Article

A urine drug screen (UDS) is commonly performed to evaluate illicit and prescribed drug use in patients to guide treatment decisions and ensure patient safety. Common uses include evaluating medication adherence, identifying ingested substances in cases of intoxication or overdose, ruling out substance-induced disorders, and screening for illicit drug use. There is a potential for false-positive or false-negative results due to the qualitative and nonspecific nature of UDSs.¹ These results can be verified with confirmatory testing using gas chromatography/mass spectrometry or liquid chromatography/ tandem mass spectrometry by identifying specific molecular structures and quantifying the amount of drug or substance present in the sample.¹

An April 2023 memorandum instructed all US Department of Veterans Affairs (VA) medical centers and community-based outpatient clinics (CBOC) to have fentanyl urine testing readily available.² Some facilities added fentanyl to a standard UDS, while others created a separate quick order. The memorandum led to increased fentanyl testing. As a result, unexpected positive fentanyl UDS results are more common. Some facilities have an automatic fentanyl confirmation test that is ordered after a positive fentanyl UDS. However, a positive result for fentanyl on a UDS does not automatically result in confirmation testing at all VA facilities. Without automatic confirmation testing, a clinician must decide to order a fentanyl confirmation test following the positive result. Therefore, the true rate of false-positive results for fentanyl is unknown because confirmation testing is not ordered for every positive UDS.

False-positive results can have unintended consequences, including discontinuation of prescribed medications, patient stigma, and inappropriate recommendations for substance use treatment. False-positive results may contribute to unnecessary health care costs and adversely affect patients’ lives. Previous research has reported false-positive fentanyl UDS results for patients taking risperidone, ziprasidone, and labetalol.^3-5 Studies have found that loperamide and high-concentration methamphetamine samples could cause false-positive fentanyl UDS results.^6,7 Wang et al evaluated the performance of the SEFRIA fentanyl immunoassay using the 1 ng/mL cutoff cleared by the US Food and Drug Administration (FDA). The study of 410 patients found a 38% false-positive rate; concomitant use of trazodone, labetalol, and haloperidol accounted for 230 (56%) of the false-positive results.⁸ Limited data evaluating false-positive results for the current SEFRIA fentanyl testing assay suggest the need for additional research. This study aims to add to data on false-positive results for fentanyl on UDS samples and potential causes.

Methods

A retrospective, multicenter observational cohort study was conducted that included patients at 3 VA MidSouth Healthcare Network VA medical centers located in Tennessee with their associated CBOCs from August 1, 2023, to August 1, 2024 who had positive fentanyl UDS results. The primary outcome was the rate of false-positive fentanyl UDS results when confirmation testing was performed. Secondary outcomes included the rate of confirmation testing, prescribed medications used by patients with false-positive UDS results, and the rate of follow-up in the electronic health record (EHR) on results of confirmation testing. Confirmations were primarily obtained for positive results and not all UDSs. Therefore, it was not possible in this retrospective study to obtain the true measure of false-negative or true-negative results.

A structured query language query was performed to identify patients with a UDS positive for fentanyl from August 1, 2023, to August 1, 2024. Patients were enrolled if they were aged ≥ 18 years with a UDS positive for fentanyl. Patients were excluded from the primary outcome analysis if results for the confirmatory testing were unquantifiable or could not be found.

Study Intervention

This was a descriptive study with no comparator group. The rate of confirmed false-positive results for fentanyl, rate of confirmation testing for patients with positive fentanyl UDS results, rate of follow-up on confirmation results, and prescribed medications in patients with false-positive fentanyl results were evaluated. For true-positive results, follow-up was defined as documentation in the EHR reporting fentanyl use or illicit substance use likely to be laced with fentanyl at the time of the UDS or documentation of the confirmation result. For false-positive results, follow-up was defined as documentation in the EHR of the confirmation result.

Statistical Analysis

Descriptive statistics including means and percentages were used to analyze demographic data. Continuous variables and parametric data are presented as mean (SD) and nominal data as percentages. All statistical analyses were completed using Excel. The SEFRIA fentanyl immunoassay was used at each study site. Facilities 1 and 2 were combined for the primary outcome analysis because they used the same fentanyl immunoassay cutoff level of 1 ng/mL. Facility 3 used a cutoff level of 2 ng/mL and was analyzed separately.

Results

A total of 1228 UDS tests were positive for fentanyl, including 618 at facility 1, 308 at facility 2, and 302 at facility 3 (Figure 1). Patients were predominantly male and White, with a mean age of 55 years, though age and race varied by location (Table 1). Patients may have had ≥ 1 UDS. Of 1228 UDSs recorded in the EHR, 578 were sent for confirmation testing and 546 had confirmation results available in the EHR (84 at facility 1, 271 at facility 2, and 191 at facility 3). Of 546 confirmation tests, 186 were negative for fentanyl, indicating a false-positive rate of 34.1%. Most confirmation tests (43%) were requested for patients seen in a mental health clinic.

The combined false-positive rate was 49.9% for 355 UDS confirmation results at facilities 1 and 2 (70.2% and 43.5%, respectively) and 4.7% for 191 UDS confirmation results at facility 3, which used the higher 2 ng/mL cutoff level (Figure 2). Confirmation testing was ordered for 578 tests (47.1%). There were 87 confirmation tests (14.1%) at facility 1, 277 tests (89.9%) at facility 2, and 214 (70.9%) at facility 3 (Figure 3). Follow-up after confirmation tests was completed for 406 patients (74.4%): 56 follow-ups (66.7%) at facility 1, 190 follow-ups (70.1%) at facility 2, and 160 follow-ups (83.8%) at facility 3 (Figure 4). Trazodone was the most commonly prescribed medication for patients with false-positive fentanyl UDS results. Trazodone was prescribed to 153 patients (82,3%), followed by 116 patients (62.4%) prescribed naloxone, 86 patients (46.2%) prescribed or with reported use of acetaminophen, 72 patients (38.7%) prescribed nicotine replacement products, and 64 patients (34.4%) prescribed omeprazole (Table 2).

Discussion

There are several factors to note when interpreting the study results. First, facilities 1 and 2 used the FDA-cleared 1 ng/mL cutoff for positive results on the SEFRIA fentanyl immunoassay, whereas facility 3 used a cutoff level of 2 ng/mL. Second, during the study period, facilities 1 and 3 included fentanyl as part of their standard UDS; facility 2 required a separate fentanyl UDS order. Third, facility 2 had automatic confirmation testing for positive results on individually ordered fentanyl UDS tests. Finally, confirmation tests were primarily obtained for positive fentanyl results and not all UDSs, which limited the analyses that could be performed.

This study found a high rate of false-positive fentanyl UDS results at facilities 1 and 2 and a very low rate at facility 3, likely due to the higher cutoff level. Facility 3 used the higher cutoff level due to previously observed high rates of false-positive results. While a higher cutoff level can decrease the rate of false-positive results, it also may increase the rate of false-negative results.

Studies have found false-positive rates ranging from 3% to 45% with the SEFRIA immunoassay FDA-cleared 1 ng/mL cutoff. Increasing the cutoff to 1.3 ng/mL decreased the false-positive rate from 38% to 7.5% in a study by Wang et al.^8-11 Manar et al evaluated fentanyl assays in 42 samples using a 2 ng/mL cutoff for the SEFRIA assay and reported a false-positive rate of 0 and a false-negative rate of 22.5%.¹² Given the high rate of false-positive rates demonstrated in studies using the current FDA-recommended 1 ng/mL cutoff, additional studies evaluating different cutoff levels may be beneficial to determine the best cutoff level to reduce false-positive results without significantly increasing false-negative rates. While data on the impact of using a higher cutoff level are limited, the results of our study have led to discussions at VA MidSouth Healthcare Network facilities regarding use of different cutoff levels.

There was a low rate of confirmation testing at facility 1 compared with facilities 2 and 3. Only facility 2 had automatic confirmation testing during the study period. Pharmacists at facility 3 reviewed UDS results without needing a consultation and, during the study period, could order fentanyl UDS confirmations. Another factor that may have contributed to the disparity in confirmation testing between facilities is the location of the UDS order. Most UDS samples at facilities 2 and 3 were ordered for patients seen in mental health clinics, whereas many facility 1 orders were placed in primary care or the emergency department (ED).

Given these results, education may be indicated regarding the risk of false-positive results and the importance of confirmation testing in primary care and the ED. Facility 1 and 3 did not have automatic fentanyl confirmation testing during the study; however, facility 3 implemented automatic confirmation shortly after the study period and facility 1 implemented automatic confirmation testing for a positive fentanyl UDS result after evaluation of the study data.

Although follow-up on confirmation UDS results was fairly high, it was highest at facility 3, which does not require a consultation for pharmacist UDS result evaluations. Given the high rate of false-positive results for fentanyl, confirmation testing for a positive UDS and follow-up on confirmation results is an important step to consider. The higher rate of follow-up at the facility where pharmacists had more autonomous involvement shows the benefits of having pharmacists provide comprehensive patient care. Implementing similar protocols across all facilities may improve follow-up, which may improve patient care and safety given the implications of false-positive results.

Trazodone was prescribed in 82.3% of all patients with false-positive fentanyl tests. Even at facility 3, with the higher fentanyl immunoassay cutoff level, trazodone was prescribed in 77.8% of patients with false-positive results. While this retrospective study does not show causation, it does align with the findings reported by Wang et al, adding to the data implicating trazodone as a potential cause for false-positive fentanyl UDS results. The high incidence of trazodone prescriptions in patients with false-positive UDS results at facility 3 strengthens this association, indicating that even when using a higher cutoff level, trazodone may be implicated.

While there was a high rate of confirmed false-positive results in this study, there was also a potential for undetected true-positive results. The SEFRIA fentanyl immunoassay is sensitive to multiple fentanyl analogues. Williams et al showed that the SEFRIA immunoassay detected 57 of 58 fentanyl analogues tested; norsufentanil was the only analogue it did not detect.¹³ Most of the confirmatory tests reviewed during this study did not include all fentanyl analogues, only fentanyl and norfentanyl. Given the increased prevalence of synthetic fentanyl analogues, this is an important consideration because some identified false-positive results could potentially be undetected true-positive results for a fentanyl analogue. Switching to a more comprehensive confirmation test that includes more fentanyl analogues may reduce the risk of undetected positive results and, therefore, reduce the observed rate of false-positive UDS results.

Strengths and Limitations

Patient medications were only identified if they were documented in the EHR at the time of UDS results, which could have missed over-the-counter medications or medications prescribed outside the VA; this limits identification and implication of medications as possibly contributing to false-positive results. Only samples sent for confirmation were evaluated for true- or false-positive results; therefore, the true rate of false-positive results could not be determined. UDS confirmation tests only analyzed for fentanyl and norfentanyl, which left the potential for undetected true-positive results for other fentanyl analogues. Use of EHR data for the analysis leaves the potential for documentation errors and undetected bias.

This study adds to limited data on false-positive results for fentanyl on UDS samples. It included a large sample size of patients across multiple sites. Additionally, it included results using multiple cutoff levels on the SEFRIA fentanyl immunoassay, adding to limited data in this area.

Conclusions

This retrospective study found evidence that automatic confirmation testing should be considered for positive fentanyl UDS tests due to the high rate of false-positive results. Facility 1 began automatic confirmation testing due to the findings of this study. Facilities should consider switching to a more comprehensive confirmation test that includes more fentanyl analogues to reduce the risk of undetected true-positive results. This study also adds to the data implicating trazodone in fentanyl UDS false-positive results due to high incidence of trazodone prescriptions among patients in the study with false-positive UDS results. Future considerations include investigating different cutoff levels for the SEFRIA fentanyl immunoassay to reduce false-positive results as data are currently limited.

A urine drug screen (UDS) is commonly performed to evaluate illicit and prescribed drug use in patients to guide treatment decisions and ensure patient safety. Common uses include evaluating medication adherence, identifying ingested substances in cases of intoxication or overdose, ruling out substance-induced disorders, and screening for illicit drug use. There is a potential for false-positive or false-negative results due to the qualitative and nonspecific nature of UDSs.¹ These results can be verified with confirmatory testing using gas chromatography/mass spectrometry or liquid chromatography/ tandem mass spectrometry by identifying specific molecular structures and quantifying the amount of drug or substance present in the sample.¹

An April 2023 memorandum instructed all US Department of Veterans Affairs (VA) medical centers and community-based outpatient clinics (CBOC) to have fentanyl urine testing readily available.² Some facilities added fentanyl to a standard UDS, while others created a separate quick order. The memorandum led to increased fentanyl testing. As a result, unexpected positive fentanyl UDS results are more common. Some facilities have an automatic fentanyl confirmation test that is ordered after a positive fentanyl UDS. However, a positive result for fentanyl on a UDS does not automatically result in confirmation testing at all VA facilities. Without automatic confirmation testing, a clinician must decide to order a fentanyl confirmation test following the positive result. Therefore, the true rate of false-positive results for fentanyl is unknown because confirmation testing is not ordered for every positive UDS.

False-positive results can have unintended consequences, including discontinuation of prescribed medications, patient stigma, and inappropriate recommendations for substance use treatment. False-positive results may contribute to unnecessary health care costs and adversely affect patients’ lives. Previous research has reported false-positive fentanyl UDS results for patients taking risperidone, ziprasidone, and labetalol.^3-5 Studies have found that loperamide and high-concentration methamphetamine samples could cause false-positive fentanyl UDS results.^6,7 Wang et al evaluated the performance of the SEFRIA fentanyl immunoassay using the 1 ng/mL cutoff cleared by the US Food and Drug Administration (FDA). The study of 410 patients found a 38% false-positive rate; concomitant use of trazodone, labetalol, and haloperidol accounted for 230 (56%) of the false-positive results.⁸ Limited data evaluating false-positive results for the current SEFRIA fentanyl testing assay suggest the need for additional research. This study aims to add to data on false-positive results for fentanyl on UDS samples and potential causes.

Methods

A retrospective, multicenter observational cohort study was conducted that included patients at 3 VA MidSouth Healthcare Network VA medical centers located in Tennessee with their associated CBOCs from August 1, 2023, to August 1, 2024 who had positive fentanyl UDS results. The primary outcome was the rate of false-positive fentanyl UDS results when confirmation testing was performed. Secondary outcomes included the rate of confirmation testing, prescribed medications used by patients with false-positive UDS results, and the rate of follow-up in the electronic health record (EHR) on results of confirmation testing. Confirmations were primarily obtained for positive results and not all UDSs. Therefore, it was not possible in this retrospective study to obtain the true measure of false-negative or true-negative results.

A structured query language query was performed to identify patients with a UDS positive for fentanyl from August 1, 2023, to August 1, 2024. Patients were enrolled if they were aged ≥ 18 years with a UDS positive for fentanyl. Patients were excluded from the primary outcome analysis if results for the confirmatory testing were unquantifiable or could not be found.

Study Intervention

This was a descriptive study with no comparator group. The rate of confirmed false-positive results for fentanyl, rate of confirmation testing for patients with positive fentanyl UDS results, rate of follow-up on confirmation results, and prescribed medications in patients with false-positive fentanyl results were evaluated. For true-positive results, follow-up was defined as documentation in the EHR reporting fentanyl use or illicit substance use likely to be laced with fentanyl at the time of the UDS or documentation of the confirmation result. For false-positive results, follow-up was defined as documentation in the EHR of the confirmation result.

Statistical Analysis

Descriptive statistics including means and percentages were used to analyze demographic data. Continuous variables and parametric data are presented as mean (SD) and nominal data as percentages. All statistical analyses were completed using Excel. The SEFRIA fentanyl immunoassay was used at each study site. Facilities 1 and 2 were combined for the primary outcome analysis because they used the same fentanyl immunoassay cutoff level of 1 ng/mL. Facility 3 used a cutoff level of 2 ng/mL and was analyzed separately.

Results

A total of 1228 UDS tests were positive for fentanyl, including 618 at facility 1, 308 at facility 2, and 302 at facility 3 (Figure 1). Patients were predominantly male and White, with a mean age of 55 years, though age and race varied by location (Table 1). Patients may have had ≥ 1 UDS. Of 1228 UDSs recorded in the EHR, 578 were sent for confirmation testing and 546 had confirmation results available in the EHR (84 at facility 1, 271 at facility 2, and 191 at facility 3). Of 546 confirmation tests, 186 were negative for fentanyl, indicating a false-positive rate of 34.1%. Most confirmation tests (43%) were requested for patients seen in a mental health clinic.

The combined false-positive rate was 49.9% for 355 UDS confirmation results at facilities 1 and 2 (70.2% and 43.5%, respectively) and 4.7% for 191 UDS confirmation results at facility 3, which used the higher 2 ng/mL cutoff level (Figure 2). Confirmation testing was ordered for 578 tests (47.1%). There were 87 confirmation tests (14.1%) at facility 1, 277 tests (89.9%) at facility 2, and 214 (70.9%) at facility 3 (Figure 3). Follow-up after confirmation tests was completed for 406 patients (74.4%): 56 follow-ups (66.7%) at facility 1, 190 follow-ups (70.1%) at facility 2, and 160 follow-ups (83.8%) at facility 3 (Figure 4). Trazodone was the most commonly prescribed medication for patients with false-positive fentanyl UDS results. Trazodone was prescribed to 153 patients (82,3%), followed by 116 patients (62.4%) prescribed naloxone, 86 patients (46.2%) prescribed or with reported use of acetaminophen, 72 patients (38.7%) prescribed nicotine replacement products, and 64 patients (34.4%) prescribed omeprazole (Table 2).

Discussion

There are several factors to note when interpreting the study results. First, facilities 1 and 2 used the FDA-cleared 1 ng/mL cutoff for positive results on the SEFRIA fentanyl immunoassay, whereas facility 3 used a cutoff level of 2 ng/mL. Second, during the study period, facilities 1 and 3 included fentanyl as part of their standard UDS; facility 2 required a separate fentanyl UDS order. Third, facility 2 had automatic confirmation testing for positive results on individually ordered fentanyl UDS tests. Finally, confirmation tests were primarily obtained for positive fentanyl results and not all UDSs, which limited the analyses that could be performed.

This study found a high rate of false-positive fentanyl UDS results at facilities 1 and 2 and a very low rate at facility 3, likely due to the higher cutoff level. Facility 3 used the higher cutoff level due to previously observed high rates of false-positive results. While a higher cutoff level can decrease the rate of false-positive results, it also may increase the rate of false-negative results.

Studies have found false-positive rates ranging from 3% to 45% with the SEFRIA immunoassay FDA-cleared 1 ng/mL cutoff. Increasing the cutoff to 1.3 ng/mL decreased the false-positive rate from 38% to 7.5% in a study by Wang et al.^8-11 Manar et al evaluated fentanyl assays in 42 samples using a 2 ng/mL cutoff for the SEFRIA assay and reported a false-positive rate of 0 and a false-negative rate of 22.5%.¹² Given the high rate of false-positive rates demonstrated in studies using the current FDA-recommended 1 ng/mL cutoff, additional studies evaluating different cutoff levels may be beneficial to determine the best cutoff level to reduce false-positive results without significantly increasing false-negative rates. While data on the impact of using a higher cutoff level are limited, the results of our study have led to discussions at VA MidSouth Healthcare Network facilities regarding use of different cutoff levels.

There was a low rate of confirmation testing at facility 1 compared with facilities 2 and 3. Only facility 2 had automatic confirmation testing during the study period. Pharmacists at facility 3 reviewed UDS results without needing a consultation and, during the study period, could order fentanyl UDS confirmations. Another factor that may have contributed to the disparity in confirmation testing between facilities is the location of the UDS order. Most UDS samples at facilities 2 and 3 were ordered for patients seen in mental health clinics, whereas many facility 1 orders were placed in primary care or the emergency department (ED).

Given these results, education may be indicated regarding the risk of false-positive results and the importance of confirmation testing in primary care and the ED. Facility 1 and 3 did not have automatic fentanyl confirmation testing during the study; however, facility 3 implemented automatic confirmation shortly after the study period and facility 1 implemented automatic confirmation testing for a positive fentanyl UDS result after evaluation of the study data.

Although follow-up on confirmation UDS results was fairly high, it was highest at facility 3, which does not require a consultation for pharmacist UDS result evaluations. Given the high rate of false-positive results for fentanyl, confirmation testing for a positive UDS and follow-up on confirmation results is an important step to consider. The higher rate of follow-up at the facility where pharmacists had more autonomous involvement shows the benefits of having pharmacists provide comprehensive patient care. Implementing similar protocols across all facilities may improve follow-up, which may improve patient care and safety given the implications of false-positive results.

Trazodone was prescribed in 82.3% of all patients with false-positive fentanyl tests. Even at facility 3, with the higher fentanyl immunoassay cutoff level, trazodone was prescribed in 77.8% of patients with false-positive results. While this retrospective study does not show causation, it does align with the findings reported by Wang et al, adding to the data implicating trazodone as a potential cause for false-positive fentanyl UDS results. The high incidence of trazodone prescriptions in patients with false-positive UDS results at facility 3 strengthens this association, indicating that even when using a higher cutoff level, trazodone may be implicated.

While there was a high rate of confirmed false-positive results in this study, there was also a potential for undetected true-positive results. The SEFRIA fentanyl immunoassay is sensitive to multiple fentanyl analogues. Williams et al showed that the SEFRIA immunoassay detected 57 of 58 fentanyl analogues tested; norsufentanil was the only analogue it did not detect.¹³ Most of the confirmatory tests reviewed during this study did not include all fentanyl analogues, only fentanyl and norfentanyl. Given the increased prevalence of synthetic fentanyl analogues, this is an important consideration because some identified false-positive results could potentially be undetected true-positive results for a fentanyl analogue. Switching to a more comprehensive confirmation test that includes more fentanyl analogues may reduce the risk of undetected positive results and, therefore, reduce the observed rate of false-positive UDS results.

Strengths and Limitations

Patient medications were only identified if they were documented in the EHR at the time of UDS results, which could have missed over-the-counter medications or medications prescribed outside the VA; this limits identification and implication of medications as possibly contributing to false-positive results. Only samples sent for confirmation were evaluated for true- or false-positive results; therefore, the true rate of false-positive results could not be determined. UDS confirmation tests only analyzed for fentanyl and norfentanyl, which left the potential for undetected true-positive results for other fentanyl analogues. Use of EHR data for the analysis leaves the potential for documentation errors and undetected bias.

This study adds to limited data on false-positive results for fentanyl on UDS samples. It included a large sample size of patients across multiple sites. Additionally, it included results using multiple cutoff levels on the SEFRIA fentanyl immunoassay, adding to limited data in this area.

Conclusions

This retrospective study found evidence that automatic confirmation testing should be considered for positive fentanyl UDS tests due to the high rate of false-positive results. Facility 1 began automatic confirmation testing due to the findings of this study. Facilities should consider switching to a more comprehensive confirmation test that includes more fentanyl analogues to reduce the risk of undetected true-positive results. This study also adds to the data implicating trazodone in fentanyl UDS false-positive results due to high incidence of trazodone prescriptions among patients in the study with false-positive UDS results. Future considerations include investigating different cutoff levels for the SEFRIA fentanyl immunoassay to reduce false-positive results as data are currently limited.

A urine drug screen (UDS) is commonly performed to evaluate illicit and prescribed drug use in patients to guide treatment decisions and ensure patient safety. Common uses include evaluating medication adherence, identifying ingested substances in cases of intoxication or overdose, ruling out substance-induced disorders, and screening for illicit drug use. There is a potential for false-positive or false-negative results due to the qualitative and nonspecific nature of UDSs.¹ These results can be verified with confirmatory testing using gas chromatography/mass spectrometry or liquid chromatography/ tandem mass spectrometry by identifying specific molecular structures and quantifying the amount of drug or substance present in the sample.¹

An April 2023 memorandum instructed all US Department of Veterans Affairs (VA) medical centers and community-based outpatient clinics (CBOC) to have fentanyl urine testing readily available.² Some facilities added fentanyl to a standard UDS, while others created a separate quick order. The memorandum led to increased fentanyl testing. As a result, unexpected positive fentanyl UDS results are more common. Some facilities have an automatic fentanyl confirmation test that is ordered after a positive fentanyl UDS. However, a positive result for fentanyl on a UDS does not automatically result in confirmation testing at all VA facilities. Without automatic confirmation testing, a clinician must decide to order a fentanyl confirmation test following the positive result. Therefore, the true rate of false-positive results for fentanyl is unknown because confirmation testing is not ordered for every positive UDS.

False-positive results can have unintended consequences, including discontinuation of prescribed medications, patient stigma, and inappropriate recommendations for substance use treatment. False-positive results may contribute to unnecessary health care costs and adversely affect patients’ lives. Previous research has reported false-positive fentanyl UDS results for patients taking risperidone, ziprasidone, and labetalol.^3-5 Studies have found that loperamide and high-concentration methamphetamine samples could cause false-positive fentanyl UDS results.^6,7 Wang et al evaluated the performance of the SEFRIA fentanyl immunoassay using the 1 ng/mL cutoff cleared by the US Food and Drug Administration (FDA). The study of 410 patients found a 38% false-positive rate; concomitant use of trazodone, labetalol, and haloperidol accounted for 230 (56%) of the false-positive results.⁸ Limited data evaluating false-positive results for the current SEFRIA fentanyl testing assay suggest the need for additional research. This study aims to add to data on false-positive results for fentanyl on UDS samples and potential causes.

Methods

A retrospective, multicenter observational cohort study was conducted that included patients at 3 VA MidSouth Healthcare Network VA medical centers located in Tennessee with their associated CBOCs from August 1, 2023, to August 1, 2024 who had positive fentanyl UDS results. The primary outcome was the rate of false-positive fentanyl UDS results when confirmation testing was performed. Secondary outcomes included the rate of confirmation testing, prescribed medications used by patients with false-positive UDS results, and the rate of follow-up in the electronic health record (EHR) on results of confirmation testing. Confirmations were primarily obtained for positive results and not all UDSs. Therefore, it was not possible in this retrospective study to obtain the true measure of false-negative or true-negative results.

A structured query language query was performed to identify patients with a UDS positive for fentanyl from August 1, 2023, to August 1, 2024. Patients were enrolled if they were aged ≥ 18 years with a UDS positive for fentanyl. Patients were excluded from the primary outcome analysis if results for the confirmatory testing were unquantifiable or could not be found.

Study Intervention

This was a descriptive study with no comparator group. The rate of confirmed false-positive results for fentanyl, rate of confirmation testing for patients with positive fentanyl UDS results, rate of follow-up on confirmation results, and prescribed medications in patients with false-positive fentanyl results were evaluated. For true-positive results, follow-up was defined as documentation in the EHR reporting fentanyl use or illicit substance use likely to be laced with fentanyl at the time of the UDS or documentation of the confirmation result. For false-positive results, follow-up was defined as documentation in the EHR of the confirmation result.

Statistical Analysis

Descriptive statistics including means and percentages were used to analyze demographic data. Continuous variables and parametric data are presented as mean (SD) and nominal data as percentages. All statistical analyses were completed using Excel. The SEFRIA fentanyl immunoassay was used at each study site. Facilities 1 and 2 were combined for the primary outcome analysis because they used the same fentanyl immunoassay cutoff level of 1 ng/mL. Facility 3 used a cutoff level of 2 ng/mL and was analyzed separately.

Results

A total of 1228 UDS tests were positive for fentanyl, including 618 at facility 1, 308 at facility 2, and 302 at facility 3 (Figure 1). Patients were predominantly male and White, with a mean age of 55 years, though age and race varied by location (Table 1). Patients may have had ≥ 1 UDS. Of 1228 UDSs recorded in the EHR, 578 were sent for confirmation testing and 546 had confirmation results available in the EHR (84 at facility 1, 271 at facility 2, and 191 at facility 3). Of 546 confirmation tests, 186 were negative for fentanyl, indicating a false-positive rate of 34.1%. Most confirmation tests (43%) were requested for patients seen in a mental health clinic.

The combined false-positive rate was 49.9% for 355 UDS confirmation results at facilities 1 and 2 (70.2% and 43.5%, respectively) and 4.7% for 191 UDS confirmation results at facility 3, which used the higher 2 ng/mL cutoff level (Figure 2). Confirmation testing was ordered for 578 tests (47.1%). There were 87 confirmation tests (14.1%) at facility 1, 277 tests (89.9%) at facility 2, and 214 (70.9%) at facility 3 (Figure 3). Follow-up after confirmation tests was completed for 406 patients (74.4%): 56 follow-ups (66.7%) at facility 1, 190 follow-ups (70.1%) at facility 2, and 160 follow-ups (83.8%) at facility 3 (Figure 4). Trazodone was the most commonly prescribed medication for patients with false-positive fentanyl UDS results. Trazodone was prescribed to 153 patients (82,3%), followed by 116 patients (62.4%) prescribed naloxone, 86 patients (46.2%) prescribed or with reported use of acetaminophen, 72 patients (38.7%) prescribed nicotine replacement products, and 64 patients (34.4%) prescribed omeprazole (Table 2).

Discussion

There are several factors to note when interpreting the study results. First, facilities 1 and 2 used the FDA-cleared 1 ng/mL cutoff for positive results on the SEFRIA fentanyl immunoassay, whereas facility 3 used a cutoff level of 2 ng/mL. Second, during the study period, facilities 1 and 3 included fentanyl as part of their standard UDS; facility 2 required a separate fentanyl UDS order. Third, facility 2 had automatic confirmation testing for positive results on individually ordered fentanyl UDS tests. Finally, confirmation tests were primarily obtained for positive fentanyl results and not all UDSs, which limited the analyses that could be performed.

This study found a high rate of false-positive fentanyl UDS results at facilities 1 and 2 and a very low rate at facility 3, likely due to the higher cutoff level. Facility 3 used the higher cutoff level due to previously observed high rates of false-positive results. While a higher cutoff level can decrease the rate of false-positive results, it also may increase the rate of false-negative results.

Studies have found false-positive rates ranging from 3% to 45% with the SEFRIA immunoassay FDA-cleared 1 ng/mL cutoff. Increasing the cutoff to 1.3 ng/mL decreased the false-positive rate from 38% to 7.5% in a study by Wang et al.^8-11 Manar et al evaluated fentanyl assays in 42 samples using a 2 ng/mL cutoff for the SEFRIA assay and reported a false-positive rate of 0 and a false-negative rate of 22.5%.¹² Given the high rate of false-positive rates demonstrated in studies using the current FDA-recommended 1 ng/mL cutoff, additional studies evaluating different cutoff levels may be beneficial to determine the best cutoff level to reduce false-positive results without significantly increasing false-negative rates. While data on the impact of using a higher cutoff level are limited, the results of our study have led to discussions at VA MidSouth Healthcare Network facilities regarding use of different cutoff levels.

There was a low rate of confirmation testing at facility 1 compared with facilities 2 and 3. Only facility 2 had automatic confirmation testing during the study period. Pharmacists at facility 3 reviewed UDS results without needing a consultation and, during the study period, could order fentanyl UDS confirmations. Another factor that may have contributed to the disparity in confirmation testing between facilities is the location of the UDS order. Most UDS samples at facilities 2 and 3 were ordered for patients seen in mental health clinics, whereas many facility 1 orders were placed in primary care or the emergency department (ED).

Given these results, education may be indicated regarding the risk of false-positive results and the importance of confirmation testing in primary care and the ED. Facility 1 and 3 did not have automatic fentanyl confirmation testing during the study; however, facility 3 implemented automatic confirmation shortly after the study period and facility 1 implemented automatic confirmation testing for a positive fentanyl UDS result after evaluation of the study data.

Although follow-up on confirmation UDS results was fairly high, it was highest at facility 3, which does not require a consultation for pharmacist UDS result evaluations. Given the high rate of false-positive results for fentanyl, confirmation testing for a positive UDS and follow-up on confirmation results is an important step to consider. The higher rate of follow-up at the facility where pharmacists had more autonomous involvement shows the benefits of having pharmacists provide comprehensive patient care. Implementing similar protocols across all facilities may improve follow-up, which may improve patient care and safety given the implications of false-positive results.

Trazodone was prescribed in 82.3% of all patients with false-positive fentanyl tests. Even at facility 3, with the higher fentanyl immunoassay cutoff level, trazodone was prescribed in 77.8% of patients with false-positive results. While this retrospective study does not show causation, it does align with the findings reported by Wang et al, adding to the data implicating trazodone as a potential cause for false-positive fentanyl UDS results. The high incidence of trazodone prescriptions in patients with false-positive UDS results at facility 3 strengthens this association, indicating that even when using a higher cutoff level, trazodone may be implicated.

While there was a high rate of confirmed false-positive results in this study, there was also a potential for undetected true-positive results. The SEFRIA fentanyl immunoassay is sensitive to multiple fentanyl analogues. Williams et al showed that the SEFRIA immunoassay detected 57 of 58 fentanyl analogues tested; norsufentanil was the only analogue it did not detect.¹³ Most of the confirmatory tests reviewed during this study did not include all fentanyl analogues, only fentanyl and norfentanyl. Given the increased prevalence of synthetic fentanyl analogues, this is an important consideration because some identified false-positive results could potentially be undetected true-positive results for a fentanyl analogue. Switching to a more comprehensive confirmation test that includes more fentanyl analogues may reduce the risk of undetected positive results and, therefore, reduce the observed rate of false-positive UDS results.

Strengths and Limitations

Patient medications were only identified if they were documented in the EHR at the time of UDS results, which could have missed over-the-counter medications or medications prescribed outside the VA; this limits identification and implication of medications as possibly contributing to false-positive results. Only samples sent for confirmation were evaluated for true- or false-positive results; therefore, the true rate of false-positive results could not be determined. UDS confirmation tests only analyzed for fentanyl and norfentanyl, which left the potential for undetected true-positive results for other fentanyl analogues. Use of EHR data for the analysis leaves the potential for documentation errors and undetected bias.

This study adds to limited data on false-positive results for fentanyl on UDS samples. It included a large sample size of patients across multiple sites. Additionally, it included results using multiple cutoff levels on the SEFRIA fentanyl immunoassay, adding to limited data in this area.

Conclusions

This retrospective study found evidence that automatic confirmation testing should be considered for positive fentanyl UDS tests due to the high rate of false-positive results. Facility 1 began automatic confirmation testing due to the findings of this study. Facilities should consider switching to a more comprehensive confirmation test that includes more fentanyl analogues to reduce the risk of undetected true-positive results. This study also adds to the data implicating trazodone in fentanyl UDS false-positive results due to high incidence of trazodone prescriptions among patients in the study with false-positive UDS results. Future considerations include investigating different cutoff levels for the SEFRIA fentanyl immunoassay to reduce false-positive results as data are currently limited.

The US Department of Veterans Affairs (VA) mission realizes President Abraham Lincoln’s promise to “to care for him who shall have borne the battle, and for his widow, and his orphan.”¹ Evidence-based care fulfills this promise and is the backbone of Veterans Health Administration (VHA) mental health care.^2,3 To ensure veterans receive state-of-the-art clinical care, a skilled workforce and investment in data-driven approaches are necessary to identify best treatments and strategies to implement them in practice.

Through scientific and clinical training tailored to VA, the 23 VA Advanced Fellowships have secured a steady flow of highly trained PhD professionals (ie, psychologists and other allied health professionals), and medical doctors (ie, psychiatrists and neurologists) into the VA workforce.⁴ The VA Advanced Fellows are funded by the Office of Academic Affiliations (OAA) and offer 2-year training opportunities for postresidency MDs and postdoctoral PhDs. This article describes a VA Advanced Fellowship in mental health as an example of how these programs can have a broad and positive impact on the VA health care system.

Advanced Fellows Program

The VA Advanced Fellowship in Mental Illness Research and Treatment (AF MIRT), formerly known as the VA Special Fellowship Program in Advanced Psychiatry and Psychology, educates and trains clinician and nonclinician researchers to meet VA priority mental health care needs.⁵ Clinical AF MIRT fellows dedicate 75% of their time to training and research activities and 25% to direct clinical services. Data science fellows complete projects that inform veteran clinical care through qualitative data collection, program evaluation, and analysis of large datasets. The full translational pathway to evidence-based clinical care is represented by fellow research spanning basic animal models, genetics, and neuroimaging to implementation science and applied clinical care for veterans.

In 2025, AF MIRT marked its 25th year of training postdoctoral-level mental health scientific practitioners and scholars. This investment in clinical research training has had profound benefits for innovation and retention of clinicians and scientists within the VA system. As of April 1, 2026, AF MIRT trained 700 fellows, including 152 MD or MD/PhD fellows, 544 PhD or PsyD fellows, 3 PharmDs fellows, and 1 doctor of nursing practice fellow.

Fellowship Structure

The AF MIRT coordinating center provides key administrative support to fellowship site directors and topical didactic training to Advanced Fellows, ensuring consistent standard of quality training across locations in 15 states and 4 times zones. The training provided by the AF MIRT coordinating center deepens the nationally-mandated focus of local translational clinical centers (eg, Mental Illness Research Education and Clinical Centers, Centers of Excellence) on posttraumatic stress disorder (PTSD), serious mental illness, dementia, and other areas.

The AF MIRT coordinating center also promotes VA workforce sustainability. Advanced Fellows in programs with a coordinating center are much more likely to be retained in VA for postfellowship employment compared with fellows in programs without such a coordinating center (60% vs 38%) according to unpublished Office of Academic Affiliations data (Joel Schmidt, oral communication, May 15, 2025). The AF MIRT coordinating center provides central standardization and uses evidence-based approaches to ensure fellows receive consistent support, resources, and training. More specifically, the coordinating center develops and delivers a standardized, core curriculum to the program’s 28 sites. The program pioneered video delivery of integrated didactics that enlist national experts, many of them VA researchers and clinicians themselves. Didactics include high priority veteran mental health topics, such as suicide prevention, new and emerging evidence-based treatments (eg, neurostimulation for treatment resistant PTSD, psychotherapeutic approaches for traumatic brain injury), and VA health system considerations for mental health treatment delivery.

This curated didactic series also covers professional and technical issues, such as statistical and methodological considerations for clinical trials, scientific writing, and grant-writing skill development. These offerings support the career pathways of advanced fellows to pursue careers as researchers, scientifically-informed clinicians, or data scientists at VA or academic medical centers. The coordinating center prepares fellows to apply for mentored career award funding or independent investigator awards through the VA, National Institutes of Health (NIH), US Department of Defense, and other organizations by offering an annual mock grant review session and monthly reviews and discussions of fellows’ grant applications.

AF MIRT continuously fine tunes the didactic series curriculum based on feedback from fellows on how the program meets their training needs. For example, learning about the strategies Advanced Fellows used to remain productive during COVID-19 pandemic lockdowns revealed a strong trend toward use of secondary data (eg, publicly available data or VA electronic health record data). This fueled curriculum adjustments to include more topics relevant to fellow interests and needs for accessing secondary data resources for high priority veteran mental health topics.⁶

VA Advanced Fellowships Successes

From July 2020 to June 2025, MIRT advanced fellows published 906 peer-reviewed articles in psychiatry, psychology, and other disciplines. Each year, about 20 to 25 articles are published in high-impact journals. In this 5-year period, fellows have received 153 grants (114 VA grants) as principal investigators– many examining new innovations to improve the quality of care of veterans. Of the 165 fellows who graduated since 2020, 63% continued working in veteran health care: 38% transitioned to full-time VA employment and 25% moved to VA employment with an academic-affiliated role. Nineteen percent transitioned to academic positions, 12% transitioned to the private sector, and 5% transitioned to other government, industry, or nonprofit employment where these professionals contribute to scientific and clinical innovation benefiting the US public; 1% did not provide postfellowship employment information. The Figure displays geographic locations of graduated fellows’ postfellowship employment from July 2020 to June 2025.

The accomplishments of fellows are wide-ranging and aligned with VA’s mission. Each year, roughly 15 fellows receive new investigator awards, travel awards, and poster or presentation awards from prominent professional societies. Fellows have obtained VA Career Development Awards in diverse topics, including suicide prevention through clinician resources and training programs, firearm safety discussions, digital phenotyping and neuroimaging to enhance social integration in veterans with schizophrenia, rapid transcranial magnetic stimulation to treat nicotine use and PTSD, and evidence-based psychotherapy techniques for female veterans experiencing issues in menopause.

Several recent MIRT fellows have also received highly competitive NIH K Career Development Awards. One notable example is a fellow who studied pharmacologic approaches for treatment-resistant depression informed by novel brain circuit findings, first testing these approaches in community samples through a NIH K grant and translating findings to veterans. Fellows have gone on to become directors of important national research centers and studies, chairs of academic departments, and presidents of national medical organizations. Importantly, many MIRT fellows have become local directors and mentors to a new generation of VA fellows and researchers.

Conclusions

The AF MIRT coordinating center supports the VA’s mission of fulfilling President Lincoln’s promise to care for veterans. There are multiple benefits to evidence-based work that helps veterans and fosters a highly skilled VA workforce. Veterans are at the center of the MIRT data-driven approach, which is critical given their complex needs. Approaches to building the AF MIRT’s evidence base include randomized controlled trials open to veteran participants; program evaluation of current local, regional, or national VHA clinical services through measurement-based care and evaluation of national clinician training programs; and even smaller quality improvement projects in local VA clinics. These efforts support effective, efficient, and accessible provision of treatments that benefit veterans.

The US Department of Veterans Affairs (VA) mission realizes President Abraham Lincoln’s promise to “to care for him who shall have borne the battle, and for his widow, and his orphan.”¹ Evidence-based care fulfills this promise and is the backbone of Veterans Health Administration (VHA) mental health care.^2,3 To ensure veterans receive state-of-the-art clinical care, a skilled workforce and investment in data-driven approaches are necessary to identify best treatments and strategies to implement them in practice.

Through scientific and clinical training tailored to VA, the 23 VA Advanced Fellowships have secured a steady flow of highly trained PhD professionals (ie, psychologists and other allied health professionals), and medical doctors (ie, psychiatrists and neurologists) into the VA workforce.⁴ The VA Advanced Fellows are funded by the Office of Academic Affiliations (OAA) and offer 2-year training opportunities for postresidency MDs and postdoctoral PhDs. This article describes a VA Advanced Fellowship in mental health as an example of how these programs can have a broad and positive impact on the VA health care system.

Advanced Fellows Program

The VA Advanced Fellowship in Mental Illness Research and Treatment (AF MIRT), formerly known as the VA Special Fellowship Program in Advanced Psychiatry and Psychology, educates and trains clinician and nonclinician researchers to meet VA priority mental health care needs.⁵ Clinical AF MIRT fellows dedicate 75% of their time to training and research activities and 25% to direct clinical services. Data science fellows complete projects that inform veteran clinical care through qualitative data collection, program evaluation, and analysis of large datasets. The full translational pathway to evidence-based clinical care is represented by fellow research spanning basic animal models, genetics, and neuroimaging to implementation science and applied clinical care for veterans.

In 2025, AF MIRT marked its 25th year of training postdoctoral-level mental health scientific practitioners and scholars. This investment in clinical research training has had profound benefits for innovation and retention of clinicians and scientists within the VA system. As of April 1, 2026, AF MIRT trained 700 fellows, including 152 MD or MD/PhD fellows, 544 PhD or PsyD fellows, 3 PharmDs fellows, and 1 doctor of nursing practice fellow.

Fellowship Structure

The AF MIRT coordinating center provides key administrative support to fellowship site directors and topical didactic training to Advanced Fellows, ensuring consistent standard of quality training across locations in 15 states and 4 times zones. The training provided by the AF MIRT coordinating center deepens the nationally-mandated focus of local translational clinical centers (eg, Mental Illness Research Education and Clinical Centers, Centers of Excellence) on posttraumatic stress disorder (PTSD), serious mental illness, dementia, and other areas.

The AF MIRT coordinating center also promotes VA workforce sustainability. Advanced Fellows in programs with a coordinating center are much more likely to be retained in VA for postfellowship employment compared with fellows in programs without such a coordinating center (60% vs 38%) according to unpublished Office of Academic Affiliations data (Joel Schmidt, oral communication, May 15, 2025). The AF MIRT coordinating center provides central standardization and uses evidence-based approaches to ensure fellows receive consistent support, resources, and training. More specifically, the coordinating center develops and delivers a standardized, core curriculum to the program’s 28 sites. The program pioneered video delivery of integrated didactics that enlist national experts, many of them VA researchers and clinicians themselves. Didactics include high priority veteran mental health topics, such as suicide prevention, new and emerging evidence-based treatments (eg, neurostimulation for treatment resistant PTSD, psychotherapeutic approaches for traumatic brain injury), and VA health system considerations for mental health treatment delivery.

This curated didactic series also covers professional and technical issues, such as statistical and methodological considerations for clinical trials, scientific writing, and grant-writing skill development. These offerings support the career pathways of advanced fellows to pursue careers as researchers, scientifically-informed clinicians, or data scientists at VA or academic medical centers. The coordinating center prepares fellows to apply for mentored career award funding or independent investigator awards through the VA, National Institutes of Health (NIH), US Department of Defense, and other organizations by offering an annual mock grant review session and monthly reviews and discussions of fellows’ grant applications.

AF MIRT continuously fine tunes the didactic series curriculum based on feedback from fellows on how the program meets their training needs. For example, learning about the strategies Advanced Fellows used to remain productive during COVID-19 pandemic lockdowns revealed a strong trend toward use of secondary data (eg, publicly available data or VA electronic health record data). This fueled curriculum adjustments to include more topics relevant to fellow interests and needs for accessing secondary data resources for high priority veteran mental health topics.⁶

VA Advanced Fellowships Successes

From July 2020 to June 2025, MIRT advanced fellows published 906 peer-reviewed articles in psychiatry, psychology, and other disciplines. Each year, about 20 to 25 articles are published in high-impact journals. In this 5-year period, fellows have received 153 grants (114 VA grants) as principal investigators– many examining new innovations to improve the quality of care of veterans. Of the 165 fellows who graduated since 2020, 63% continued working in veteran health care: 38% transitioned to full-time VA employment and 25% moved to VA employment with an academic-affiliated role. Nineteen percent transitioned to academic positions, 12% transitioned to the private sector, and 5% transitioned to other government, industry, or nonprofit employment where these professionals contribute to scientific and clinical innovation benefiting the US public; 1% did not provide postfellowship employment information. The Figure displays geographic locations of graduated fellows’ postfellowship employment from July 2020 to June 2025.

The accomplishments of fellows are wide-ranging and aligned with VA’s mission. Each year, roughly 15 fellows receive new investigator awards, travel awards, and poster or presentation awards from prominent professional societies. Fellows have obtained VA Career Development Awards in diverse topics, including suicide prevention through clinician resources and training programs, firearm safety discussions, digital phenotyping and neuroimaging to enhance social integration in veterans with schizophrenia, rapid transcranial magnetic stimulation to treat nicotine use and PTSD, and evidence-based psychotherapy techniques for female veterans experiencing issues in menopause.

Several recent MIRT fellows have also received highly competitive NIH K Career Development Awards. One notable example is a fellow who studied pharmacologic approaches for treatment-resistant depression informed by novel brain circuit findings, first testing these approaches in community samples through a NIH K grant and translating findings to veterans. Fellows have gone on to become directors of important national research centers and studies, chairs of academic departments, and presidents of national medical organizations. Importantly, many MIRT fellows have become local directors and mentors to a new generation of VA fellows and researchers.

Conclusions

The AF MIRT coordinating center supports the VA’s mission of fulfilling President Lincoln’s promise to care for veterans. There are multiple benefits to evidence-based work that helps veterans and fosters a highly skilled VA workforce. Veterans are at the center of the MIRT data-driven approach, which is critical given their complex needs. Approaches to building the AF MIRT’s evidence base include randomized controlled trials open to veteran participants; program evaluation of current local, regional, or national VHA clinical services through measurement-based care and evaluation of national clinician training programs; and even smaller quality improvement projects in local VA clinics. These efforts support effective, efficient, and accessible provision of treatments that benefit veterans.

The US Department of Veterans Affairs (VA) mission realizes President Abraham Lincoln’s promise to “to care for him who shall have borne the battle, and for his widow, and his orphan.”¹ Evidence-based care fulfills this promise and is the backbone of Veterans Health Administration (VHA) mental health care.^2,3 To ensure veterans receive state-of-the-art clinical care, a skilled workforce and investment in data-driven approaches are necessary to identify best treatments and strategies to implement them in practice.

Through scientific and clinical training tailored to VA, the 23 VA Advanced Fellowships have secured a steady flow of highly trained PhD professionals (ie, psychologists and other allied health professionals), and medical doctors (ie, psychiatrists and neurologists) into the VA workforce.⁴ The VA Advanced Fellows are funded by the Office of Academic Affiliations (OAA) and offer 2-year training opportunities for postresidency MDs and postdoctoral PhDs. This article describes a VA Advanced Fellowship in mental health as an example of how these programs can have a broad and positive impact on the VA health care system.

Advanced Fellows Program

The VA Advanced Fellowship in Mental Illness Research and Treatment (AF MIRT), formerly known as the VA Special Fellowship Program in Advanced Psychiatry and Psychology, educates and trains clinician and nonclinician researchers to meet VA priority mental health care needs.⁵ Clinical AF MIRT fellows dedicate 75% of their time to training and research activities and 25% to direct clinical services. Data science fellows complete projects that inform veteran clinical care through qualitative data collection, program evaluation, and analysis of large datasets. The full translational pathway to evidence-based clinical care is represented by fellow research spanning basic animal models, genetics, and neuroimaging to implementation science and applied clinical care for veterans.

In 2025, AF MIRT marked its 25th year of training postdoctoral-level mental health scientific practitioners and scholars. This investment in clinical research training has had profound benefits for innovation and retention of clinicians and scientists within the VA system. As of April 1, 2026, AF MIRT trained 700 fellows, including 152 MD or MD/PhD fellows, 544 PhD or PsyD fellows, 3 PharmDs fellows, and 1 doctor of nursing practice fellow.

Fellowship Structure

The AF MIRT coordinating center provides key administrative support to fellowship site directors and topical didactic training to Advanced Fellows, ensuring consistent standard of quality training across locations in 15 states and 4 times zones. The training provided by the AF MIRT coordinating center deepens the nationally-mandated focus of local translational clinical centers (eg, Mental Illness Research Education and Clinical Centers, Centers of Excellence) on posttraumatic stress disorder (PTSD), serious mental illness, dementia, and other areas.

The AF MIRT coordinating center also promotes VA workforce sustainability. Advanced Fellows in programs with a coordinating center are much more likely to be retained in VA for postfellowship employment compared with fellows in programs without such a coordinating center (60% vs 38%) according to unpublished Office of Academic Affiliations data (Joel Schmidt, oral communication, May 15, 2025). The AF MIRT coordinating center provides central standardization and uses evidence-based approaches to ensure fellows receive consistent support, resources, and training. More specifically, the coordinating center develops and delivers a standardized, core curriculum to the program’s 28 sites. The program pioneered video delivery of integrated didactics that enlist national experts, many of them VA researchers and clinicians themselves. Didactics include high priority veteran mental health topics, such as suicide prevention, new and emerging evidence-based treatments (eg, neurostimulation for treatment resistant PTSD, psychotherapeutic approaches for traumatic brain injury), and VA health system considerations for mental health treatment delivery.

This curated didactic series also covers professional and technical issues, such as statistical and methodological considerations for clinical trials, scientific writing, and grant-writing skill development. These offerings support the career pathways of advanced fellows to pursue careers as researchers, scientifically-informed clinicians, or data scientists at VA or academic medical centers. The coordinating center prepares fellows to apply for mentored career award funding or independent investigator awards through the VA, National Institutes of Health (NIH), US Department of Defense, and other organizations by offering an annual mock grant review session and monthly reviews and discussions of fellows’ grant applications.

AF MIRT continuously fine tunes the didactic series curriculum based on feedback from fellows on how the program meets their training needs. For example, learning about the strategies Advanced Fellows used to remain productive during COVID-19 pandemic lockdowns revealed a strong trend toward use of secondary data (eg, publicly available data or VA electronic health record data). This fueled curriculum adjustments to include more topics relevant to fellow interests and needs for accessing secondary data resources for high priority veteran mental health topics.⁶

VA Advanced Fellowships Successes

From July 2020 to June 2025, MIRT advanced fellows published 906 peer-reviewed articles in psychiatry, psychology, and other disciplines. Each year, about 20 to 25 articles are published in high-impact journals. In this 5-year period, fellows have received 153 grants (114 VA grants) as principal investigators– many examining new innovations to improve the quality of care of veterans. Of the 165 fellows who graduated since 2020, 63% continued working in veteran health care: 38% transitioned to full-time VA employment and 25% moved to VA employment with an academic-affiliated role. Nineteen percent transitioned to academic positions, 12% transitioned to the private sector, and 5% transitioned to other government, industry, or nonprofit employment where these professionals contribute to scientific and clinical innovation benefiting the US public; 1% did not provide postfellowship employment information. The Figure displays geographic locations of graduated fellows’ postfellowship employment from July 2020 to June 2025.

The accomplishments of fellows are wide-ranging and aligned with VA’s mission. Each year, roughly 15 fellows receive new investigator awards, travel awards, and poster or presentation awards from prominent professional societies. Fellows have obtained VA Career Development Awards in diverse topics, including suicide prevention through clinician resources and training programs, firearm safety discussions, digital phenotyping and neuroimaging to enhance social integration in veterans with schizophrenia, rapid transcranial magnetic stimulation to treat nicotine use and PTSD, and evidence-based psychotherapy techniques for female veterans experiencing issues in menopause.

Several recent MIRT fellows have also received highly competitive NIH K Career Development Awards. One notable example is a fellow who studied pharmacologic approaches for treatment-resistant depression informed by novel brain circuit findings, first testing these approaches in community samples through a NIH K grant and translating findings to veterans. Fellows have gone on to become directors of important national research centers and studies, chairs of academic departments, and presidents of national medical organizations. Importantly, many MIRT fellows have become local directors and mentors to a new generation of VA fellows and researchers.

Conclusions

The AF MIRT coordinating center supports the VA’s mission of fulfilling President Lincoln’s promise to care for veterans. There are multiple benefits to evidence-based work that helps veterans and fosters a highly skilled VA workforce. Veterans are at the center of the MIRT data-driven approach, which is critical given their complex needs. Approaches to building the AF MIRT’s evidence base include randomized controlled trials open to veteran participants; program evaluation of current local, regional, or national VHA clinical services through measurement-based care and evaluation of national clinician training programs; and even smaller quality improvement projects in local VA clinics. These efforts support effective, efficient, and accessible provision of treatments that benefit veterans.

The Veterans Health Administration (VHA) Home Improvements and Structural Alterations (HISA) program is a primary means through which veterans can obtain home modifications necessary to continue safe and independent living in their home, including fall risk reduction and accessibility to essential parts of the home. However, not all eligible veterans who may benefit from this program participate, for a variety of reasons.^1-6 Historically, the HISA program has been administered in a decentralized and nonstandardized fashion dictated by the organizational structure of each US Department of Veterans Affairs (VA) medical center (VAMC) within a certain region or Veterans Integrated Service Network (VISN). Previous research found differential access to the HISA program by younger veterans, women, minorities, veterans with certain disability types, and veterans living in rural vs urban settings. These disparities in access and use of benefits conferred by the HISA program suggests an area of unmet need, which may improve veterans’ health care outcomes and reduce costs associated with their care.^2-8

The purpose of this article is to provide information to improve equitable provision and effective eligible use of resources available through the HISA program in a more generalizable manner by providing insight to highlight common program process deficiencies and care provision gaps relevant to VAMCs nationwide. This information can be used to inform the VA Physical Medicine and Rehabilitation (PM&R) and Prosthetic and Sensory Aid Service (PSAS) national policy initiatives, as well as hiring practices, clinic organization, specific care provision, and administrative goals and metrics at each VISN and at the VA Healthcare System level.

Methods

Veterans who participated in the HISA program, VHA administrators, and VHA clinicians from select VAMCs were identified and interviewed to better understand what helps increase access to the program, barriers to access, and how existing program components and processes impact use of the service. These interviews were taken from a directed convenience sample of selected VAMCs. To obtain this directed convenience sample, 167 VAMCs that participated in the HISA program were categorized as facilities that provided either a high or low number of HISA program prescriptions based on data from 2010 to 2018. Ten facilities from the top quartiles and 10 from the bottom quartiles of prescribing locations were selected. This facility selection was driven by the proportion of rural veterans served by each facility, favoring those serving a greater proportion of rural veterans, as well geographic location, with the aim of avoiding overrepresentation of any specific region. The convenience sample included 45 individuals (20 VHA employees and 25 veterans) across 22 states from the Northeast, West, South, and Midwest US Census regions.

Interview Process

Interviews underwent a coding process. The development of topical themes followed a systematic, 2-phase approach. Initially, researchers analyzed responses to semistructured interview questions addressing specific aspects of the HISA program, such as program awareness and accessibility. These responses naturally clustered into preliminary categories based on the interview guide structure. For example, responses related to program discovery formed a marketing-related category, while recommendations about program implementation contributed to a training and development category.

Following this initial categorization, the research team conducted a more rigorous coding process. A team of 3 researchers systematically reviewed assigned interview transcripts to extract practical recommendations for the guide. The researchers first identified relevant responses individually and then convened during group meetings to discuss and finalize selections. This second phase refined the preliminary categorization while maintaining alignment with the original interview structure.

This approach allowed the team to preserve the practical utility of participant feedback while ensuring methodological rigor in the analysis process. Resulting themes reflect both the structured nature of the original inquiry and the practical recommendations identified for improving the HISA program. Information on the following areas were collected: education about the HISA program, the contracting process, use of telehealth, interaction between VHA clinical care and the PSAS, marketing of the program, program funding, and revising the application process.

Results

Interview respondents provided several recommendations for improving the HISA program (Table). Regarding training and education, respondents noted deficiencies in VHA employee communication about the HISA program to veterans. Some employees did not know details or were unaware the HISA program existed. Additionally, a lack of knowledge about HISA program alternatives, including other available programs for obtaining home modifications or other durable medical equipment alternatives (eg, provision of a portable ramp rather than construction of a permanent one), was apparent. It was strongly recommended to provide additional education to effectively disseminate knowledge about the HISA program. Specifically, VHA employees, especially those in Primary Care, Geriatrics, Home Based Primary Care, the Caregiver Support Program, and Blind Rehabilitation Services, require greater awareness of the program and its processes.

PSAS and PM&R professionals, including physicians, nurse practitioners, physician assistants, and physical and occupational therapists, would be expected to have some knowledge of the HISA program, and therefore be more likely to connect a veteran with it. However, they may lack specific details about the program such as correct contact persons in the other service (PSAS or PM&R, respectively), facility- specific processes, such as how to enter a HISA consultation within the veteran’s electronic health record, how the entered consultation would progress through the system and avoid cancellation, and what should routinely be done to avoid HISA consultation cancellation, such as referral to Occupational Therapy for a functional assessment so appropriate durable medical equipment can be trialed with the veteran prior to proceeding with more costly and time-consuming home modifications.

In addition, there is no routine standard work process to ensure that PM&R staff are aware of updates in HISA program regulations and policy. Further recommendations in this area include having supervisory employees in PSAS and PM&R work both individually and together to develop effective information dissemination methods for key stakeholders. These include targeted in-services (ie, educational trainings often scheduled and conducted during recurring meetings), whether faceto- face or virtually in real time, or recorded, that occur on an ongoing and regular basis with sister services such as Primary Care, Geriatrics, Home Based Primary Care, the Caregiver Support Program, and Blind Rehabilitation Services (eg, the facility Vision Impairment Services Team coordinator). Regularly updated educational materials should be provided to veterans and VHA adjacent stakeholders such as Veteran Service Organizations and Veteran County Service Officers, via a variety of platforms.

Successfully navigating the provision of home modifications via the HISA program involves identifying a contractor to perform the home modification and obtaining service and construction plan pricing. A key barrier in this area is that veterans and VHA clinicians perceive the funds available through HISA as insufficient, regardless of whether they have serviceconnected status or not. Service connection refers to designation of ≥ 1 medical conditions determined to be related to military service and thus eligible to receive VHA care.⁹ Service-connected veterans receive a lifetime maximum award of $6800 from HISA while veterans without service connection receive a lifetime maximum award of $2000.^1,2

Rural veterans face a greater challenge than urban veterans, as there are fewer contractors located nearby. Thus, providing higher funding for rural veterans, or specific funding such as for travel expenses, would be especially helpful to find a willing contractor to perform home medications.¹ The current requirement of working with a licensed contractor was also a barrier, especially for smaller jobs, and could result in VHA employees (including clinicians) feeling pressured to become overly involved to assist veterans to move through the process.

To that point, respondents requested resources such as a regularly updated list of licensed contractors in the area, especially those familiar with working with the HISA program, be provided to veterans and their assisting groups. In addition, respondents asked that VHA take on greater responsibility and liability with regard to contractors accessing HISA funding, such as not releasing final payment until VHA approved the completed home modification. On the other hand, respondents also expressed concerns about the length of time associated with HISA program payment and noted it should be sped up to allow contractors who participate to receive payment sooner, which many believed would increase the number of contractors willing to take on this work.

The role of telehealth was noted as a great facilitator of increased access to care, especially following the COVID-19 pandemic. Telehealth modalities adapted for the HISA program could help increase access to the program and improve processing speed. Barriers include lack of appropriate veteran telehealth equipment and poor understanding of information needed to move the process forward. Recommendations included providing veterans tablets to connect to virtual services, and developing information on home measurements needed, assistance in obtaining and sending photographs, and detailed information on successfully using telehealth for the HISA application process. Of note, some clinicians, representing home-based primary care, prosthetics services, geriatrics, rehabilitation therapy, mobile clinic, and the telehealth division, and including both clinical staff (eg, occupational therapists) and nonclinical staff (eg, prosthetics representatives and administrative personnel), have found patients expressed comparable satisfaction with the process whether faceto- face or via telehealth.

The essential relationship between PSAS and PM&R regarding the HISA program was a key finding. Both services are integral to helping veterans successfully obtain home modifications via the HISA program.^1,2 Barriers include insufficient communication and a lack of clearly defined points of contact for each service, poorly defined roles, and inefficiencies because 2 services are involved in navigating the process. Recommendations therefore include addressing these issues, such as adopting a case management or liaison model between the services to better manage the process.

Respondents indicated that insufficient program funding was a concern. Veterans living in poorer quality housing, such as older homes, often require more expensive home modifications, necessitating greater out-of-pocket expenses. Veterans and VHA employees advocated for the creation of an exception to the lower funding cap for veterans without service connection in cases of financial hardship. Overall, the funding limits for both service-connected veterans and those without service connection were thought to be insufficient, especially as the COVID-19 pandemic increased the cost of construction materials.

Respondents also noted that veterans would benefit from clear messaging that receiving HISA funds does not impact eligibility for other VA benefits and services. Veterans must understand that home modifications work must be approved by VHA before being started and should be aware that if their disability rating increases so that they become eligible for the higher level service-connected benefits, they would then become eligible for the higher maximum benefit. Respondents recommended veterans should receive assistance in understanding the full costs of the home modification and ongoing maintenance, and the HISA research team recommended that the National Program develop a fact sheet that can be used to advise veterans.

Respondents consistently indicated that information about the HISA program was not disseminated effectively to key internal and external stakeholders, and opportunities to highlight the program on VHA websites, brochures throughout VHA facilities, and other outlets such as direct mailing should be used. Veterans who have used the program are overwhelmingly older (mean age 71 years), White, and male, suggesting missed opportunities and unmet need for underrepresented groups. Therefore, targeted marketing interventions would especially benefit these groups.

Respondents also noted inefficiencies throughout the HISA program application process and advocated for changes such as national standard operating procedures (SOPs) to guide navigation through the HISA process. The national SOPs could include home evaluation prior to HISA application submission, clearly identified points of contact for the HISA program in PSAS and PM&R, and standardized documentation.

Future Directions

Information from respondents provided several avenues for future studies. Recommendations were obtained from each of the 7 broad topical areas: training and educational needs, potential, contracting challenges and opportunities, telehealth as a conduit to facilitate the availability of the HISA program, PSAS, and clinical services collaboration, marketing, need for increased funding, and revision of the application process. Input from stakeholders can help direct efficient use of resources to guide future studies for the greatest impact and highlight current and future priorities. Easy areas of intervention indicated by respondents include creating a national standard work process regarding the HISA program with standardized educational materials for key stakeholders, revised at regular intervals, and readily available on national websites. A pre- and postimplementation survey could help provide quantifiable information about the benefits of such an intervention.

Conclusions

A qualitative analysis of interviews with veterans and VHA clinicians provides evidence of potential barriers for the HISA program. Addressing these barriers could allow HISA to better meet the VHA goal of providing home modifications that allow veterans to live safely and independently in their homes. There is a need for ongoing review and assessment of the program to ensure optimization and efficient use of resources across the spectrum of veteran needs.

The Veterans Health Administration (VHA) Home Improvements and Structural Alterations (HISA) program is a primary means through which veterans can obtain home modifications necessary to continue safe and independent living in their home, including fall risk reduction and accessibility to essential parts of the home. However, not all eligible veterans who may benefit from this program participate, for a variety of reasons.^1-6 Historically, the HISA program has been administered in a decentralized and nonstandardized fashion dictated by the organizational structure of each US Department of Veterans Affairs (VA) medical center (VAMC) within a certain region or Veterans Integrated Service Network (VISN). Previous research found differential access to the HISA program by younger veterans, women, minorities, veterans with certain disability types, and veterans living in rural vs urban settings. These disparities in access and use of benefits conferred by the HISA program suggests an area of unmet need, which may improve veterans’ health care outcomes and reduce costs associated with their care.^2-8

The purpose of this article is to provide information to improve equitable provision and effective eligible use of resources available through the HISA program in a more generalizable manner by providing insight to highlight common program process deficiencies and care provision gaps relevant to VAMCs nationwide. This information can be used to inform the VA Physical Medicine and Rehabilitation (PM&R) and Prosthetic and Sensory Aid Service (PSAS) national policy initiatives, as well as hiring practices, clinic organization, specific care provision, and administrative goals and metrics at each VISN and at the VA Healthcare System level.

Methods

Veterans who participated in the HISA program, VHA administrators, and VHA clinicians from select VAMCs were identified and interviewed to better understand what helps increase access to the program, barriers to access, and how existing program components and processes impact use of the service. These interviews were taken from a directed convenience sample of selected VAMCs. To obtain this directed convenience sample, 167 VAMCs that participated in the HISA program were categorized as facilities that provided either a high or low number of HISA program prescriptions based on data from 2010 to 2018. Ten facilities from the top quartiles and 10 from the bottom quartiles of prescribing locations were selected. This facility selection was driven by the proportion of rural veterans served by each facility, favoring those serving a greater proportion of rural veterans, as well geographic location, with the aim of avoiding overrepresentation of any specific region. The convenience sample included 45 individuals (20 VHA employees and 25 veterans) across 22 states from the Northeast, West, South, and Midwest US Census regions.

Interview Process

Interviews underwent a coding process. The development of topical themes followed a systematic, 2-phase approach. Initially, researchers analyzed responses to semistructured interview questions addressing specific aspects of the HISA program, such as program awareness and accessibility. These responses naturally clustered into preliminary categories based on the interview guide structure. For example, responses related to program discovery formed a marketing-related category, while recommendations about program implementation contributed to a training and development category.

Following this initial categorization, the research team conducted a more rigorous coding process. A team of 3 researchers systematically reviewed assigned interview transcripts to extract practical recommendations for the guide. The researchers first identified relevant responses individually and then convened during group meetings to discuss and finalize selections. This second phase refined the preliminary categorization while maintaining alignment with the original interview structure.

This approach allowed the team to preserve the practical utility of participant feedback while ensuring methodological rigor in the analysis process. Resulting themes reflect both the structured nature of the original inquiry and the practical recommendations identified for improving the HISA program. Information on the following areas were collected: education about the HISA program, the contracting process, use of telehealth, interaction between VHA clinical care and the PSAS, marketing of the program, program funding, and revising the application process.

Results

Interview respondents provided several recommendations for improving the HISA program (Table). Regarding training and education, respondents noted deficiencies in VHA employee communication about the HISA program to veterans. Some employees did not know details or were unaware the HISA program existed. Additionally, a lack of knowledge about HISA program alternatives, including other available programs for obtaining home modifications or other durable medical equipment alternatives (eg, provision of a portable ramp rather than construction of a permanent one), was apparent. It was strongly recommended to provide additional education to effectively disseminate knowledge about the HISA program. Specifically, VHA employees, especially those in Primary Care, Geriatrics, Home Based Primary Care, the Caregiver Support Program, and Blind Rehabilitation Services, require greater awareness of the program and its processes.

PSAS and PM&R professionals, including physicians, nurse practitioners, physician assistants, and physical and occupational therapists, would be expected to have some knowledge of the HISA program, and therefore be more likely to connect a veteran with it. However, they may lack specific details about the program such as correct contact persons in the other service (PSAS or PM&R, respectively), facility- specific processes, such as how to enter a HISA consultation within the veteran’s electronic health record, how the entered consultation would progress through the system and avoid cancellation, and what should routinely be done to avoid HISA consultation cancellation, such as referral to Occupational Therapy for a functional assessment so appropriate durable medical equipment can be trialed with the veteran prior to proceeding with more costly and time-consuming home modifications.

In addition, there is no routine standard work process to ensure that PM&R staff are aware of updates in HISA program regulations and policy. Further recommendations in this area include having supervisory employees in PSAS and PM&R work both individually and together to develop effective information dissemination methods for key stakeholders. These include targeted in-services (ie, educational trainings often scheduled and conducted during recurring meetings), whether faceto- face or virtually in real time, or recorded, that occur on an ongoing and regular basis with sister services such as Primary Care, Geriatrics, Home Based Primary Care, the Caregiver Support Program, and Blind Rehabilitation Services (eg, the facility Vision Impairment Services Team coordinator). Regularly updated educational materials should be provided to veterans and VHA adjacent stakeholders such as Veteran Service Organizations and Veteran County Service Officers, via a variety of platforms.

Successfully navigating the provision of home modifications via the HISA program involves identifying a contractor to perform the home modification and obtaining service and construction plan pricing. A key barrier in this area is that veterans and VHA clinicians perceive the funds available through HISA as insufficient, regardless of whether they have serviceconnected status or not. Service connection refers to designation of ≥ 1 medical conditions determined to be related to military service and thus eligible to receive VHA care.⁹ Service-connected veterans receive a lifetime maximum award of $6800 from HISA while veterans without service connection receive a lifetime maximum award of $2000.^1,2

Rural veterans face a greater challenge than urban veterans, as there are fewer contractors located nearby. Thus, providing higher funding for rural veterans, or specific funding such as for travel expenses, would be especially helpful to find a willing contractor to perform home medications.¹ The current requirement of working with a licensed contractor was also a barrier, especially for smaller jobs, and could result in VHA employees (including clinicians) feeling pressured to become overly involved to assist veterans to move through the process.

To that point, respondents requested resources such as a regularly updated list of licensed contractors in the area, especially those familiar with working with the HISA program, be provided to veterans and their assisting groups. In addition, respondents asked that VHA take on greater responsibility and liability with regard to contractors accessing HISA funding, such as not releasing final payment until VHA approved the completed home modification. On the other hand, respondents also expressed concerns about the length of time associated with HISA program payment and noted it should be sped up to allow contractors who participate to receive payment sooner, which many believed would increase the number of contractors willing to take on this work.

The role of telehealth was noted as a great facilitator of increased access to care, especially following the COVID-19 pandemic. Telehealth modalities adapted for the HISA program could help increase access to the program and improve processing speed. Barriers include lack of appropriate veteran telehealth equipment and poor understanding of information needed to move the process forward. Recommendations included providing veterans tablets to connect to virtual services, and developing information on home measurements needed, assistance in obtaining and sending photographs, and detailed information on successfully using telehealth for the HISA application process. Of note, some clinicians, representing home-based primary care, prosthetics services, geriatrics, rehabilitation therapy, mobile clinic, and the telehealth division, and including both clinical staff (eg, occupational therapists) and nonclinical staff (eg, prosthetics representatives and administrative personnel), have found patients expressed comparable satisfaction with the process whether faceto- face or via telehealth.

The essential relationship between PSAS and PM&R regarding the HISA program was a key finding. Both services are integral to helping veterans successfully obtain home modifications via the HISA program.^1,2 Barriers include insufficient communication and a lack of clearly defined points of contact for each service, poorly defined roles, and inefficiencies because 2 services are involved in navigating the process. Recommendations therefore include addressing these issues, such as adopting a case management or liaison model between the services to better manage the process.

Respondents indicated that insufficient program funding was a concern. Veterans living in poorer quality housing, such as older homes, often require more expensive home modifications, necessitating greater out-of-pocket expenses. Veterans and VHA employees advocated for the creation of an exception to the lower funding cap for veterans without service connection in cases of financial hardship. Overall, the funding limits for both service-connected veterans and those without service connection were thought to be insufficient, especially as the COVID-19 pandemic increased the cost of construction materials.

Respondents also noted that veterans would benefit from clear messaging that receiving HISA funds does not impact eligibility for other VA benefits and services. Veterans must understand that home modifications work must be approved by VHA before being started and should be aware that if their disability rating increases so that they become eligible for the higher level service-connected benefits, they would then become eligible for the higher maximum benefit. Respondents recommended veterans should receive assistance in understanding the full costs of the home modification and ongoing maintenance, and the HISA research team recommended that the National Program develop a fact sheet that can be used to advise veterans.

Respondents consistently indicated that information about the HISA program was not disseminated effectively to key internal and external stakeholders, and opportunities to highlight the program on VHA websites, brochures throughout VHA facilities, and other outlets such as direct mailing should be used. Veterans who have used the program are overwhelmingly older (mean age 71 years), White, and male, suggesting missed opportunities and unmet need for underrepresented groups. Therefore, targeted marketing interventions would especially benefit these groups.

Respondents also noted inefficiencies throughout the HISA program application process and advocated for changes such as national standard operating procedures (SOPs) to guide navigation through the HISA process. The national SOPs could include home evaluation prior to HISA application submission, clearly identified points of contact for the HISA program in PSAS and PM&R, and standardized documentation.

Future Directions

Information from respondents provided several avenues for future studies. Recommendations were obtained from each of the 7 broad topical areas: training and educational needs, potential, contracting challenges and opportunities, telehealth as a conduit to facilitate the availability of the HISA program, PSAS, and clinical services collaboration, marketing, need for increased funding, and revision of the application process. Input from stakeholders can help direct efficient use of resources to guide future studies for the greatest impact and highlight current and future priorities. Easy areas of intervention indicated by respondents include creating a national standard work process regarding the HISA program with standardized educational materials for key stakeholders, revised at regular intervals, and readily available on national websites. A pre- and postimplementation survey could help provide quantifiable information about the benefits of such an intervention.

Conclusions

A qualitative analysis of interviews with veterans and VHA clinicians provides evidence of potential barriers for the HISA program. Addressing these barriers could allow HISA to better meet the VHA goal of providing home modifications that allow veterans to live safely and independently in their homes. There is a need for ongoing review and assessment of the program to ensure optimization and efficient use of resources across the spectrum of veteran needs.

The Veterans Health Administration (VHA) Home Improvements and Structural Alterations (HISA) program is a primary means through which veterans can obtain home modifications necessary to continue safe and independent living in their home, including fall risk reduction and accessibility to essential parts of the home. However, not all eligible veterans who may benefit from this program participate, for a variety of reasons.^1-6 Historically, the HISA program has been administered in a decentralized and nonstandardized fashion dictated by the organizational structure of each US Department of Veterans Affairs (VA) medical center (VAMC) within a certain region or Veterans Integrated Service Network (VISN). Previous research found differential access to the HISA program by younger veterans, women, minorities, veterans with certain disability types, and veterans living in rural vs urban settings. These disparities in access and use of benefits conferred by the HISA program suggests an area of unmet need, which may improve veterans’ health care outcomes and reduce costs associated with their care.^2-8

The purpose of this article is to provide information to improve equitable provision and effective eligible use of resources available through the HISA program in a more generalizable manner by providing insight to highlight common program process deficiencies and care provision gaps relevant to VAMCs nationwide. This information can be used to inform the VA Physical Medicine and Rehabilitation (PM&R) and Prosthetic and Sensory Aid Service (PSAS) national policy initiatives, as well as hiring practices, clinic organization, specific care provision, and administrative goals and metrics at each VISN and at the VA Healthcare System level.

Methods

Veterans who participated in the HISA program, VHA administrators, and VHA clinicians from select VAMCs were identified and interviewed to better understand what helps increase access to the program, barriers to access, and how existing program components and processes impact use of the service. These interviews were taken from a directed convenience sample of selected VAMCs. To obtain this directed convenience sample, 167 VAMCs that participated in the HISA program were categorized as facilities that provided either a high or low number of HISA program prescriptions based on data from 2010 to 2018. Ten facilities from the top quartiles and 10 from the bottom quartiles of prescribing locations were selected. This facility selection was driven by the proportion of rural veterans served by each facility, favoring those serving a greater proportion of rural veterans, as well geographic location, with the aim of avoiding overrepresentation of any specific region. The convenience sample included 45 individuals (20 VHA employees and 25 veterans) across 22 states from the Northeast, West, South, and Midwest US Census regions.

Interview Process

Interviews underwent a coding process. The development of topical themes followed a systematic, 2-phase approach. Initially, researchers analyzed responses to semistructured interview questions addressing specific aspects of the HISA program, such as program awareness and accessibility. These responses naturally clustered into preliminary categories based on the interview guide structure. For example, responses related to program discovery formed a marketing-related category, while recommendations about program implementation contributed to a training and development category.

Following this initial categorization, the research team conducted a more rigorous coding process. A team of 3 researchers systematically reviewed assigned interview transcripts to extract practical recommendations for the guide. The researchers first identified relevant responses individually and then convened during group meetings to discuss and finalize selections. This second phase refined the preliminary categorization while maintaining alignment with the original interview structure.

This approach allowed the team to preserve the practical utility of participant feedback while ensuring methodological rigor in the analysis process. Resulting themes reflect both the structured nature of the original inquiry and the practical recommendations identified for improving the HISA program. Information on the following areas were collected: education about the HISA program, the contracting process, use of telehealth, interaction between VHA clinical care and the PSAS, marketing of the program, program funding, and revising the application process.

Results

Interview respondents provided several recommendations for improving the HISA program (Table). Regarding training and education, respondents noted deficiencies in VHA employee communication about the HISA program to veterans. Some employees did not know details or were unaware the HISA program existed. Additionally, a lack of knowledge about HISA program alternatives, including other available programs for obtaining home modifications or other durable medical equipment alternatives (eg, provision of a portable ramp rather than construction of a permanent one), was apparent. It was strongly recommended to provide additional education to effectively disseminate knowledge about the HISA program. Specifically, VHA employees, especially those in Primary Care, Geriatrics, Home Based Primary Care, the Caregiver Support Program, and Blind Rehabilitation Services, require greater awareness of the program and its processes.

PSAS and PM&R professionals, including physicians, nurse practitioners, physician assistants, and physical and occupational therapists, would be expected to have some knowledge of the HISA program, and therefore be more likely to connect a veteran with it. However, they may lack specific details about the program such as correct contact persons in the other service (PSAS or PM&R, respectively), facility- specific processes, such as how to enter a HISA consultation within the veteran’s electronic health record, how the entered consultation would progress through the system and avoid cancellation, and what should routinely be done to avoid HISA consultation cancellation, such as referral to Occupational Therapy for a functional assessment so appropriate durable medical equipment can be trialed with the veteran prior to proceeding with more costly and time-consuming home modifications.

In addition, there is no routine standard work process to ensure that PM&R staff are aware of updates in HISA program regulations and policy. Further recommendations in this area include having supervisory employees in PSAS and PM&R work both individually and together to develop effective information dissemination methods for key stakeholders. These include targeted in-services (ie, educational trainings often scheduled and conducted during recurring meetings), whether faceto- face or virtually in real time, or recorded, that occur on an ongoing and regular basis with sister services such as Primary Care, Geriatrics, Home Based Primary Care, the Caregiver Support Program, and Blind Rehabilitation Services (eg, the facility Vision Impairment Services Team coordinator). Regularly updated educational materials should be provided to veterans and VHA adjacent stakeholders such as Veteran Service Organizations and Veteran County Service Officers, via a variety of platforms.

Successfully navigating the provision of home modifications via the HISA program involves identifying a contractor to perform the home modification and obtaining service and construction plan pricing. A key barrier in this area is that veterans and VHA clinicians perceive the funds available through HISA as insufficient, regardless of whether they have serviceconnected status or not. Service connection refers to designation of ≥ 1 medical conditions determined to be related to military service and thus eligible to receive VHA care.⁹ Service-connected veterans receive a lifetime maximum award of $6800 from HISA while veterans without service connection receive a lifetime maximum award of $2000.^1,2

Rural veterans face a greater challenge than urban veterans, as there are fewer contractors located nearby. Thus, providing higher funding for rural veterans, or specific funding such as for travel expenses, would be especially helpful to find a willing contractor to perform home medications.¹ The current requirement of working with a licensed contractor was also a barrier, especially for smaller jobs, and could result in VHA employees (including clinicians) feeling pressured to become overly involved to assist veterans to move through the process.

To that point, respondents requested resources such as a regularly updated list of licensed contractors in the area, especially those familiar with working with the HISA program, be provided to veterans and their assisting groups. In addition, respondents asked that VHA take on greater responsibility and liability with regard to contractors accessing HISA funding, such as not releasing final payment until VHA approved the completed home modification. On the other hand, respondents also expressed concerns about the length of time associated with HISA program payment and noted it should be sped up to allow contractors who participate to receive payment sooner, which many believed would increase the number of contractors willing to take on this work.

The role of telehealth was noted as a great facilitator of increased access to care, especially following the COVID-19 pandemic. Telehealth modalities adapted for the HISA program could help increase access to the program and improve processing speed. Barriers include lack of appropriate veteran telehealth equipment and poor understanding of information needed to move the process forward. Recommendations included providing veterans tablets to connect to virtual services, and developing information on home measurements needed, assistance in obtaining and sending photographs, and detailed information on successfully using telehealth for the HISA application process. Of note, some clinicians, representing home-based primary care, prosthetics services, geriatrics, rehabilitation therapy, mobile clinic, and the telehealth division, and including both clinical staff (eg, occupational therapists) and nonclinical staff (eg, prosthetics representatives and administrative personnel), have found patients expressed comparable satisfaction with the process whether faceto- face or via telehealth.

The essential relationship between PSAS and PM&R regarding the HISA program was a key finding. Both services are integral to helping veterans successfully obtain home modifications via the HISA program.^1,2 Barriers include insufficient communication and a lack of clearly defined points of contact for each service, poorly defined roles, and inefficiencies because 2 services are involved in navigating the process. Recommendations therefore include addressing these issues, such as adopting a case management or liaison model between the services to better manage the process.

Respondents indicated that insufficient program funding was a concern. Veterans living in poorer quality housing, such as older homes, often require more expensive home modifications, necessitating greater out-of-pocket expenses. Veterans and VHA employees advocated for the creation of an exception to the lower funding cap for veterans without service connection in cases of financial hardship. Overall, the funding limits for both service-connected veterans and those without service connection were thought to be insufficient, especially as the COVID-19 pandemic increased the cost of construction materials.

Respondents also noted that veterans would benefit from clear messaging that receiving HISA funds does not impact eligibility for other VA benefits and services. Veterans must understand that home modifications work must be approved by VHA before being started and should be aware that if their disability rating increases so that they become eligible for the higher level service-connected benefits, they would then become eligible for the higher maximum benefit. Respondents recommended veterans should receive assistance in understanding the full costs of the home modification and ongoing maintenance, and the HISA research team recommended that the National Program develop a fact sheet that can be used to advise veterans.

Respondents consistently indicated that information about the HISA program was not disseminated effectively to key internal and external stakeholders, and opportunities to highlight the program on VHA websites, brochures throughout VHA facilities, and other outlets such as direct mailing should be used. Veterans who have used the program are overwhelmingly older (mean age 71 years), White, and male, suggesting missed opportunities and unmet need for underrepresented groups. Therefore, targeted marketing interventions would especially benefit these groups.

Respondents also noted inefficiencies throughout the HISA program application process and advocated for changes such as national standard operating procedures (SOPs) to guide navigation through the HISA process. The national SOPs could include home evaluation prior to HISA application submission, clearly identified points of contact for the HISA program in PSAS and PM&R, and standardized documentation.

Future Directions

Information from respondents provided several avenues for future studies. Recommendations were obtained from each of the 7 broad topical areas: training and educational needs, potential, contracting challenges and opportunities, telehealth as a conduit to facilitate the availability of the HISA program, PSAS, and clinical services collaboration, marketing, need for increased funding, and revision of the application process. Input from stakeholders can help direct efficient use of resources to guide future studies for the greatest impact and highlight current and future priorities. Easy areas of intervention indicated by respondents include creating a national standard work process regarding the HISA program with standardized educational materials for key stakeholders, revised at regular intervals, and readily available on national websites. A pre- and postimplementation survey could help provide quantifiable information about the benefits of such an intervention.

Conclusions

A qualitative analysis of interviews with veterans and VHA clinicians provides evidence of potential barriers for the HISA program. Addressing these barriers could allow HISA to better meet the VHA goal of providing home modifications that allow veterans to live safely and independently in their homes. There is a need for ongoing review and assessment of the program to ensure optimization and efficient use of resources across the spectrum of veteran needs.

Often disguised as comorbid conditions, nonhealing and chronic wounds have emerged as a silent epidemic that affects about 6.5 million Americans.^1-3 In 2023, estimated US wound care costs were $126.86 billion.⁴ About 1% to 2% of individuals worldwide will experience a chronic wound in their lifetime. The Veterans Health Administration reported 277,000 inpatient and outpatient encounters for ulcers in 2011, including chronic ulcers of the lower extremity due to diabetes, venous disease, or arterial disease.⁵ Associated costs of chronic wounds are expected to increase as the populations of developed countries age.⁶ Effective treatment of chronic wounds requires a nuanced understanding of complex wound pathophysiology, best practices in interdisciplinary and multidisciplinary wound care, and advanced wound care technologies.^7,8

The typical 4-year medical school curriculum, followed by residency, offers little in the way of formal didactic training in wound care.^9,10 Without specialized and advanced fellowship training dedicated to wound care, health care will lack specialists prepared to manage complex wounds. As a result, wound care-related difficulties may be exacerbated by prolonged recovery time, increased costs, productivity loss, and increased mortality risk.⁸ Wound care is a growing field of study and practice, and there is a critical need for rigorous training, research, and quality improvement efforts to enhance outcomes for patients with nonhealing wounds.⁵

One of the most direct ways to address the need for more physicians with specialty training in wound medicine is to implement a comprehensive training curriculum for advanced wound care practice. Although specialized advanced wound care fellowships are available, the curricula primarily detail rotation names and areas for practice without accompanying competencies, milestones, or entrustable professional activities.¹¹ Furthermore, wound care is not recognized as a subspecialty by the Accreditation Council for Graduate Medical Education (ACGME).

This article synthesized the literature and integrated innovative, evidence-based practices into a curriculum for a formal advanced fellowship training program. To our knowledge, no comprehensive wound care curriculum is publicly available that includes rotations, competencies, milestones, entrustable professional activities, and 360-degree evaluation forms.

Program Development

The advanced wound care fellowship program started in January 2014 at the Michael E. DeBakey Veterans Affairs Medical Center in affiliation with the Baylor College of Medicine. The fellowship program was originally designed for geriatrics fellows to extend the 1-year fellowship for an additional year to learn wound care. It has been adjusted to address formal program goals and objectives, competencies, milestones, entrustable professional activities, and evaluations, with the goal of developing an example curriculum for wound care fellowships across specialties. Although the ACGME does not recognize a wound care subspecialty, this curriculum complies with the ACGME 1-year fellowship common program requirements.^12,13

Scoping Review

A scoping literature review of Google Scholar and PubMed was performed using the medical subject heading terms “wound care + curriculum” and “wound + care + curriculum” to find advanced wound care medical training, fellowship programs, boards, and related ACGME-accredited specialty curricula. The local wound care fellowship program was initially implemented based on an informal literature review by faculty and their respective contributions to curriculum (ie, process establishing wound care-specific competency domains in accordance with ACGME accreditation competency requirements of 1-year fellowships). ^12,13 Standing program practice-based competencies and activities were examined and determined to align with best practices. This scoping review considered additional competencies, competency domains, and entrustable professional activities of reputable wound care fellowship training programs (eg, University of Chicago at Illinois and Wake Forest School of Medicine),^8,11,14 a specialty wound care board (American Board of Wound Medicine and Surgery),¹⁵ an international wound specialist professional society (European Union of Medical Specialists), ¹⁶ and recommended curriculum guidelines for wound care residency programs.¹⁷ ACGME-accredited specialty and subspecialty milestones professional activities were examined, including vascular surgery,¹⁸ plastic surgery,¹⁹ dermatology, ²⁰ foot and ankle,²¹ orthopedic surgery,²² spinal cord injury,²³ and geriatric medicine.²⁴

The competencies, milestones, and entrustable professional activities were compiled and redundancies were eliminated. Wound care specialists from geriatrics, family medicine, internal medicine, undersea and hyperbaric medicine, general surgery, podiatry, and physical therapy examined the findings and suggested eliminating redundancies, irrelevant content, and content that fell below the minimal expected level of competence for an advanced medical specialist in wound care. An expert consensus meeting further refined items presented to the panel before unanimous consensus resulted in the final set of curriculum competencies, milestones, and entrustable professional activities.

Training Program Feedback

We developed a comprehensive wound care curriculum for an advanced physician fellowship training program based on the streamlined competencies, milestones, and entrustable professional activities (Appendix). Multiple wound care experts from various interdisciplinary backgrounds reached consensus to establish this fellowship curriculum as adaptable for use across training settings. The training program is 12 core rotations and 2 elective rotations (Table 1). Additionally, we developed wound care evaluation forms for faculty-, peer-, and self-assessment of trainees which were adapted from an evidence-based 360-degree evaluation template.²⁵ Suggestions for structured, advanced didactics are in Table 2.

Seventeen fellows have successfully matriculated through the wound care training program. Although wound care certification is not required to work as a wound care specialist, after completion of this fellowship, graduates are able to sit for a wound care certification examination. The American Board of Wound Medicine and Surgery (ABWMS) and the American Board of Wound Management (ABWM) allow physicians to take a certification examination after 1 year of a dedicated wound fellowship program, instead of the typical wound care practice experience ≥ 3 years.

The Clinical Wound Care Fellowship Program collected data for program improvement, and 15 alumni responded (response rate, 88%) to a survey using a 5-point Likert scale. Respondents indicated high mean scores for overall satisfaction (4.7), instructional methods (4.7), program enjoyment (4.7), teaching materials (4.6), and relevance (4.6). All respondents indicated that the fellowship prepared them for a career in wound care as well as their current employment, and 13 of 15 (87%) reported they obtained immediate relevant postfellowship wound care positions and stated that the fellowship prepared them for their current roles. Nine respondents (69%) reported that they were engaged in wound care ≥ 26% of work time. Six respondents (46%) worked in private practice, 3 (23%) at academic medical centers, and 2 (15%) at government- funded hospitals. Four respondents indicated they were board certified in wound care. Program alumni are currently involved in scholarly activities, including 8 in quality improvement and 3 in research.

Discussion

An easily accessible, comprehensive wound care fellowship curriculum has not been previously developed or published. This limited the sources that informed this curriculum. However, the developmental process for this curriculum was robust, as the authors reviewed previously published materials related to wound care, including: 1) descriptive overviews of wound care fellowships; 2) details of month-long rotations for medical students and residents; and 3) practices of the specific environment in which this curriculum was created. Confidence in the practical nature of the curriculum can be assumed, as the experts involved in the development process represented diverse physician specializations, including geriatrics, family medicine, internal medicine, undersea and hyperbaric medicine, general surgery, podiatry, and physical therapy.

Most wound care clinicians have not completed a formal comprehensive fellowship program. Instead, due to the lack of a comprehensive training curriculum, clinicians have had to use various continuing medical education programs and practice in a wound care setting for ≥ 3 years to be eligible for certification in the specialty. This curriculum will help academic medical centers develop their own fellowship programs, enabling new wound care clinicians to attain certifications more efficiently. As more fellowship programs develop, the goal would be to obtain recognition as an ACGME specialty and standardize the training and competencies for graduates of wound care fellowships.

Conclusions

As new wound care fellowships develop, wound care may become formally acknowledged as its own specialty within medicine and surgery. This will provide wound care with a voice at the national level, particularly in an era of value-based care. Wound care clinicians will be able to advocate for specialty-specific quality metrics and avoid potential penalization for not meeting quality metrics that are irrelevant to wound care.

Often disguised as comorbid conditions, nonhealing and chronic wounds have emerged as a silent epidemic that affects about 6.5 million Americans.^1-3 In 2023, estimated US wound care costs were $126.86 billion.⁴ About 1% to 2% of individuals worldwide will experience a chronic wound in their lifetime. The Veterans Health Administration reported 277,000 inpatient and outpatient encounters for ulcers in 2011, including chronic ulcers of the lower extremity due to diabetes, venous disease, or arterial disease.⁵ Associated costs of chronic wounds are expected to increase as the populations of developed countries age.⁶ Effective treatment of chronic wounds requires a nuanced understanding of complex wound pathophysiology, best practices in interdisciplinary and multidisciplinary wound care, and advanced wound care technologies.^7,8

The typical 4-year medical school curriculum, followed by residency, offers little in the way of formal didactic training in wound care.^9,10 Without specialized and advanced fellowship training dedicated to wound care, health care will lack specialists prepared to manage complex wounds. As a result, wound care-related difficulties may be exacerbated by prolonged recovery time, increased costs, productivity loss, and increased mortality risk.⁸ Wound care is a growing field of study and practice, and there is a critical need for rigorous training, research, and quality improvement efforts to enhance outcomes for patients with nonhealing wounds.⁵

One of the most direct ways to address the need for more physicians with specialty training in wound medicine is to implement a comprehensive training curriculum for advanced wound care practice. Although specialized advanced wound care fellowships are available, the curricula primarily detail rotation names and areas for practice without accompanying competencies, milestones, or entrustable professional activities.¹¹ Furthermore, wound care is not recognized as a subspecialty by the Accreditation Council for Graduate Medical Education (ACGME).

This article synthesized the literature and integrated innovative, evidence-based practices into a curriculum for a formal advanced fellowship training program. To our knowledge, no comprehensive wound care curriculum is publicly available that includes rotations, competencies, milestones, entrustable professional activities, and 360-degree evaluation forms.

Program Development

The advanced wound care fellowship program started in January 2014 at the Michael E. DeBakey Veterans Affairs Medical Center in affiliation with the Baylor College of Medicine. The fellowship program was originally designed for geriatrics fellows to extend the 1-year fellowship for an additional year to learn wound care. It has been adjusted to address formal program goals and objectives, competencies, milestones, entrustable professional activities, and evaluations, with the goal of developing an example curriculum for wound care fellowships across specialties. Although the ACGME does not recognize a wound care subspecialty, this curriculum complies with the ACGME 1-year fellowship common program requirements.^12,13

Scoping Review

A scoping literature review of Google Scholar and PubMed was performed using the medical subject heading terms “wound care + curriculum” and “wound + care + curriculum” to find advanced wound care medical training, fellowship programs, boards, and related ACGME-accredited specialty curricula. The local wound care fellowship program was initially implemented based on an informal literature review by faculty and their respective contributions to curriculum (ie, process establishing wound care-specific competency domains in accordance with ACGME accreditation competency requirements of 1-year fellowships). ^12,13 Standing program practice-based competencies and activities were examined and determined to align with best practices. This scoping review considered additional competencies, competency domains, and entrustable professional activities of reputable wound care fellowship training programs (eg, University of Chicago at Illinois and Wake Forest School of Medicine),^8,11,14 a specialty wound care board (American Board of Wound Medicine and Surgery),¹⁵ an international wound specialist professional society (European Union of Medical Specialists), ¹⁶ and recommended curriculum guidelines for wound care residency programs.¹⁷ ACGME-accredited specialty and subspecialty milestones professional activities were examined, including vascular surgery,¹⁸ plastic surgery,¹⁹ dermatology, ²⁰ foot and ankle,²¹ orthopedic surgery,²² spinal cord injury,²³ and geriatric medicine.²⁴

The competencies, milestones, and entrustable professional activities were compiled and redundancies were eliminated. Wound care specialists from geriatrics, family medicine, internal medicine, undersea and hyperbaric medicine, general surgery, podiatry, and physical therapy examined the findings and suggested eliminating redundancies, irrelevant content, and content that fell below the minimal expected level of competence for an advanced medical specialist in wound care. An expert consensus meeting further refined items presented to the panel before unanimous consensus resulted in the final set of curriculum competencies, milestones, and entrustable professional activities.

Training Program Feedback

We developed a comprehensive wound care curriculum for an advanced physician fellowship training program based on the streamlined competencies, milestones, and entrustable professional activities (Appendix). Multiple wound care experts from various interdisciplinary backgrounds reached consensus to establish this fellowship curriculum as adaptable for use across training settings. The training program is 12 core rotations and 2 elective rotations (Table 1). Additionally, we developed wound care evaluation forms for faculty-, peer-, and self-assessment of trainees which were adapted from an evidence-based 360-degree evaluation template.²⁵ Suggestions for structured, advanced didactics are in Table 2.

Seventeen fellows have successfully matriculated through the wound care training program. Although wound care certification is not required to work as a wound care specialist, after completion of this fellowship, graduates are able to sit for a wound care certification examination. The American Board of Wound Medicine and Surgery (ABWMS) and the American Board of Wound Management (ABWM) allow physicians to take a certification examination after 1 year of a dedicated wound fellowship program, instead of the typical wound care practice experience ≥ 3 years.

The Clinical Wound Care Fellowship Program collected data for program improvement, and 15 alumni responded (response rate, 88%) to a survey using a 5-point Likert scale. Respondents indicated high mean scores for overall satisfaction (4.7), instructional methods (4.7), program enjoyment (4.7), teaching materials (4.6), and relevance (4.6). All respondents indicated that the fellowship prepared them for a career in wound care as well as their current employment, and 13 of 15 (87%) reported they obtained immediate relevant postfellowship wound care positions and stated that the fellowship prepared them for their current roles. Nine respondents (69%) reported that they were engaged in wound care ≥ 26% of work time. Six respondents (46%) worked in private practice, 3 (23%) at academic medical centers, and 2 (15%) at government- funded hospitals. Four respondents indicated they were board certified in wound care. Program alumni are currently involved in scholarly activities, including 8 in quality improvement and 3 in research.

Discussion

An easily accessible, comprehensive wound care fellowship curriculum has not been previously developed or published. This limited the sources that informed this curriculum. However, the developmental process for this curriculum was robust, as the authors reviewed previously published materials related to wound care, including: 1) descriptive overviews of wound care fellowships; 2) details of month-long rotations for medical students and residents; and 3) practices of the specific environment in which this curriculum was created. Confidence in the practical nature of the curriculum can be assumed, as the experts involved in the development process represented diverse physician specializations, including geriatrics, family medicine, internal medicine, undersea and hyperbaric medicine, general surgery, podiatry, and physical therapy.

Most wound care clinicians have not completed a formal comprehensive fellowship program. Instead, due to the lack of a comprehensive training curriculum, clinicians have had to use various continuing medical education programs and practice in a wound care setting for ≥ 3 years to be eligible for certification in the specialty. This curriculum will help academic medical centers develop their own fellowship programs, enabling new wound care clinicians to attain certifications more efficiently. As more fellowship programs develop, the goal would be to obtain recognition as an ACGME specialty and standardize the training and competencies for graduates of wound care fellowships.

Conclusions

As new wound care fellowships develop, wound care may become formally acknowledged as its own specialty within medicine and surgery. This will provide wound care with a voice at the national level, particularly in an era of value-based care. Wound care clinicians will be able to advocate for specialty-specific quality metrics and avoid potential penalization for not meeting quality metrics that are irrelevant to wound care.

Often disguised as comorbid conditions, nonhealing and chronic wounds have emerged as a silent epidemic that affects about 6.5 million Americans.^1-3 In 2023, estimated US wound care costs were $126.86 billion.⁴ About 1% to 2% of individuals worldwide will experience a chronic wound in their lifetime. The Veterans Health Administration reported 277,000 inpatient and outpatient encounters for ulcers in 2011, including chronic ulcers of the lower extremity due to diabetes, venous disease, or arterial disease.⁵ Associated costs of chronic wounds are expected to increase as the populations of developed countries age.⁶ Effective treatment of chronic wounds requires a nuanced understanding of complex wound pathophysiology, best practices in interdisciplinary and multidisciplinary wound care, and advanced wound care technologies.^7,8

The typical 4-year medical school curriculum, followed by residency, offers little in the way of formal didactic training in wound care.^9,10 Without specialized and advanced fellowship training dedicated to wound care, health care will lack specialists prepared to manage complex wounds. As a result, wound care-related difficulties may be exacerbated by prolonged recovery time, increased costs, productivity loss, and increased mortality risk.⁸ Wound care is a growing field of study and practice, and there is a critical need for rigorous training, research, and quality improvement efforts to enhance outcomes for patients with nonhealing wounds.⁵

One of the most direct ways to address the need for more physicians with specialty training in wound medicine is to implement a comprehensive training curriculum for advanced wound care practice. Although specialized advanced wound care fellowships are available, the curricula primarily detail rotation names and areas for practice without accompanying competencies, milestones, or entrustable professional activities.¹¹ Furthermore, wound care is not recognized as a subspecialty by the Accreditation Council for Graduate Medical Education (ACGME).

This article synthesized the literature and integrated innovative, evidence-based practices into a curriculum for a formal advanced fellowship training program. To our knowledge, no comprehensive wound care curriculum is publicly available that includes rotations, competencies, milestones, entrustable professional activities, and 360-degree evaluation forms.

Program Development

The advanced wound care fellowship program started in January 2014 at the Michael E. DeBakey Veterans Affairs Medical Center in affiliation with the Baylor College of Medicine. The fellowship program was originally designed for geriatrics fellows to extend the 1-year fellowship for an additional year to learn wound care. It has been adjusted to address formal program goals and objectives, competencies, milestones, entrustable professional activities, and evaluations, with the goal of developing an example curriculum for wound care fellowships across specialties. Although the ACGME does not recognize a wound care subspecialty, this curriculum complies with the ACGME 1-year fellowship common program requirements.^12,13

Scoping Review

A scoping literature review of Google Scholar and PubMed was performed using the medical subject heading terms “wound care + curriculum” and “wound + care + curriculum” to find advanced wound care medical training, fellowship programs, boards, and related ACGME-accredited specialty curricula. The local wound care fellowship program was initially implemented based on an informal literature review by faculty and their respective contributions to curriculum (ie, process establishing wound care-specific competency domains in accordance with ACGME accreditation competency requirements of 1-year fellowships). ^12,13 Standing program practice-based competencies and activities were examined and determined to align with best practices. This scoping review considered additional competencies, competency domains, and entrustable professional activities of reputable wound care fellowship training programs (eg, University of Chicago at Illinois and Wake Forest School of Medicine),^8,11,14 a specialty wound care board (American Board of Wound Medicine and Surgery),¹⁵ an international wound specialist professional society (European Union of Medical Specialists), ¹⁶ and recommended curriculum guidelines for wound care residency programs.¹⁷ ACGME-accredited specialty and subspecialty milestones professional activities were examined, including vascular surgery,¹⁸ plastic surgery,¹⁹ dermatology, ²⁰ foot and ankle,²¹ orthopedic surgery,²² spinal cord injury,²³ and geriatric medicine.²⁴

The competencies, milestones, and entrustable professional activities were compiled and redundancies were eliminated. Wound care specialists from geriatrics, family medicine, internal medicine, undersea and hyperbaric medicine, general surgery, podiatry, and physical therapy examined the findings and suggested eliminating redundancies, irrelevant content, and content that fell below the minimal expected level of competence for an advanced medical specialist in wound care. An expert consensus meeting further refined items presented to the panel before unanimous consensus resulted in the final set of curriculum competencies, milestones, and entrustable professional activities.

Training Program Feedback

We developed a comprehensive wound care curriculum for an advanced physician fellowship training program based on the streamlined competencies, milestones, and entrustable professional activities (Appendix). Multiple wound care experts from various interdisciplinary backgrounds reached consensus to establish this fellowship curriculum as adaptable for use across training settings. The training program is 12 core rotations and 2 elective rotations (Table 1). Additionally, we developed wound care evaluation forms for faculty-, peer-, and self-assessment of trainees which were adapted from an evidence-based 360-degree evaluation template.²⁵ Suggestions for structured, advanced didactics are in Table 2.

Seventeen fellows have successfully matriculated through the wound care training program. Although wound care certification is not required to work as a wound care specialist, after completion of this fellowship, graduates are able to sit for a wound care certification examination. The American Board of Wound Medicine and Surgery (ABWMS) and the American Board of Wound Management (ABWM) allow physicians to take a certification examination after 1 year of a dedicated wound fellowship program, instead of the typical wound care practice experience ≥ 3 years.

The Clinical Wound Care Fellowship Program collected data for program improvement, and 15 alumni responded (response rate, 88%) to a survey using a 5-point Likert scale. Respondents indicated high mean scores for overall satisfaction (4.7), instructional methods (4.7), program enjoyment (4.7), teaching materials (4.6), and relevance (4.6). All respondents indicated that the fellowship prepared them for a career in wound care as well as their current employment, and 13 of 15 (87%) reported they obtained immediate relevant postfellowship wound care positions and stated that the fellowship prepared them for their current roles. Nine respondents (69%) reported that they were engaged in wound care ≥ 26% of work time. Six respondents (46%) worked in private practice, 3 (23%) at academic medical centers, and 2 (15%) at government- funded hospitals. Four respondents indicated they were board certified in wound care. Program alumni are currently involved in scholarly activities, including 8 in quality improvement and 3 in research.

Discussion

An easily accessible, comprehensive wound care fellowship curriculum has not been previously developed or published. This limited the sources that informed this curriculum. However, the developmental process for this curriculum was robust, as the authors reviewed previously published materials related to wound care, including: 1) descriptive overviews of wound care fellowships; 2) details of month-long rotations for medical students and residents; and 3) practices of the specific environment in which this curriculum was created. Confidence in the practical nature of the curriculum can be assumed, as the experts involved in the development process represented diverse physician specializations, including geriatrics, family medicine, internal medicine, undersea and hyperbaric medicine, general surgery, podiatry, and physical therapy.

Most wound care clinicians have not completed a formal comprehensive fellowship program. Instead, due to the lack of a comprehensive training curriculum, clinicians have had to use various continuing medical education programs and practice in a wound care setting for ≥ 3 years to be eligible for certification in the specialty. This curriculum will help academic medical centers develop their own fellowship programs, enabling new wound care clinicians to attain certifications more efficiently. As more fellowship programs develop, the goal would be to obtain recognition as an ACGME specialty and standardize the training and competencies for graduates of wound care fellowships.

Conclusions

As new wound care fellowships develop, wound care may become formally acknowledged as its own specialty within medicine and surgery. This will provide wound care with a voice at the national level, particularly in an era of value-based care. Wound care clinicians will be able to advocate for specialty-specific quality metrics and avoid potential penalization for not meeting quality metrics that are irrelevant to wound care.

The US Department of Veterans Affairs (VA) Home Loan Program, administered by the Veterans Benefits Administration (VBA), is a unique benefit for veterans, active-duty service members, National Guard and Reserve members, and eligible surviving spouses. Established in 1944, the program aims to help these individuals achieve homeownership by leveraging a third-party guarantee, typically from a government agency, to enhance access to credit and improve loan terms for borrowers who may not meet conventional loan qualifications.¹ Since its inception, the VA has guaranteed > 28.5 million loans, enabling millions of veterans to buy, build, repair, retain, or adapt homes for personal occupancy.² The program is designed to support veterans and eligible individuals to become homeowners, recognizing homeownership as a pathway to financial stability and community integration. VA home loans are provided by private lenders (eg, banks, mortgage companies) with a portion guaranteed by the VA, which reduces the risk for lenders and enables them to offer competitive terms, such as no down payment and lower interest rates, making homeownership more accessible to veterans.²

Eligibility criteria for the VA Home Loan Program include military service criteria such as active-duty service members with ≥ 90 continuous days of service; veterans with an honorable discharge meeting minimum service requirements; individuals who served in the National Guard/Reserve for ≥ 90 days of active service or 6 years of service with an honorable discharge; and surviving spouses of veterans who died in service or from a service-connected disability, were designated as missing in action/ prisoner of war, and the spouse is receiving Dependency and Indemnity Compensation. Financial criteria also apply: borrowers must meet lender requirements for credit and income (although VA loans are more flexible than conventional loans) and the home must be for personal occupancy rather than an investment property.³

A June 2025 PubMed literature search did not reveal any prior research on the VA Home Loan Program, although a limited number of studies tackled a wide range of issues related to federal and private home loans.^4-12 To our knowledge, there is no prior published examination of the VA Home Loan Program. Understanding VA Home Loan Program usage among Veterans Health Administration (VHA) users can inform the future direction of the program. The VHA operates the largest integrated US health care system, serving > 9 million enrolled veterans annually at 1321 facilities, including 172 medical centers and 1138 outpatient clinics, providing primary and specialized health care, and related medical and social support services for enrolled veterans, including those who are experiencing housing instability or homelessness.¹³ Specialized VHA programs for homeless veterans include housing, employment, health care, justice, and re-entryrelated services in collaboration with federal and community partners.¹⁴ Housing instability has been defined as the state of being at risk of losing housing due to challenges such as difficulties paying rent, overcrowding, frequent relocation, and a substantial proportion of income spent on housing.^15,16 Homelessness is a severe manifestation of housing instability that has been defined as the lack of stable, safe, and functioning housing.^17,18

Health care and social services, including those that address housing instability and homelessness, are major priorities for the VHA and VBA.¹⁹ The VA Home Loan Program may represent an important resource to help veterans achieve long-term housing stability through home ownership. There has been wide public concern about housing affordability and the ability of many Americans, including veterans, to achieve home ownership.²⁰ Homeownership is considered an important part of developing financial assets and achieving financial stability. Lowincome veterans, in particular, may benefit from this program as a national study found that 8.0% of low-income veterans and 13.9% of veterans with a history of homelessness have previously experienced a home foreclosure. ²¹ A greater understanding of who applies for and receives assistance from the VA Home Loan Program would inform homelessness prevention services and future planning for this program.

We conducted a quality improvement (QI) project on behalf of the VHA Homeless Programs Office and in partnership with the VBA. Our goals were to: (1) describe the annual number of applicants and recipients of the VA Home Loan Program by age group, sex, race/ethnicity, presence of any diagnosed substance use and/or mental health disorder, and history of homelessness; and (2) compare demographic, clinical, and homelessness characteristics among individuals who apply and are granted a loan through this program, individuals who apply and are denied a loan through this program, and individuals who do not apply for a loan through this program.

Methods

This project involved linked VA administrative national databases and was undertaken by the VHA Homeless Programs Office in partnership with the VBA. Specifically, VHA and VBA databases were linked together using veteran identifiers and all data were managed and analyzed on secure VA servers. The project followed VA’s Program Guide 1200.21 for nonresearch activities and institutional review board approval was waived through sponsorship by the VA Homeless Programs Office. The VHA Corporate Data Warehouse (CDW) was accessed to obtain data from the Homeless Operations Management and Evaluation System (HOMES) and other clinical data systems used by VHA clinicians and administrators that capture diagnoses, workload, and other health care data.^22,23 HOMES collects intake, progress, and outcome data on homeless veterans within its care system that enables the VA to assess the effectiveness of programs and strategically allocate resources to prevent homelessness.^24,25

A list of veterans who filed disability compensation and pension claims was obtained from the VBA Office of Performance Analysis and Integrity, including Social Security number, name, city and state, date of claim submission, grant or increase in benefits, homeless status, VA home loan approval, and homeless aid for dependent children from fiscal year (FY) 2022 through FY 2024. VBA data were linked to VHA CDW electronic health record data from veterans who sought VA health care services and HOMES data on veteran participation in homeless programs who were also experiencing homelessness. VHA data included demographic characteristics (eg, sex, age, race, marital status, combat service) at an index date (earliest visit to the VHA between October 1, 2021, and September 30, 2024); military sexual trauma; clinical characteristics within 12 months prior to the index date (VHA disability rating, substance use disorder [SUD] diagnosis, mental health disorder diagnosis, Charlson Comorbidity Index [CCI] score), and homelessness experience ≤ 5 years prior to the index date.

History of homelessness ≤ 5 years prior to the index date was determined using an operational definition of homelessness based on multiple indicators, including International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic code Z59.0; clinic stop codes or HOMES records indicating VA homeless programs clinical encounters; or a positive screen on an annual homelessness screener.¹⁶ US Department of Housing and Urban Development-VA Supportive Housing enrollees were excluded because they are considered to no longer be experiencing homelessness, and Veterans Justice Program enrollees were excluded because the program primarily focuses on serving criminal justice-involved veterans. The CCI predicts the risk of death ≤ 1 year by assessing the number and severity of a patient’s coexisting health conditions and is a valuable tool for understanding a patient’s overall health burden, aiding in clinical decision-making and evaluation research studies.^26-29 Diagnoses based on ICD-10-CM codes were used to determine SUDs, mental health disorders, and CCI score, using methods that have been described in other publications.³⁰

Population

The VBA cohort of veterans requesting benefits was further restricted to those who met the following eligibility criteria: (1) requested VA benefits FYs 2022 to 2024; (2) sought VHA services ≥ 1 time between FY 2022 and 2024; (3) had matching VBA/VHA records; (4) had no missing data on claim status and/ or demographic, clinical, and homelessness characteristics; and (5) had known home loan status FYs 2022 to 2024. The original VBA dataset consisted of 4,219,755 records and the original VHA dataset consisted of 7,170,199 records (Figure 1). The final linked VBA/VHA dataset after excluding 29 records with missing data on sex, 7 with missing data on age, 6 with missing data on marital status, and an additional 143,444 with unknown VBA claim status, consisted of 3,089,295 records corresponding to 2,260,851 unique veterans. Specifically, 251,796 records corresponded to veterans who had applied and received a loan, 84,751 to veterans who had applied and were nonrecipients of a loan, and 2,752,748 to veterans who did not apply for a loan.

Statistical Analysis

All statistical analyses were performed using SAS Enterprise Guide, an application that provides a point-and-click interface for data access, analysis, and management, accommodating both code-based and visual programming. ³¹ First, we relied on the final analytic sample to calculate the annual proportions of veterans who applied for and/or received a loan through the VA Home Loan Program. We also generated descriptive statistics stratified by age group, sex, race/ethnicity, SUD, mental health disorder, and homelessness, overall and within each FY. Pearson χ² and Cochran-Armitage trend tests were applied to examine differences in application and receipt of a home loan by baseline characteristics and FY, respectively. Second, we conducted bivariate and multivariable analyses to compare demographic, clinical, and homelessness characteristics between 3 groups of veterans as they pertain to the VA Home Loan Program. Veterans who applied and were nonrecipients of a loan (group 1), veterans who applied and were recipients of a loan (group 2), and veterans who did not apply for a loan (group 3). Similar analyses compared VA Home Loan Program applicants who were recipients of a home loan vs VA Home Loan Program applicants who were nonrecipients of a home loan. Multinomial and binary logistic regression models were constructed to estimate the relative risk ratio (RR) and odds ratio (OR) with 95% CIs for comparisons between these distinct groups on demographic, clinical, and homelessness characteristics. Two-sided statistical tests were evaluated at α = 0.05.

Results

Tables 1 and 2 present the number of VBA applicants, including those who applied for and received benefits through the VA Home Loan Program, by age group, sex, race/ethnicity, as well as histories of SUDs, mental health disorders, and homelessness, overall, and by FY. As shown in Figure 2, 336,547 of 3,089,295 VBA applications (10.9%) pertained to the VA Home Loan Program, with a statistically significant decline in application rates, from 12.2% in FY 2022 to 9.9% in FY 2024 (P < .001 for trend). Among 336,547 veterans who applied for the VA Home Loan Program, 251,796 (74.8%) received a home loan during FYs 2022 to 2024, ranging between 73.8% for FY 2024 and 75.5% for FY 2023 (P < .001 for trend).

Multinomial logistic regression models for demographic, clinical, and homelessness characteristics as predictors of VA Home Loan Program status are provided in Appendix 1. Based on the fully adjusted model, compared with veterans who did not apply to the VA Home Loan Program, those who applied for a home loan were less likely to be aged ≥ 50 years, unmarried, Hispanic ethnicity, mixed race, or other race, diagnosed with a SUD, or history of homelessness. Veterans with higher VA service-connected disability ratings were more frequently recipients of VA home loans, whereas those who self-identified as non-Hispanic Black and those with higher CCI scores were less frequently recipients of VA home loans. Finally, those with mental health disorders were more likely than their counterparts to be applicants (recipients or nonrecipients) of VA home loans.

Binary logistic regression models for demographic, clinical, and homelessness characteristics as predictors of receipt status among applicants to the VA Home Loan Program are provided in Appendix 2. Among applicants, those who were granted a VA home loan were less likely to be aged ≥ 50 years; have a CCI score > 0; have experienced combat service and/or military sexual trauma; be diagnosed with a SUD and/or mental health disorder; or to have a history of homelessness compared with those denied a VA home loan. Applicants granted a VA home loan were also more likely to be female, non-Hispanic White, single or never married, and/or have a VA service-connected disability ratings > 0%.

Discussion

The VA Home Loan Program is a unique benefit and resource for eligible veterans that may be increasingly important in a time of growing concern about the affordability of housing for many Americans. Research on other federally-supported home loan programs as well as private home mortgage programs has been mostly conducted in the economic realm, and studies focused on understanding these programs from a health care system perspective have been sparse.^32,33 However, there is a large body of literature documenting the importance of stable, safe, and secure housing on health and well-being.^34-37 This study did not focus on evaluating the effects of the VA Home Loan Program, because we wanted to first examine the characteristics of veterans who benefited from the program and how they differed from veterans who did not apply or did apply but had a denied application.

Our findings suggest that several thousands of veterans benefit from the VA Home Loan Program each year. For historical context, the time period examined was one of economic downturn with rising costs of living, including housing, and steady increases in homelessness as reported in the annual point-in-time count of sheltered and unsheltered people experiencing homelessness on a single night as mandated by the US Department of Housing and Urban Development.^38-40 The Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022 expanded health care and benefits for veterans exposed to burn pits, Agent Orange, and other toxic substances, resulting in more VA disability benefit claims, including large retroactive payments.^41-43 Anecdotally, the VBA has noted that the PACT Act helped some homeless veterans with funds and stability to exit homelessness and enroll in the VA Home Loan Program.

Our analysis suggests that beneficiaries of the VA Home Loan Program were frequently aged < 50 years, female, of non-Hispanic White race, and did not have histories of psychiatric disorders or homelessness. Most of these demographic and clinical characteristics were not surprising given the composition of the veteran population, although in-depth analyses are needed to examine sex differences that may have led to more females than males benefiting from the VA Home Loan Program. In addition, it was notable that many younger and non-Hispanic Black veterans had applied. While relatively few veterans with SUDs benefited from the VA Home Loan Program, few had applied. Research is warranted into why veterans with SUDs are less likely to apply for home loans. Quite surprisingly, a sizable proportion of veterans with histories of homelessness reported they had applied to the VA Home Loan Program, although they were less likely than veterans who had not experienced homelessness to be granted a loan.

The examination of differences between veterans who did not apply, were granted, and denied a loan through the VA Home Loan Program revealed several key predictors of application outcomes in multivariable models. Specifically, veterans who applied for home loans were less likely to be aged ≥ 50 years, unmarried, of Hispanic, mixed, or other race/ethnicity, diagnosed with an SUD, or have a history of homelessness. Veterans with higher disability ratings were less frequently denied and more frequently approved, while non-Hispanic Black veterans and those with higher CCI scores were more frequently denied and less frequently approved. VBA applicants with mental health disorders were also more likely to apply for a home loan. Conversely, those granted a home loan were more likely than those denied a home loan to be female, non-Hispanic White, single/unmarried, or to have > 0% VA service-connected disability rating, but less likely to be aged ≥ 50 years, have CCI score > 0, be diagnosed with psychiatric disorders, or have a history of homelessness.

Limitations

This analysis was restricted to a subset of FY 2022 to FY 2024 linked VBA/VHA databases (ie, to veterans who had both VBA and VHA records and met prespecified eligibility criteria). Despite the large number of linked records, a small percentage of these records corresponded to veterans who were applicants or recipients of the VA Home Loan Program. Future studies should expand the time frame to examine variations in application outcomes over time and by background characteristics of veterans enrolled in VHA care who applied for VBA benefits. In addition, we relied on data and ICD-10-CM diagnostic codes from existing electronic health records and claims data to define histories of homelessness, comorbidities, SUDs, and mental health disorders. Given the time-varying nature of these conditions, the temporal sequence of events was difficult to ascertain. Third, it is worth noting that these findings can only be generalized to veterans who applied for VBA benefits and met eligibility criteria, and that these veterans may differ in terms of their demographic and clinical characteristics from those who did not apply for these benefits.

Conclusions

This study analyzed data from 251,796 individuals who applied for and received a VA home loan, 84,751 who were denied a VA home loan, and 2,752,748 veterans who did not apply for a VA home loan from FY 2022 to FY 2024. Accordingly, 11% of applications pertained to the VA Home Loan Program, and 75% of VA Home Loan Program applicants received a home loan. Distinct demographic and clinical characteristics were observed for applicants and recipients of the VA Home Loan Program, which can set the stage for future planning and evaluation of the program. Despite the broad accessibility of veterans to the VA Home Loan Program, there were differences in approval rates among applicants based on sociodemographic and clinical characteristics. Further evaluation, perhaps using qualitative methods, is needed to better understand opportunities and challenges to achieving a VA home loan, especially among underserved veteran populations. Investigation and research can guide future recommendations for any development or corrective actions that can help increase access to veterans who can benefit from the program. Future analyses are also needed to compare veterans enrolled and not enrolled in the VA Home Loan Program on health care-related outcomes.

The US Department of Veterans Affairs (VA) Home Loan Program, administered by the Veterans Benefits Administration (VBA), is a unique benefit for veterans, active-duty service members, National Guard and Reserve members, and eligible surviving spouses. Established in 1944, the program aims to help these individuals achieve homeownership by leveraging a third-party guarantee, typically from a government agency, to enhance access to credit and improve loan terms for borrowers who may not meet conventional loan qualifications.¹ Since its inception, the VA has guaranteed > 28.5 million loans, enabling millions of veterans to buy, build, repair, retain, or adapt homes for personal occupancy.² The program is designed to support veterans and eligible individuals to become homeowners, recognizing homeownership as a pathway to financial stability and community integration. VA home loans are provided by private lenders (eg, banks, mortgage companies) with a portion guaranteed by the VA, which reduces the risk for lenders and enables them to offer competitive terms, such as no down payment and lower interest rates, making homeownership more accessible to veterans.²

Eligibility criteria for the VA Home Loan Program include military service criteria such as active-duty service members with ≥ 90 continuous days of service; veterans with an honorable discharge meeting minimum service requirements; individuals who served in the National Guard/Reserve for ≥ 90 days of active service or 6 years of service with an honorable discharge; and surviving spouses of veterans who died in service or from a service-connected disability, were designated as missing in action/ prisoner of war, and the spouse is receiving Dependency and Indemnity Compensation. Financial criteria also apply: borrowers must meet lender requirements for credit and income (although VA loans are more flexible than conventional loans) and the home must be for personal occupancy rather than an investment property.³

A June 2025 PubMed literature search did not reveal any prior research on the VA Home Loan Program, although a limited number of studies tackled a wide range of issues related to federal and private home loans.^4-12 To our knowledge, there is no prior published examination of the VA Home Loan Program. Understanding VA Home Loan Program usage among Veterans Health Administration (VHA) users can inform the future direction of the program. The VHA operates the largest integrated US health care system, serving > 9 million enrolled veterans annually at 1321 facilities, including 172 medical centers and 1138 outpatient clinics, providing primary and specialized health care, and related medical and social support services for enrolled veterans, including those who are experiencing housing instability or homelessness.¹³ Specialized VHA programs for homeless veterans include housing, employment, health care, justice, and re-entryrelated services in collaboration with federal and community partners.¹⁴ Housing instability has been defined as the state of being at risk of losing housing due to challenges such as difficulties paying rent, overcrowding, frequent relocation, and a substantial proportion of income spent on housing.^15,16 Homelessness is a severe manifestation of housing instability that has been defined as the lack of stable, safe, and functioning housing.^17,18

Health care and social services, including those that address housing instability and homelessness, are major priorities for the VHA and VBA.¹⁹ The VA Home Loan Program may represent an important resource to help veterans achieve long-term housing stability through home ownership. There has been wide public concern about housing affordability and the ability of many Americans, including veterans, to achieve home ownership.²⁰ Homeownership is considered an important part of developing financial assets and achieving financial stability. Lowincome veterans, in particular, may benefit from this program as a national study found that 8.0% of low-income veterans and 13.9% of veterans with a history of homelessness have previously experienced a home foreclosure. ²¹ A greater understanding of who applies for and receives assistance from the VA Home Loan Program would inform homelessness prevention services and future planning for this program.

We conducted a quality improvement (QI) project on behalf of the VHA Homeless Programs Office and in partnership with the VBA. Our goals were to: (1) describe the annual number of applicants and recipients of the VA Home Loan Program by age group, sex, race/ethnicity, presence of any diagnosed substance use and/or mental health disorder, and history of homelessness; and (2) compare demographic, clinical, and homelessness characteristics among individuals who apply and are granted a loan through this program, individuals who apply and are denied a loan through this program, and individuals who do not apply for a loan through this program.

Methods

This project involved linked VA administrative national databases and was undertaken by the VHA Homeless Programs Office in partnership with the VBA. Specifically, VHA and VBA databases were linked together using veteran identifiers and all data were managed and analyzed on secure VA servers. The project followed VA’s Program Guide 1200.21 for nonresearch activities and institutional review board approval was waived through sponsorship by the VA Homeless Programs Office. The VHA Corporate Data Warehouse (CDW) was accessed to obtain data from the Homeless Operations Management and Evaluation System (HOMES) and other clinical data systems used by VHA clinicians and administrators that capture diagnoses, workload, and other health care data.^22,23 HOMES collects intake, progress, and outcome data on homeless veterans within its care system that enables the VA to assess the effectiveness of programs and strategically allocate resources to prevent homelessness.^24,25

A list of veterans who filed disability compensation and pension claims was obtained from the VBA Office of Performance Analysis and Integrity, including Social Security number, name, city and state, date of claim submission, grant or increase in benefits, homeless status, VA home loan approval, and homeless aid for dependent children from fiscal year (FY) 2022 through FY 2024. VBA data were linked to VHA CDW electronic health record data from veterans who sought VA health care services and HOMES data on veteran participation in homeless programs who were also experiencing homelessness. VHA data included demographic characteristics (eg, sex, age, race, marital status, combat service) at an index date (earliest visit to the VHA between October 1, 2021, and September 30, 2024); military sexual trauma; clinical characteristics within 12 months prior to the index date (VHA disability rating, substance use disorder [SUD] diagnosis, mental health disorder diagnosis, Charlson Comorbidity Index [CCI] score), and homelessness experience ≤ 5 years prior to the index date.

History of homelessness ≤ 5 years prior to the index date was determined using an operational definition of homelessness based on multiple indicators, including International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic code Z59.0; clinic stop codes or HOMES records indicating VA homeless programs clinical encounters; or a positive screen on an annual homelessness screener.¹⁶ US Department of Housing and Urban Development-VA Supportive Housing enrollees were excluded because they are considered to no longer be experiencing homelessness, and Veterans Justice Program enrollees were excluded because the program primarily focuses on serving criminal justice-involved veterans. The CCI predicts the risk of death ≤ 1 year by assessing the number and severity of a patient’s coexisting health conditions and is a valuable tool for understanding a patient’s overall health burden, aiding in clinical decision-making and evaluation research studies.^26-29 Diagnoses based on ICD-10-CM codes were used to determine SUDs, mental health disorders, and CCI score, using methods that have been described in other publications.³⁰

Population

The VBA cohort of veterans requesting benefits was further restricted to those who met the following eligibility criteria: (1) requested VA benefits FYs 2022 to 2024; (2) sought VHA services ≥ 1 time between FY 2022 and 2024; (3) had matching VBA/VHA records; (4) had no missing data on claim status and/ or demographic, clinical, and homelessness characteristics; and (5) had known home loan status FYs 2022 to 2024. The original VBA dataset consisted of 4,219,755 records and the original VHA dataset consisted of 7,170,199 records (Figure 1). The final linked VBA/VHA dataset after excluding 29 records with missing data on sex, 7 with missing data on age, 6 with missing data on marital status, and an additional 143,444 with unknown VBA claim status, consisted of 3,089,295 records corresponding to 2,260,851 unique veterans. Specifically, 251,796 records corresponded to veterans who had applied and received a loan, 84,751 to veterans who had applied and were nonrecipients of a loan, and 2,752,748 to veterans who did not apply for a loan.

Statistical Analysis

All statistical analyses were performed using SAS Enterprise Guide, an application that provides a point-and-click interface for data access, analysis, and management, accommodating both code-based and visual programming. ³¹ First, we relied on the final analytic sample to calculate the annual proportions of veterans who applied for and/or received a loan through the VA Home Loan Program. We also generated descriptive statistics stratified by age group, sex, race/ethnicity, SUD, mental health disorder, and homelessness, overall and within each FY. Pearson χ² and Cochran-Armitage trend tests were applied to examine differences in application and receipt of a home loan by baseline characteristics and FY, respectively. Second, we conducted bivariate and multivariable analyses to compare demographic, clinical, and homelessness characteristics between 3 groups of veterans as they pertain to the VA Home Loan Program. Veterans who applied and were nonrecipients of a loan (group 1), veterans who applied and were recipients of a loan (group 2), and veterans who did not apply for a loan (group 3). Similar analyses compared VA Home Loan Program applicants who were recipients of a home loan vs VA Home Loan Program applicants who were nonrecipients of a home loan. Multinomial and binary logistic regression models were constructed to estimate the relative risk ratio (RR) and odds ratio (OR) with 95% CIs for comparisons between these distinct groups on demographic, clinical, and homelessness characteristics. Two-sided statistical tests were evaluated at α = 0.05.

Results

Tables 1 and 2 present the number of VBA applicants, including those who applied for and received benefits through the VA Home Loan Program, by age group, sex, race/ethnicity, as well as histories of SUDs, mental health disorders, and homelessness, overall, and by FY. As shown in Figure 2, 336,547 of 3,089,295 VBA applications (10.9%) pertained to the VA Home Loan Program, with a statistically significant decline in application rates, from 12.2% in FY 2022 to 9.9% in FY 2024 (P < .001 for trend). Among 336,547 veterans who applied for the VA Home Loan Program, 251,796 (74.8%) received a home loan during FYs 2022 to 2024, ranging between 73.8% for FY 2024 and 75.5% for FY 2023 (P < .001 for trend).

Multinomial logistic regression models for demographic, clinical, and homelessness characteristics as predictors of VA Home Loan Program status are provided in Appendix 1. Based on the fully adjusted model, compared with veterans who did not apply to the VA Home Loan Program, those who applied for a home loan were less likely to be aged ≥ 50 years, unmarried, Hispanic ethnicity, mixed race, or other race, diagnosed with a SUD, or history of homelessness. Veterans with higher VA service-connected disability ratings were more frequently recipients of VA home loans, whereas those who self-identified as non-Hispanic Black and those with higher CCI scores were less frequently recipients of VA home loans. Finally, those with mental health disorders were more likely than their counterparts to be applicants (recipients or nonrecipients) of VA home loans.

Binary logistic regression models for demographic, clinical, and homelessness characteristics as predictors of receipt status among applicants to the VA Home Loan Program are provided in Appendix 2. Among applicants, those who were granted a VA home loan were less likely to be aged ≥ 50 years; have a CCI score > 0; have experienced combat service and/or military sexual trauma; be diagnosed with a SUD and/or mental health disorder; or to have a history of homelessness compared with those denied a VA home loan. Applicants granted a VA home loan were also more likely to be female, non-Hispanic White, single or never married, and/or have a VA service-connected disability ratings > 0%.

Discussion

The VA Home Loan Program is a unique benefit and resource for eligible veterans that may be increasingly important in a time of growing concern about the affordability of housing for many Americans. Research on other federally-supported home loan programs as well as private home mortgage programs has been mostly conducted in the economic realm, and studies focused on understanding these programs from a health care system perspective have been sparse.^32,33 However, there is a large body of literature documenting the importance of stable, safe, and secure housing on health and well-being.^34-37 This study did not focus on evaluating the effects of the VA Home Loan Program, because we wanted to first examine the characteristics of veterans who benefited from the program and how they differed from veterans who did not apply or did apply but had a denied application.

Our findings suggest that several thousands of veterans benefit from the VA Home Loan Program each year. For historical context, the time period examined was one of economic downturn with rising costs of living, including housing, and steady increases in homelessness as reported in the annual point-in-time count of sheltered and unsheltered people experiencing homelessness on a single night as mandated by the US Department of Housing and Urban Development.^38-40 The Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022 expanded health care and benefits for veterans exposed to burn pits, Agent Orange, and other toxic substances, resulting in more VA disability benefit claims, including large retroactive payments.^41-43 Anecdotally, the VBA has noted that the PACT Act helped some homeless veterans with funds and stability to exit homelessness and enroll in the VA Home Loan Program.

Our analysis suggests that beneficiaries of the VA Home Loan Program were frequently aged < 50 years, female, of non-Hispanic White race, and did not have histories of psychiatric disorders or homelessness. Most of these demographic and clinical characteristics were not surprising given the composition of the veteran population, although in-depth analyses are needed to examine sex differences that may have led to more females than males benefiting from the VA Home Loan Program. In addition, it was notable that many younger and non-Hispanic Black veterans had applied. While relatively few veterans with SUDs benefited from the VA Home Loan Program, few had applied. Research is warranted into why veterans with SUDs are less likely to apply for home loans. Quite surprisingly, a sizable proportion of veterans with histories of homelessness reported they had applied to the VA Home Loan Program, although they were less likely than veterans who had not experienced homelessness to be granted a loan.

The examination of differences between veterans who did not apply, were granted, and denied a loan through the VA Home Loan Program revealed several key predictors of application outcomes in multivariable models. Specifically, veterans who applied for home loans were less likely to be aged ≥ 50 years, unmarried, of Hispanic, mixed, or other race/ethnicity, diagnosed with an SUD, or have a history of homelessness. Veterans with higher disability ratings were less frequently denied and more frequently approved, while non-Hispanic Black veterans and those with higher CCI scores were more frequently denied and less frequently approved. VBA applicants with mental health disorders were also more likely to apply for a home loan. Conversely, those granted a home loan were more likely than those denied a home loan to be female, non-Hispanic White, single/unmarried, or to have > 0% VA service-connected disability rating, but less likely to be aged ≥ 50 years, have CCI score > 0, be diagnosed with psychiatric disorders, or have a history of homelessness.

Limitations

This analysis was restricted to a subset of FY 2022 to FY 2024 linked VBA/VHA databases (ie, to veterans who had both VBA and VHA records and met prespecified eligibility criteria). Despite the large number of linked records, a small percentage of these records corresponded to veterans who were applicants or recipients of the VA Home Loan Program. Future studies should expand the time frame to examine variations in application outcomes over time and by background characteristics of veterans enrolled in VHA care who applied for VBA benefits. In addition, we relied on data and ICD-10-CM diagnostic codes from existing electronic health records and claims data to define histories of homelessness, comorbidities, SUDs, and mental health disorders. Given the time-varying nature of these conditions, the temporal sequence of events was difficult to ascertain. Third, it is worth noting that these findings can only be generalized to veterans who applied for VBA benefits and met eligibility criteria, and that these veterans may differ in terms of their demographic and clinical characteristics from those who did not apply for these benefits.

Conclusions

This study analyzed data from 251,796 individuals who applied for and received a VA home loan, 84,751 who were denied a VA home loan, and 2,752,748 veterans who did not apply for a VA home loan from FY 2022 to FY 2024. Accordingly, 11% of applications pertained to the VA Home Loan Program, and 75% of VA Home Loan Program applicants received a home loan. Distinct demographic and clinical characteristics were observed for applicants and recipients of the VA Home Loan Program, which can set the stage for future planning and evaluation of the program. Despite the broad accessibility of veterans to the VA Home Loan Program, there were differences in approval rates among applicants based on sociodemographic and clinical characteristics. Further evaluation, perhaps using qualitative methods, is needed to better understand opportunities and challenges to achieving a VA home loan, especially among underserved veteran populations. Investigation and research can guide future recommendations for any development or corrective actions that can help increase access to veterans who can benefit from the program. Future analyses are also needed to compare veterans enrolled and not enrolled in the VA Home Loan Program on health care-related outcomes.

The US Department of Veterans Affairs (VA) Home Loan Program, administered by the Veterans Benefits Administration (VBA), is a unique benefit for veterans, active-duty service members, National Guard and Reserve members, and eligible surviving spouses. Established in 1944, the program aims to help these individuals achieve homeownership by leveraging a third-party guarantee, typically from a government agency, to enhance access to credit and improve loan terms for borrowers who may not meet conventional loan qualifications.¹ Since its inception, the VA has guaranteed > 28.5 million loans, enabling millions of veterans to buy, build, repair, retain, or adapt homes for personal occupancy.² The program is designed to support veterans and eligible individuals to become homeowners, recognizing homeownership as a pathway to financial stability and community integration. VA home loans are provided by private lenders (eg, banks, mortgage companies) with a portion guaranteed by the VA, which reduces the risk for lenders and enables them to offer competitive terms, such as no down payment and lower interest rates, making homeownership more accessible to veterans.²

Eligibility criteria for the VA Home Loan Program include military service criteria such as active-duty service members with ≥ 90 continuous days of service; veterans with an honorable discharge meeting minimum service requirements; individuals who served in the National Guard/Reserve for ≥ 90 days of active service or 6 years of service with an honorable discharge; and surviving spouses of veterans who died in service or from a service-connected disability, were designated as missing in action/ prisoner of war, and the spouse is receiving Dependency and Indemnity Compensation. Financial criteria also apply: borrowers must meet lender requirements for credit and income (although VA loans are more flexible than conventional loans) and the home must be for personal occupancy rather than an investment property.³

A June 2025 PubMed literature search did not reveal any prior research on the VA Home Loan Program, although a limited number of studies tackled a wide range of issues related to federal and private home loans.^4-12 To our knowledge, there is no prior published examination of the VA Home Loan Program. Understanding VA Home Loan Program usage among Veterans Health Administration (VHA) users can inform the future direction of the program. The VHA operates the largest integrated US health care system, serving > 9 million enrolled veterans annually at 1321 facilities, including 172 medical centers and 1138 outpatient clinics, providing primary and specialized health care, and related medical and social support services for enrolled veterans, including those who are experiencing housing instability or homelessness.¹³ Specialized VHA programs for homeless veterans include housing, employment, health care, justice, and re-entryrelated services in collaboration with federal and community partners.¹⁴ Housing instability has been defined as the state of being at risk of losing housing due to challenges such as difficulties paying rent, overcrowding, frequent relocation, and a substantial proportion of income spent on housing.^15,16 Homelessness is a severe manifestation of housing instability that has been defined as the lack of stable, safe, and functioning housing.^17,18

Health care and social services, including those that address housing instability and homelessness, are major priorities for the VHA and VBA.¹⁹ The VA Home Loan Program may represent an important resource to help veterans achieve long-term housing stability through home ownership. There has been wide public concern about housing affordability and the ability of many Americans, including veterans, to achieve home ownership.²⁰ Homeownership is considered an important part of developing financial assets and achieving financial stability. Lowincome veterans, in particular, may benefit from this program as a national study found that 8.0% of low-income veterans and 13.9% of veterans with a history of homelessness have previously experienced a home foreclosure. ²¹ A greater understanding of who applies for and receives assistance from the VA Home Loan Program would inform homelessness prevention services and future planning for this program.

We conducted a quality improvement (QI) project on behalf of the VHA Homeless Programs Office and in partnership with the VBA. Our goals were to: (1) describe the annual number of applicants and recipients of the VA Home Loan Program by age group, sex, race/ethnicity, presence of any diagnosed substance use and/or mental health disorder, and history of homelessness; and (2) compare demographic, clinical, and homelessness characteristics among individuals who apply and are granted a loan through this program, individuals who apply and are denied a loan through this program, and individuals who do not apply for a loan through this program.

Methods

This project involved linked VA administrative national databases and was undertaken by the VHA Homeless Programs Office in partnership with the VBA. Specifically, VHA and VBA databases were linked together using veteran identifiers and all data were managed and analyzed on secure VA servers. The project followed VA’s Program Guide 1200.21 for nonresearch activities and institutional review board approval was waived through sponsorship by the VA Homeless Programs Office. The VHA Corporate Data Warehouse (CDW) was accessed to obtain data from the Homeless Operations Management and Evaluation System (HOMES) and other clinical data systems used by VHA clinicians and administrators that capture diagnoses, workload, and other health care data.^22,23 HOMES collects intake, progress, and outcome data on homeless veterans within its care system that enables the VA to assess the effectiveness of programs and strategically allocate resources to prevent homelessness.^24,25

A list of veterans who filed disability compensation and pension claims was obtained from the VBA Office of Performance Analysis and Integrity, including Social Security number, name, city and state, date of claim submission, grant or increase in benefits, homeless status, VA home loan approval, and homeless aid for dependent children from fiscal year (FY) 2022 through FY 2024. VBA data were linked to VHA CDW electronic health record data from veterans who sought VA health care services and HOMES data on veteran participation in homeless programs who were also experiencing homelessness. VHA data included demographic characteristics (eg, sex, age, race, marital status, combat service) at an index date (earliest visit to the VHA between October 1, 2021, and September 30, 2024); military sexual trauma; clinical characteristics within 12 months prior to the index date (VHA disability rating, substance use disorder [SUD] diagnosis, mental health disorder diagnosis, Charlson Comorbidity Index [CCI] score), and homelessness experience ≤ 5 years prior to the index date.

History of homelessness ≤ 5 years prior to the index date was determined using an operational definition of homelessness based on multiple indicators, including International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnostic code Z59.0; clinic stop codes or HOMES records indicating VA homeless programs clinical encounters; or a positive screen on an annual homelessness screener.¹⁶ US Department of Housing and Urban Development-VA Supportive Housing enrollees were excluded because they are considered to no longer be experiencing homelessness, and Veterans Justice Program enrollees were excluded because the program primarily focuses on serving criminal justice-involved veterans. The CCI predicts the risk of death ≤ 1 year by assessing the number and severity of a patient’s coexisting health conditions and is a valuable tool for understanding a patient’s overall health burden, aiding in clinical decision-making and evaluation research studies.^26-29 Diagnoses based on ICD-10-CM codes were used to determine SUDs, mental health disorders, and CCI score, using methods that have been described in other publications.³⁰

Population

The VBA cohort of veterans requesting benefits was further restricted to those who met the following eligibility criteria: (1) requested VA benefits FYs 2022 to 2024; (2) sought VHA services ≥ 1 time between FY 2022 and 2024; (3) had matching VBA/VHA records; (4) had no missing data on claim status and/ or demographic, clinical, and homelessness characteristics; and (5) had known home loan status FYs 2022 to 2024. The original VBA dataset consisted of 4,219,755 records and the original VHA dataset consisted of 7,170,199 records (Figure 1). The final linked VBA/VHA dataset after excluding 29 records with missing data on sex, 7 with missing data on age, 6 with missing data on marital status, and an additional 143,444 with unknown VBA claim status, consisted of 3,089,295 records corresponding to 2,260,851 unique veterans. Specifically, 251,796 records corresponded to veterans who had applied and received a loan, 84,751 to veterans who had applied and were nonrecipients of a loan, and 2,752,748 to veterans who did not apply for a loan.

Statistical Analysis

All statistical analyses were performed using SAS Enterprise Guide, an application that provides a point-and-click interface for data access, analysis, and management, accommodating both code-based and visual programming. ³¹ First, we relied on the final analytic sample to calculate the annual proportions of veterans who applied for and/or received a loan through the VA Home Loan Program. We also generated descriptive statistics stratified by age group, sex, race/ethnicity, SUD, mental health disorder, and homelessness, overall and within each FY. Pearson χ² and Cochran-Armitage trend tests were applied to examine differences in application and receipt of a home loan by baseline characteristics and FY, respectively. Second, we conducted bivariate and multivariable analyses to compare demographic, clinical, and homelessness characteristics between 3 groups of veterans as they pertain to the VA Home Loan Program. Veterans who applied and were nonrecipients of a loan (group 1), veterans who applied and were recipients of a loan (group 2), and veterans who did not apply for a loan (group 3). Similar analyses compared VA Home Loan Program applicants who were recipients of a home loan vs VA Home Loan Program applicants who were nonrecipients of a home loan. Multinomial and binary logistic regression models were constructed to estimate the relative risk ratio (RR) and odds ratio (OR) with 95% CIs for comparisons between these distinct groups on demographic, clinical, and homelessness characteristics. Two-sided statistical tests were evaluated at α = 0.05.

Results

Tables 1 and 2 present the number of VBA applicants, including those who applied for and received benefits through the VA Home Loan Program, by age group, sex, race/ethnicity, as well as histories of SUDs, mental health disorders, and homelessness, overall, and by FY. As shown in Figure 2, 336,547 of 3,089,295 VBA applications (10.9%) pertained to the VA Home Loan Program, with a statistically significant decline in application rates, from 12.2% in FY 2022 to 9.9% in FY 2024 (P < .001 for trend). Among 336,547 veterans who applied for the VA Home Loan Program, 251,796 (74.8%) received a home loan during FYs 2022 to 2024, ranging between 73.8% for FY 2024 and 75.5% for FY 2023 (P < .001 for trend).

Multinomial logistic regression models for demographic, clinical, and homelessness characteristics as predictors of VA Home Loan Program status are provided in Appendix 1. Based on the fully adjusted model, compared with veterans who did not apply to the VA Home Loan Program, those who applied for a home loan were less likely to be aged ≥ 50 years, unmarried, Hispanic ethnicity, mixed race, or other race, diagnosed with a SUD, or history of homelessness. Veterans with higher VA service-connected disability ratings were more frequently recipients of VA home loans, whereas those who self-identified as non-Hispanic Black and those with higher CCI scores were less frequently recipients of VA home loans. Finally, those with mental health disorders were more likely than their counterparts to be applicants (recipients or nonrecipients) of VA home loans.

Binary logistic regression models for demographic, clinical, and homelessness characteristics as predictors of receipt status among applicants to the VA Home Loan Program are provided in Appendix 2. Among applicants, those who were granted a VA home loan were less likely to be aged ≥ 50 years; have a CCI score > 0; have experienced combat service and/or military sexual trauma; be diagnosed with a SUD and/or mental health disorder; or to have a history of homelessness compared with those denied a VA home loan. Applicants granted a VA home loan were also more likely to be female, non-Hispanic White, single or never married, and/or have a VA service-connected disability ratings > 0%.

Discussion

The VA Home Loan Program is a unique benefit and resource for eligible veterans that may be increasingly important in a time of growing concern about the affordability of housing for many Americans. Research on other federally-supported home loan programs as well as private home mortgage programs has been mostly conducted in the economic realm, and studies focused on understanding these programs from a health care system perspective have been sparse.^32,33 However, there is a large body of literature documenting the importance of stable, safe, and secure housing on health and well-being.^34-37 This study did not focus on evaluating the effects of the VA Home Loan Program, because we wanted to first examine the characteristics of veterans who benefited from the program and how they differed from veterans who did not apply or did apply but had a denied application.

Our findings suggest that several thousands of veterans benefit from the VA Home Loan Program each year. For historical context, the time period examined was one of economic downturn with rising costs of living, including housing, and steady increases in homelessness as reported in the annual point-in-time count of sheltered and unsheltered people experiencing homelessness on a single night as mandated by the US Department of Housing and Urban Development.^38-40 The Sergeant First Class Heath Robinson Honoring Our Promise to Address Comprehensive Toxics (PACT) Act of 2022 expanded health care and benefits for veterans exposed to burn pits, Agent Orange, and other toxic substances, resulting in more VA disability benefit claims, including large retroactive payments.^41-43 Anecdotally, the VBA has noted that the PACT Act helped some homeless veterans with funds and stability to exit homelessness and enroll in the VA Home Loan Program.

Our analysis suggests that beneficiaries of the VA Home Loan Program were frequently aged < 50 years, female, of non-Hispanic White race, and did not have histories of psychiatric disorders or homelessness. Most of these demographic and clinical characteristics were not surprising given the composition of the veteran population, although in-depth analyses are needed to examine sex differences that may have led to more females than males benefiting from the VA Home Loan Program. In addition, it was notable that many younger and non-Hispanic Black veterans had applied. While relatively few veterans with SUDs benefited from the VA Home Loan Program, few had applied. Research is warranted into why veterans with SUDs are less likely to apply for home loans. Quite surprisingly, a sizable proportion of veterans with histories of homelessness reported they had applied to the VA Home Loan Program, although they were less likely than veterans who had not experienced homelessness to be granted a loan.

The examination of differences between veterans who did not apply, were granted, and denied a loan through the VA Home Loan Program revealed several key predictors of application outcomes in multivariable models. Specifically, veterans who applied for home loans were less likely to be aged ≥ 50 years, unmarried, of Hispanic, mixed, or other race/ethnicity, diagnosed with an SUD, or have a history of homelessness. Veterans with higher disability ratings were less frequently denied and more frequently approved, while non-Hispanic Black veterans and those with higher CCI scores were more frequently denied and less frequently approved. VBA applicants with mental health disorders were also more likely to apply for a home loan. Conversely, those granted a home loan were more likely than those denied a home loan to be female, non-Hispanic White, single/unmarried, or to have > 0% VA service-connected disability rating, but less likely to be aged ≥ 50 years, have CCI score > 0, be diagnosed with psychiatric disorders, or have a history of homelessness.

Limitations

This analysis was restricted to a subset of FY 2022 to FY 2024 linked VBA/VHA databases (ie, to veterans who had both VBA and VHA records and met prespecified eligibility criteria). Despite the large number of linked records, a small percentage of these records corresponded to veterans who were applicants or recipients of the VA Home Loan Program. Future studies should expand the time frame to examine variations in application outcomes over time and by background characteristics of veterans enrolled in VHA care who applied for VBA benefits. In addition, we relied on data and ICD-10-CM diagnostic codes from existing electronic health records and claims data to define histories of homelessness, comorbidities, SUDs, and mental health disorders. Given the time-varying nature of these conditions, the temporal sequence of events was difficult to ascertain. Third, it is worth noting that these findings can only be generalized to veterans who applied for VBA benefits and met eligibility criteria, and that these veterans may differ in terms of their demographic and clinical characteristics from those who did not apply for these benefits.

Conclusions

This study analyzed data from 251,796 individuals who applied for and received a VA home loan, 84,751 who were denied a VA home loan, and 2,752,748 veterans who did not apply for a VA home loan from FY 2022 to FY 2024. Accordingly, 11% of applications pertained to the VA Home Loan Program, and 75% of VA Home Loan Program applicants received a home loan. Distinct demographic and clinical characteristics were observed for applicants and recipients of the VA Home Loan Program, which can set the stage for future planning and evaluation of the program. Despite the broad accessibility of veterans to the VA Home Loan Program, there were differences in approval rates among applicants based on sociodemographic and clinical characteristics. Further evaluation, perhaps using qualitative methods, is needed to better understand opportunities and challenges to achieving a VA home loan, especially among underserved veteran populations. Investigation and research can guide future recommendations for any development or corrective actions that can help increase access to veterans who can benefit from the program. Future analyses are also needed to compare veterans enrolled and not enrolled in the VA Home Loan Program on health care-related outcomes.