The Road to Reintegration: Evaluating the Effectiveness of VA Healthcare in Vocational Rehabilitation and Employment Retention for Veterans with Mental Health and Substance Use Disorders

Figures & data

Table 1 Demographic Characteristics

	Passed over N=245	Enrolled N=157	Employed at Discharge (No) N = 381	Employed at Discharge (Yes) N = 21
Age, mean (SD)	47.7 (13.5)	50.1 (12.7)	48.4 (13.2)	53.4 (12.3)
	N (%)	N (%)
Race
White (ref. category)	171 (69.8)	117 (74.5)	273 (71.7)	15 (71.4)
Black or AA	52 (21.2)	35 (22.3)	82 (21.5)	5 (23.8)
Hispanic or Latinx	2 (0.8)	1 (0.6)	2 (0.5)	1 (4.8)
Asian	1 (0.4)	1 (0.6)	2 (0.5)	0 (0.0)
AIAN	1 (0.4)	1 (0.6)	2 (0.5)	0 (0.0)
“Unknown”	5 (2.0)	0 (0.0)	5 (1.3)	0 (0.0)
Race/Ethnicity not reported	13 (5.3)	2 (1.3)	15 (3.9)	0 (0.0)
Gender
Male (ref. category)	221 (90.2)	145 (92.4)	346 (90.8)	20 (95.2)
Female	23 (9.4)	11 (7.0)	33 (8.7)	1 (4.8)
Transgender	1 (0.4)	1 (0.6)	2 (0.5)	0 (0.0)
Homeless status – yes	55 (22.5)	54 (34.4)	102 (26.8)	7 (33.3)
Felony – yes	25 (10.2)	17 (10.8)	39 (10.2)	3 (14.3)
Psychiatric Diagnosis – yes	241 (87.4)	142 (90.5)	335 (87.9)	21 (100.0)
Mental Health/SUD Tx
SUD Tx (prior) yes	42 (17.1)	42 (26.8)	75 (19.7)	9 (42.9)
Mental Health Tx (prior) yes	146 (59.6)	102 (65.0)	231 (60.6)	17 (81.0)
SUD Tx (# sess. 60 days prior), mean (SD)	3.55 (10.69)	6.74 (15.68)	4.07 (11.48)	17.90 (25.82)
SUD Tx (# sess. 60 days prior), mean (SD)	7.64 (13.29)	13.27 (20.90)	9.10 (15.39)	23.14 (31.87)
EHS score	6.70 (2.53)	7.52 (2.46)	6.98 (2.54)	7.79 (2.35)

Table 2 Hierarchical Logistic Regression Results for VA Vocational Rehabilitation Program Referrals with Covariates and Program Enrollment Outcomes

	Block 1		Block 2		Block 3		Block 4		Block 5
	OR	CI (95%)	OR	CI (95%)	OR	CI (95%)	OR	CI (95%)	OR	CI (95%)
Age	1.012	0.996–1.028	1.012	0.996–1.029	1.013	0.997–1.030	1.014	0.997–1.030	1.012	0.996–1.029
Race
White (ref. category)
Black or AA	0.923	0.560–1.521	0.862	0.517–1.435	0.844	0.504–1.414	0.811	0.481–1.367	0.750	0.441–1.276
Hispanic or Latinx	0.731	0.065–8.223	0.539	0.045–6.436	0.500	0.040–6.172	0.504	0.040–6.317	0.441	0.035–5.622
Asian	1.700	0.104–27.733	2.140	0.129–35.596	2.285	0.137–38.149	2.343	0.141–39.052	2.547	0.149–43.687
AIAN	1.979	0.118–33.133	2.205	0.132–36.884	2.328	0.139–39.014	2.142	0.127–36.123	2.092	0.125–35.091
“Unknown”	0.000	N/A	0.000	N/A	0.000	N/A	0.000	N/A	0.000	N/A
Race/Ethnicity not reported	0.257	0.056–1.172	0.237	0.052–1.088	0.247	0.053–1.141	0.247	0.053–1.148	0.243	0.052–1.142
Gender
Male (ref. category)
Female	0.783	0.362–1.691	0.874	0.401–1.906	0.867	0.396–1.898	0.872	0.397–1.916	0.810	0.366–1.794
Transgender	1.358	0.084–21.962	0.839	0.051–13.922	0.752	0.044–12.723	0.795	0.047–13.411	0.907	0.054–15.232
Homeless status – yes/no			1.882**	1.171–3.025	1.764*	1.087–2.862	1.639*	1.001–2.685	1.706*	1.036–2.809
Felony – yes/no			0.872	0.437–1.742	0.842	0.420–1.688	0.886	0.439–1.787	0.800	0.394–1.625
Psychiatric Diagnosis – yes/no					1.314	0.655–2.637	1.282	0.636–2.584	1.213	0.595–2.471
Mental Health/SUD Tx
SUD Tx (prior) yes/no					1.523	0.888–2.611	1.177	0.579–2.393	1.154	0.563–2.365
Mental Health Tx (prior) yes/no					0.992	0.623–1.579	0.881	0.544–1.427	0.871	0.535–1.418
SUD Tx (# sess. 60 days prior)							0.998	0.972–1.023	0.997	0.971–1.023
SUD Tx (# sess. 60 days prior)							1.017	0.998–1.035	1.016	0.997–1.035
EHS score									1.139**	1.038–1.249
Nagelkerke R2 (change)	0.043		0.065		0.077		0.089		0.114**
C-Statistic	0.577	0.5201–0.6332	0.612	0.5562–0.6682	0.629	0.5749–0.6840	0.637	0.5823–0.6919	0.663	0.6083–0.7168

Note: *p≤.05; **p≤.01.

Abbreviations: SUD, Substance Use Disorder; AIAN, American Indian or Alaskan Native; AA, African American.

Table 3 Multivariable Logistic Regression Results for VA Vocational Rehabilitation Program Referrals with Covariates and Program Enrollment Outcomes with Effect Modification

Interaction Term**	OR	95% CI	p-value
Race (AIAN^$)* SUD Tx (prior) yes	0.000	0.000–999.99	–
Race (Asian)* SUD Tx (prior) yes	0.000	0.000–999.99	–
Race (Black)* SUD Tx (prior) yes	1.308	0.070–24.294	0.8959
Race (Not reported)* SUD Tx (prior) yes	1.357	0.080–23.141	0.9035
Race (Hispanic)* SUD Tx (prior) yes	0.542	0.000–999.99	–
Race (Unknown)* SUD Tx (prior) yes	0.000	0.000–999.99	–
Race (AIAN)^$* Mental Health Tx (prior) yes	0.000	0.000–999.99	–
Race (Asian)* Mental Health Tx (prior) yes	0.000	0.000–999.99	–
Race (Black)* Mental Health Tx (prior) yes	0.945	0.493–1.809	0.9904
Race (Not reported)* Mental Health Tx (prior) yes	0.331	0.037–2.982	0.9916
Race (Hispanic)* Mental Health Tx (prior) yes	0.461	0.039–5.523	0.9886
Race (Unknown)* Mental Health Tx (prior) yes	0.000	0.000–999.99	–
Race (AIAN)^$* SUD Tx (# sess. 60 days prior, mean)	0.000	0.000–999.99	–
Race (Asian)^$* SUD Tx (# sess. 60 days prior, mean)	679.790	0.000–999.99	–
Race (Black)^$* SUD Tx (# sess. 60 days prior, mean)	0.774	0.455–1.315	0.8913
Race (Not reported)^$* SUD Tx (# sess. 60 days prior, mean)	0.205	0.009–4.546	0.8998
Race (Hispanic)^$* SUD Tx (# sess. 60 days prior, mean)	0.034	0.000–999.99	–
Race (Unknown)^$* SUD Tx (# sess. 60 days prior, mean)	0.064	0.000–999.99	–
Race (AIAN)^$* Mental Health Tx (# sess. 60 days prior, mean)	0.909	0.000–999.99	0.8712
Race (Asian)^$* Mental Health Tx (# sess. 60 days prior, mean)	0.000	0.000–999.99	–
Race (Black)^$* Mental Health Tx (# sess. 60 days prior, mean)	0.752	0.439–1.286	0.9181
Race (Not reported)^$* Mental Health Tx (# sess. 60 days prior, mean)	0.251	0.054–1.177	0.9179
Race (Hispanic)^$* Mental Health Tx (# sess. 60 days prior, mean)	0.000	0.000–999.99	–
Race (Unknown)^$* Mental Health Tx (# sess. 60 days prior, mean)	0.262	0.000–999.99	0.9900

Notes: *is used as an indicator of an statistical interaction between two variables. **Models included age, gender, homeless status, Felony, Psychiatric Diagnosis, and EHS score. ^$White was the reference.

Abbreviations: AIAN, American Indian or Alaskan Native; AA, African American; SUD, Substance Use Disorder; Tx, Treatment; EHS = Employment Hope Scale.

Table 4 Multivariable Logistic Regression Results for Prior Mental Health or Substance Use Treatment Before Consult (60 Days Prior) on Program Enrollment for VA Vocational Rehabilitation

	SUD				Mental Health				SUD + Mental Health
	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI	OR	95% CI
Age	3.06	0.001–999.999	5.179	0.008–999.999	1.019	0.991–1.048	1.108	0.990–1.047	1.004	0.980–1.030	1.005	0.980–1.031
Race
White (ref. category)	1		1		1		1		1		1
Black or AA	0.236	0.001–999.999	1.639	0.001–999.999	0.710	0.275–1.833	0.721	0.281–1.848	1.095	0.518–2.313	1.034	0.485–2.204
Hispanic or Latinx	N/A		N/A		N/A		N/A		1.000	0.050–19.981	0.947	0.049–18.146
Asian	N/A		N/A		2.688	0.144–50.173	3.023	0.159–57.303	N/A		N/A
AIAN	N/A		N/A		1.705	0.090–32.269	1.655	0.090–30.465	N/A		N/A
“Unknown”	N/A		N/A		N/A		N/A		N/A		N/A
Race/Ethnicity not reported	N/A		N/A		0.215	0.023–2.108	0.240	0.026–2.224	0.440	0.046–4.180	0.434	0.046–4.095
MENTAL HEALTH Diagnosis
Anxiety	N/A		N/A		0.755	0.371–1.536	0.795	0.392–1.610	0.723	0.392–1.333	0.747	0.406–1.375
Depressive	N/A		N/A		1.130	0.548–2.330	1.196	0.573–2.498	1.214	0.641–2.300	1.269	0.667–2.417
Homelessness	N/A		N/A		1.397	0.450–4.342	1.334	0.430–4.134	1.478	0.776–2.813	1.393	0.719–2.699
ERS score	0.985	0.155–6.250	1.416	0.386–5.202	0.986	0.963–1.010	0.984	0.960–1.007	0.983	0.966–1.001	0.985	0.968–1.003
EHS score	0.248	0.001–999.99	3.675	0.004–999.999	1.199	1.007–1.427*	1.172	0.984–1.395	1.125	0.984–1.286	1.124	0.983–1.284
PEBS score	N/A		N/A		0.926	0.463–1.852	0.937	0.469–1.875	0.721	0.408–1.273	0.709	0.401–1.254
MENTAL HEALTH/SUD Tx
SUD Tx (prior) yes/no	N/A								1.556	0.772–3.138
SUD Tx (# sess. 60 days prior)			2.449	0.065–92.653							0.995	0.968–1.023
MENTAL HEALTH Tx (prior) yes/no					0.899	0.442–1.828			1.075	0.525–2.200
MENTAL HEALTH Tx (# sess. 60 days prior)							1.014	0.987–1.042			1.017	0.993–1.042
C-Statistics	N/A		N/A		0.6945	0.6099–0.7791	0.6938	0.6081–0.7796	0.6783	0.6007–0.7558	0.6914	0.6133–0.7696

Abbreviations: AIAN, American Indian or Alaskan Native; AA, African American; SUD, Substance Use Disorder; MENTAL HEALTH, Mental health; Tx, Treatment; ERS, Employment Readiness Scale; EHS, Employment Hope Scale; PEBS, Perceived Employment Barriers Scale.

Table 5 Multivariable Logistic Regression Results for Prior Mental Health or Substance Use Treatment Before Consult (60 Days Prior) on Program Enrollment for VA Vocational Rehabilitation with Effect Modification

	SUD		Mental Health		SUD + Mental Health
	OR	95% CI	OR	95% CI	OR	95% CI
Interaction term**
Race (AIAN)^$* SUD Tx (prior) yes	--	--	3.523	0.005–999.99	--	--
Race (Asian)* SUD Tx (prior) yes	--	--	3.730	0.054–255.753	--	--
Race (Black)* SUD Tx (prior) yes	0.000	0.000–999.99	0.986	0.059–16.459	2.417	0.725–8.056
Race (Not reported)* SUD Tx (prior) yes	--	--	0.311	0.008–12.232	2.867	0.141–58.339
Race (Hispanic)* SUD Tx (prior) yes	--	--	0.000	0.000–999.99	0.000	0.000–999.99
Race (Unknown)* SUD Tx (prior) yes	--	--	0.000	0.000–999.99	0.594	0.000–999.99
Race (AIAN)^$* MENTAL HEALTH Tx (prior) yes	--	--	0.000	0.000–999.99	--	--
Race (Asian)* MENTAL HEALTH Tx (prior) yes	--	--	0.000	0.000–999.99	--	--
Race (Black)* MENTAL HEALTH Tx (prior) yes	0.000	0.000–999.99	0.358	0.086–1.497	1.368	0.574–3.260
Race (Not reported)* MENTAL HEALTH Tx (prior) yes	--	--	0.000	0.000–999.99	1.148	0.087–15.099
Race (Hispanic)* MENTAL HEALTH Tx (prior) yes	--	--	0.000	0.000–999.99	1.030	0.056–18.907
Race (Unknown)* MENTAL HEALTH Tx (prior) yes	--	--	0.000	0.000–999.99	0.000	0.000–999.99
Race (AIAN)^$* SUD Tx (# sess. 60 days prior, mean)	--	--	1.346	0.068–26.820	--	--
Race (Asian)^$* SUD Tx (# sess. 60 days prior, mean)	--	--	2.343	0.122–45.083	--	--
Race (Black)^$* SUD Tx (# sess. 60 days prior, mean)	0.000	0.000–999.99	0.713	0.275–1.848	1.147	0.538–2.445
Race (Not reported)^$* SUD Tx (# sess. 60 days prior, mean)	--	--	0.211	0.022–1.984	0.000	0.000–999.99
Race (Hispanic)^$* SUD Tx (# sess. 60 days prior, mean)	--	--	0.000	0.000–999.99	1.286	0.000–999.99
Race (Unknown)^$* SUD Tx (# sess. 60 days prior, mean)	--	--	0.000	0.000–999.99	0.009	0.000–999.99
Race (AIAN)^$* MENTAL HEALTH Tx (# sess. 60 days prior, mean)	--	--	0.000	0.000–999.99	--	--
Race (Asian)^$* MENTAL HEALTH Tx (# sess. 60 days prior, mean)	--	--	0.000	0.000–999.99	--	--
Race (Black)^$* MENTAL HEALTH Tx (# sess. 60 days prior, mean)	9.519	0.000–999.99	0.000	0.000–0.011	1.026	0.478–2.204
Race (Not reported)^$* MENTAL HEALTH Tx (# sess. 60 days prior, mean)	--	--	0.000	0.000–999.99	0.395	0.037–4.209
Race (Hispanic)^$* MENTAL HEALTH Tx (# sess. 60 days prior, mean)	--	--	0.000	0.000–999.99	0.003	0.000–999.99
Race (Unknown)^$* MENTAL HEALTH Tx (# sess. 60 days prior, mean)	--	--	0.000	0.000–999.99	0.009	0.000–999.99

Notes: *is used as an indicator of an statistical interaction between two variables. **Models included age, MENTAL HEALTH diagnosis, homeless status, ERS score, EHS score, and PEBS score. ^$White was the reference.

Abbreviations: AIAN, American Indian or Alaskan Native; AA, African American; SUD, Substance Use Disorder; MENTAL HEALTH, Mental health; Tx, Treatment; ERS, Employment Readiness Scale; EHS, Employment Hope Scale; PEBS, Perceived Employment Barriers Scale.

Table 6 Hierarchical Logistic Regression Results for VA Vocational Rehabilitation Program Veteran Referrals with Covariates and Program Enrollment Outcomes

	Block 1		Block 2		Block 3
	OR	CI (95%)	OR	CI (95%)	OR	CI (95%)
MENTAL HEALTH/SUD Tx (while enrolled in vocational rehabilitation)
SUD Tx (yes/no)	1.333	0.337–5.273	11.163	0.867–143.767	12.805	0.677–242.038
MENTAL HEALTH Tx (yes/no)	0.750	0.190–2.966	3.055	0.479–19.483	1.953	0.234–16.288
MENTAL HEALTH/SUD Tx
SUD Tx (# sess. during)			1.004	0.918–1.099	1.031	0.926–1.149
MENTAL HEALTH Tx (# sess. during)			0.805*	0.662–0.980	0.793*	0.638–0.987
Age					0.986	0.913–1.064
Race
White (ref. category)
Black or AA					0.942	0.113–7.814
Hispanic or Latinx					0.000	0.000–999.99
Asian					0.000	0.000–999.99
AIAN					--	--
“Unknown”					--	--
Race/Ethnicity not reported					0.000	0.000–999.99
Gender
Male (ref. category)
Female					0.754	0.033–17.427
Transgender					0.000	0.000–999.99
Homeless status – no/yes					0.237	0.037–1.500
Felony – no/yes					1.205	0.110–13.192
EHS score					1.143	0.827–1.579
Constant	0.667		0.741
Nagelkerke R2 (change)	0.006		0.402**		0.509*
C-statistic	0.535		0.832		0.873

Note: *p≤.05; **p≤.01.

Abbreviations: EHS, Employment Hope Scale; AIAN, American Indian or Alaskan Native; AA, African American; SUD, Substance Use Disorder; MENTAL HEALTH, Mental health; Tx, Treatment.

Table 7 Multivariable Logistic Regression Results for Veterans Enrolled in VA Vocational Rehabilitation with Covariates and Employment at Discharge Outcomes with Effect Modification

Interaction Term**	OR	95% CI	p-value
Race (AIAN)^$* SUD Tx yes	--	--	--
Race (Asian)* SUD Tx yes	0.000	0.000–999.99	0.7202
Race (Black)* SUD Tx yes	2.122	0.159–28.337	--
Race (Not reported)* SUD Tx yes	0.000	0.000–999.99	--
Race (Hispanic)* SUD Tx yes	0.000	0.000–999.99	--
Race (Unknown)* SUD Tx yes	--	--	--
Race (AIAN)^$* MENTAL HEALTH Tx (prior) yes	--	--	--
Race (Asian)* MENTAL HEALTH Tx (prior) yes	0.000	0.000–999.99	0.3942
Race (Black)* MENTAL HEALTH Tx (prior) yes	2.437	0.313–18.993	--
Race (Not reported)* MENTAL HEALTH Tx (prior) yes	0.000	0.000–999.99	--
Race (Hispanic)* MENTAL HEALTH Tx (prior) yes	0.000	0.000–999.99	--
Race (Unknown)* MENTAL HEALTH Tx (prior) yes	--	--	--
Race (AIAN)^$* SUD Tx (# sess. 60 days prior, mean)	--	--	--
Race (Asian)^$* SUD Tx (# sess. 60 days prior, mean)	0.000	0.000–999.99	0.6045
Race (Black)^$* SUD Tx (# sess. 60 days prior, mean)	1.568	0.270–9.109	--
Race (Not reported)^$* SUD Tx (# sess. 60 days prior, mean)	0.000	0.000–999.99	--
Race (Hispanic)^$* SUD Tx (# sess. 60 days prior, mean)	0.000	0.000–999.99	--
Race (Unknown)^$* SUD Tx (# sess. 60 days prior, mean)	--	--	--
Race (AIAN)^$* MENTAL HEALTH Tx (# sess. 60 days prior, mean)	--	--	--
Race (Asian)^$* MENTAL HEALTH Tx (# sess. 60 days prior, mean)	0.000	0.000–999.99	0.7530
Race (Black)^$* MENTAL HEALTH Tx (# sess. 60 days prior, mean)	1.873	0.218–16.106	--
Race (Not reported)^$* MENTAL HEALTH Tx (# sess. 60 days prior, mean)	1.942	0.000–999.99	--
Race (Hispanic)^$* MENTAL HEALTH Tx (# sess. 60 days prior, mean)	0.000	0.000–999.99	--
Race (Unknown)^$* MENTAL HEALTH Tx (# sess. 60 days prior, mean)	--	--	--

Notes: *is used as an indicator of an statistical interaction between two variables. **Models included age, gender, homeless status, Felony, Psychiatric Diagnosis, and EHS score. ^$White was the reference.

Abbreviations: AIAN, American Indian or Alaskan Native; AA, African American; SUD, Substance Use Disorder; MENTAL HEALTH, Mental health; Tx, Treatment; EHS, Employment Hope Scale.

Table 8 Multivariable Logistic Regression Results for Whether Veterans Continued SUD or MENTAL HEALTH Treatment Post-Discharge from VA Vocational Rehabilitation

	SUD		Mental Health		SUD + Mental Health
	OR	95% CI	OR	95% CI	OR	95% CI
Continued SUD treatment	N/A				0.199	0.042–0.948
Continued MENTAL HEALTH treatment			1.000	0.053–18.915	3.012	0.636–14.260

Abbreviations: SUD, Substance Use Disorders; MENTAL HEALTH, Mental health; VA, Veteran Affairs.

Data Sharing Statement

The datasets analyzed are property of the US Department of Veteran Affairs and special permission and requirements are necessary before approved access to patient information is granted. Thus, the dataset used in the current study is not available for public use.