housing instability. We find substantially lower attrition among higher users of primary care services at the VA, but higher rates of attrition among patients with SUD and housing instability. These findings underscore the importance of maintaining telehealth access for Veterans with vulnerabilities such as SUD and housing instability. SUD and housing instability should remain high priority areas for the VA, and an important focus of primary care activities. Increasing video visits in the VA will require attention to the challenges of video for Veterans with housing instability with and without SUD.