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Using the Vulnerability Index® to Assess the Health Needs of a Homeless

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DOI: 10.1080/07370016.2018.1516422

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 Journal of Community Health Nursing

ISSN: 0737-0016 (Print) 1532-7655 (Online) Journal homepage: http://www.tandfonline.com/loi/hchn20

Using the Vulnerability Index® to Assess the

Health Needs of a Homeless Community

Bonnie H. Bowie & Lauren Valk Lawson

To cite this article: Bonnie H. Bowie & Lauren Valk Lawson (2018) Using the Vulnerability Index®
to Assess the Health Needs of a Homeless Community, Journal of Community Health Nursing,
35:4, 189-195, DOI: 10.1080/07370016.2018.1516422

To link to this article: https://doi.org/10.1080/07370016.2018.1516422

Published online: 04 Oct 2018.

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JOURNAL OF COMMUNITY HEALTH NURSING
2018, VOL. 35, NO. 4, 189–195
https://doi.org/10.1080/07370016.2018.1516422

Using the Vulnerability Index® to Assess the Health Needs of a

Homeless Community
Bonnie H. Bowie and Lauren Valk Lawson
College of Nursing, Seattle University, Seattle, Washington

ABSTRACT
Compiling a health needs profile of a difficult-to-reach population such as the
homeless can be challenging, particularly when using a community-based
participatory research approach. In this article, we describe our experience
using the Vulnerability Index® (VI), a questionnaire developed by 100,000
Homes Campaign to assess and prioritize individuals in need of housing
based on their risk of mortality. We found the VI easy to administer and
helpful in creating a health needs profile of participants.

Lack of stable housing is well documented as a risk factor for poor health (Barrow, Herman, Córdova,
& Struening, 1999; Zlotnick & Zerger, 2009). People who experience homelessness have higher rates of
chronic health conditions, such as hypertension, mental illness, and substance abuse (O’Connell,
Mattison, Judge, Allen, & Koh, 2005; O’Connell et al., 2010). Individuals experiencing chronic
homelessness (defined as having a disabling condition and either being continually homeless for a year
or more or experiencing four episodes of homelessness in a 3-year period) when compared to similar
individuals who are housed have a higher mortality rate from chronic illnesses and realize a significantly
lower life expectancy (Hwang et al., 1998; Hwang, Orav, O’Connell, Lebow, & Brennan, 1997; O’Connell,
2005). When people experiencing homelessness require acute medical services, such as surgery or
hospital care for chronic disease conditions, postdischarge care is either ineffective or completely absent
since many return to the streets following a hospital stay. As a result, chronic and acute medical issues
are exacerbated, and hospital readmissions are common (O’Connell, 2005; DiPietro, Kindermann,
& Schenkel, 2012; Kertesz et al., 2009). Cycles of readmission result in a financial strain from the high
usage of publicly funded health care and community resources (O’Connell et al., 2005, 2010; Larimer
et al., 2009). Community solutions have emerged to address this spiraling issue, most notably models
of medical respite care that can provide a safe and healing environment to stabilize health and, in some
situations, enable transition out of homelessness into permanent housing (Buchanan, Doblin, Sai,
& Garcia, 2006; Ciambrone & Edgington, 2009; Gundlapalli et al., 2005; Kertesz et al., 2009).
To address the issue of lack of a safe space to recuperate posthospitalization in a neighborhood
north of Seattle, a community–academic partnership was created to assess the health care needs of
people experiencing homelessness and determine the feasibility of developing a sustainable model of
medical respite care that could utilize the resources and support of the neighborhood. The partner-
ship grew from the desire of a group of Seattle University College of Nursing (SUCON) students to
complete their community health clinical experience at a newly opened drop-in center for the
homeless, established by the Seattle Mennonite Church in 2007. As the partnership grew, faculty,
students, and the community ministry of the SMC worked together to address the health needs of
the homeless. The formation of the community–academic partnership was both intentional and
organic in nature.

CONTACT Bonnie H. Bowie bowieb@seattleu.edu College of Nursing, Seattle University, 901 12th Avenue, PO Box
222000, Seattle, WA 98122-1090.
© 2018 Taylor & Francis
190 B. H. BOWIE AND L. V. LAWSON

A community-based participatory research (CBPR) model was employed to facilitate engagement

of the neighborhood in all aspects of the intended project. CBPR requires that researchers partner
fully with members of the community to identify needs, research questions, and the design and
evaluation of programs (Community-Campus Partnerships for Health, 2011). The first step was
formation of a community advisory board that mirrored the surrounding community and was
comprised of relevant stakeholders, including individuals experiencing homelessness from the
neighborhood. Each step of the program development, as well as the research process, was vetted
through the community advisory board. Through conversations with advisory board members, it
was decided that prior to designing a recuperative care program for the local homeless population,
we needed to engage the population in a health care needs assessment.
Integral to the assessment phase was identification of an appropriate assessment instrument for
this at-risk community. The Vulnerability Index® (VI) was chosen because of its reputation and wide
use among advocates for the homeless (100K Homes, 2010). The VI, based on the research of
O’Connell, Hwang, and colleagues, was developed by the Common Ground as an instrument to
assess and prioritize individuals in need of housing based on their risk of mortality (O’Connell et al.,
2005; Hwang et al., 1997, 1998; 100K Homes, 2010; & DESC, 2009).
The instrument is easily accessible with permission from the 100,000 Homes Campaign, which
maintained a national database of completed individual VIs (100K Homes, 2010; DESC, 2009).
Another advantage to the VI is that it was created to be used by lay community members. With a
Flesch Reading Ease score of 69.9, the VI based on Flesch–Kincaid reads at a 6th grade level. Hence
the VI is an effective means of gathering data across diverse reading levels (Scott, 2013a, 2013b). In
keeping with the principles of community participatory research, unhoused community members
were included in the research team and the reading level of the VI allowed for inclusion of diverse
team members. The VI can be administered as a written questionnaire or as a short answer interview
with subjects. While the VI has been widely used to prioritize housing needs for those individuals
that are most vulnerable, it has not been used to identify health care needs of the homeless. The
purpose of this article then is to examine the feasibility of using the VI to determine the health care
needs of a local homeless community.

Method
Design
A cross-sectional survey design was utilized to assess the health status and health services utilization
of people experiencing homeless in an urban neighborhood on the edge of a large city. The survey
was part of a larger ongoing CBPR project working with community members to define services for
this population.

Data collection and sample

The first step of the project was to define the community of individuals in the area who met the
federal requirements for homelessness and to describe their current health care needs. In keeping
with a CBPR approach, research teams were composed of a member of the homeless community
paired with a faculty member or graduate nursing student. Interviews using the VI were conducted
by a research team that included a faculty member or graduate nursing student partnered with a
member of the homeless community, all of whom attended training on research procedures and
confidentiality. A total of 47 individuals who were 18 years or older and who met the federal
definition of homelessness were interviewed over a 2-month period. Individuals were encountered at
a drop-in day center, a temporary winter overnight shelter, or on the street (see Table 1 for an
overview of the demographics). Participants signed an informed consent and received bus tokens for
participating in the study.
 JOURNAL OF COMMUNITY HEALTH NURSING 191

Table 1. Demographics of sample as compared to national database.

Characteristic Community sample (%) National database1 (%)
Male 70 72.6
Female 28 25.6
25 years and under 0 2.5
26 to 61 years 95.7 82.1
62 years and older 4.3 15.4
Veterans 25.5 18.4
Victims of violence 46.8 41.9
1
100K Homes (2012). Aggregated National Homeless Survey Data. http://100khomes.org/sites/default/files/National%20QB%
20Data.pdf.

Vulnerability Index® instrument

Used throughout the United States, the VI was developed by Common Ground, a program that was
started in 2003 in New York City to end homelessness. The instrument consists of 34 short answer
questions and is divided into five sections as follows: (1) demographic information, (2) housing
history (e.g., what is the total length of time you have lived on the streets?), (3) health questions (e.g.,
where do you usually go for health care or when you’re not feeling well?), (4) medical conditions,
including substance abuse and mental health (e.g., do you have any of the following medical
conditions?), and (5) social history (e.g., have you ever been in foster care?). For many of the
questions, subjects may choose “yes,” “no,” or “refused” as answers.
To identify those individuals who are at the highest risk for mortality, the VI uses a subscale
called vulnerability risk qualifiers (VRQs). The VRQ scale incorporates eight of the highest risk
factors into a ranking system from 1 to 8 that were originally intended to determine housing priority.
The vulnerability or at-risk qualifiers are as follows: (1) emergency department (ED) usage within a
3-month period; (2) hospitalization or ED usage in a 1-year period; (3) age 60 or over; (4) HIV/
AIDS; (5) kidney disease; (6) liver disease; (7) a cold weather injury, such as frost bite, or (8)
trimorbidity condition. Trimorbidity refers to whether the subject has at least one condition in each
of these categories: mental health qualifiers, serious medical condition qualifiers, or substance abuse
qualifiers. Each qualifier receives a score of 1 if present, with a maximum score of 8; however, if just
one of these factors is present and is coupled with more than 6 months on the streets, the subject is
considered to be at higher risk for mortality. The trimorbidity qualifier also reflects the complexity of
the co-occurring conditions of mental health, substance abuse, and a serious health condition and is,
in itself, an indicator of higher risk for mortality (O’Connell et al., 2005).
Cronley, Petrovich, Spence-Almaguer, and Preble (2013) performed a postdictive validity study of
the VI by performing a retrospective review of hospital admissions and emergency room use for the
12 months prior to completed VIs by patients. The researchers found that hospital admissions
significantly predicted VI scores, including chronic health conditions, self-reported substance use,
and self-reported mental health conditions. Other than this study, we found no other published studies
through an extensive literature search that have examined the psychometric properties of the VI.

Institutional Review Board (IRB)

IRB approval (FY2012-050) was obtained prior to data collection. Partnering with members of the
homeless community to perform the VI interviews and data collection is not unusual when using a
CBPR approach; however, concerns were raised by members of the IRB regarding client confidenti-
ality. To meet the human subjects’ training requirement for researchers in a culturally sensitive
manner, we used a human subjects’ training module developed by Dr. Eugenia Eng from the Gillings
School of Global Public Health at the University of North Carolina aimed specifically at nonaca-
demic community-based research members (Israel, Eng, Schulz, & Parker, 2013). All members of the
research team (faculty, staff, students, and peer members of the unhoused community) attended the
192 B. H. BOWIE AND L. V. LAWSON

training together and were able to discuss the importance of confidentiality of collected data and
coercion of subjects. Training on the administration of the VI was also provided. The final protocol
included an option for subjects to decline the presence of the peer members of the research team
during the consent process. It was stressed to the team that if subjects experience extreme feeling
during the interview, they would be referred to a counselor on site at the day center to help them
deal with their feelings.

Results
Descriptive statistics were used to analyze and identify patterns in the sample data using the
Statistical Package for Social Services, Version 23. Of the 47 participants, 46 completed the VI.
The majority of participants were male (70%) and white (52%) and ranged in age from 28 to 66 years
with an average age of 47 years. The mean reported continuous duration of homeless was 4.7 years
with a range of less than 1 year to 19 years. These data were comparable to the 100,000 Homes
Campaign’s national database apart from age (100K Homes, 2012). The study sample was also
comprised of a larger proportion of veterans (25. 5%) as compared to the national database of 18.4%.
When scoring the VI, researchers need to first determine whether subjects fall into an at-risk
category. Subjects qualify as at risk if they have been homeless for greater than 6 months and have at
least one of the qualifiers found in Table 2.
Virtually all of the subjects in this study had been homeless for at least 6 months and were found
to have at least one of the at-risk qualifiers. In examining the vulnerability at-risk qualifiers, none of
the participants reported HIV/AIDS as a health condition. Thirty-two of the participants (69.5%)
reported use of a hospital for medical care, but only 17 participants (37%) reported a hospitalization
in the year prior to the study. Another reported source of health care was EDs. Fifty four percent
(25) of respondents reported a visit to an ED in the 3 months prior to study; they averaged 2.7 visits
with a range of 1 to 7 visits. Interestingly, subjects in the national database were nearly twice as likely
to use the ED for health care needs three times or more in one year. Also of significance to this study
is that only two participants identified the Veterans Administration as a source of health care, while
25% (n) of participants reported veteran status.
Subjects who qualify as at risk were given a vulnerability risk score which may range from 1 to 8.
Using the VRQ, 29 participants (63%) scored as “vulnerable” in a range of scores from 1 to 6. A
majority (n) of participants (78%) reported at least one to two serious medical conditions with a
range of zero to seven conditions. The three most common conditions reported were heart disease
(n = XX; 37%), skin conditions (28%) and hepatitis C (22%). Seventy eight percent (N) of
participants reported abuse of drugs or alcohol which was higher than the national database of
57.4%. Table 3 provides an overview of the vulnerability risk of the sample.
In summary, the majority of the participants were white, male, around 48 years of age, and
chronically homeless. They had one to two severe medical conditions and sought care through EDs
but were rarely admitted. The participants were more likely to experience substance abuse than the

Table 2. Vulnerability at-risk qualifiers of sample as compared to national database.

Indicator Community sample (%) National database1 (%)
HIV/AIDS 0 3.1
Cold weather injury such as frostbite 6.4 6.4
Kidney disease 6.4 3.7
Liver 8.5 7.2
ER 3X+ in 3 months 23.9 11.8
Age 60 or older 6.4 10.5
ER or Inpatient 3X or more in 1 year 10.6 19.7
1
100K Homes (2012). Aggregated National Homeless Survey Data. http://100khomes.org/sites/default/files/National%20QB%
20Data.pdf.
 JOURNAL OF COMMUNITY HEALTH NURSING 193

Table 3. Vulnerability risk of sample as compared to national database.

Indicator Community sample (%) National database1 (%)
Substance abuse 78.7 57.4
Mental health 44.7 45.0
Serious medical condition 76.6 45.7
Trimorbidity2 34.0 22.1
At-risk qualifier3 59.6 43.9
Vulnerability scores4 Range: 1 to 6 1 to 8
1
100K Homes (2012). Aggregated National Homeless Survey Data. http://100khomes.org/sites/default/files/National%20QB%
20Data.pdf.
2
Mental health + serious medical condition + substance abuse
3
More than 6 months on street and positive trimorbidity and one of the following: three or more ED visits in past 3 months, or
three or more hospitalizations in past year or 60 or more years old, or +HIV/AIDS, or kidney disease, or liver disease, or cold
weather injuries
4
Possible scores range from 1 to 8

national average (78.7% versus 57.4%) and they were more likely to have at-risk qualifiers than the
national average (59.6% versus 43.9%).
Regarding the feasibility of the VI to assist program developers and researchers in identifying
health needs of a homeless community, the VI was easy to administer by all members of the research
team and provided useful health information for program development. The participation of a peer
member as part of the research team enabled the teams to gain trust and reach many members of the
homeless community that may not have otherwise participated in the study. Community members
who assisted in the project stated that they felt comfortable asking the questions on the VI and found
the instrument easy to use. However, social services personnel who routinely work with this
community felt the absence of HIV cases was not accurate, leaving our team to wonder if an
anonymous administration of the instrument might produce better results with sensitive questions.

Discussion
A key benefit of the use of the VI as an assessment instrument for this study was the ability to create
a profile of the participants which could then be compared to a national database. This profile was
primarily used for the next steps of the initiative, which were to determine the need for a medical
respite and to plan for the development of appropriate services. The ability to compare our sample
with a national database has also helped in planning for services for this particular community. For
example, the larger percentage of veterans in our local community reinforced our belief that a strong
partnership with Veterans Administration local agencies would enhance the design of health care
services. Similarly, the larger prevalence of substance abuse found in the local community provided
guidance on the types of additional wrap around services needed. The VI also assisted in the
identification of local hospital EDs where participants frequently sought care. Using this informa-
tion, we have begun discussion with a local community hospital to identify homeless individuals
needing respite care following ED treatment or hospitalization. Therefore, the VI met the expecta-
tions of the study.
However, unlike many research scales, the VI lacks robust psychometric testing to make it useful
for outcome prediction research. Although Cronley and colleagues in a descriptive study of 97
individuals living in an urban area were able to show a significant correlation between hospitaliza-
tions and the VI, the study did not show a significant relationship between self-reported chronic
physical health conditions, mental health problems, and substance use, and, by the authors own
description, the study was small and from a specific geographic area (Cronley et al., 2013). Thus,
more testing is needed, in particular, prospective studies. In addition, the VI lacks a mechanism for
interpreting the overall vulnerability score beyond prioritizing for shelter. An additional challenge
with the use of the VI is the focus on mortality. As stated previously, the VI was originally developed
from the work by O’Connell, Hwang, and others whose focus was on identifying risk factors for
194 B. H. BOWIE AND L. V. LAWSON

death in homeless adults. Therefore, it is not surprising that the instrument relies heavily on the
assessment of indicators for mortality (O’Connell et al., 2005; Hwang et al., 1997, 1998; 100K Homes,
2010; & DESC, 2009). However, the limited scope of the medical conditions included in the VI
prevents exploring other issues of morbidity. As an example, a number of participants known to
have hypertension denied having a health condition since “high blood pressure” was not included on
the list. The VI includes the item “heart disease”; however, most participants did not consider
hypertension as heart disease.
Using the results from this study, we have been able to design and implement a model of respite
care that meets the needs identified for this particular community. The next step for our research
team is to reevaluate the health care needs of the community to determine if there has been a
significant change in the VI profile, including at-risk qualifiers, trimorbidity, and overall vulner-
ability scores for this homeless community. To our knowledge, the VI has not been used in this
fashion to determine whether a specific intervention affects outcomes.
In summary, the VI was a good instrument for compiling a health needs profile of people
experiencing homelessness in a community. The instrument was also effective for use in a CBPR
project that included peer members in the data collection process. The next steps necessary for use of
the VI in research will be to perform additional psychometric testing to determine the reliability and
validity of the instrument. Predictive validity related to chronic medical conditions and morbidity/
mortality and a comparison of the VI with a comparable, reliable instrument for construct validity
would be helpful.

Funding
This work was supported through the Sinegal Foundation

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