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Innovative Efforts to Address Homelessness Among Veterans

Ending homelessness among veterans has been a goal of the Department of Veterans Affairs for some time, and it is now becoming a reality in many communities. Unprecedented strides have been made through the rapid implementation of evidence-based innovations, capacity building, and a comprehensive strategic focus on 4 goals: prevention, moving veterans into permanent housing, providing the population-tailored care and services needed to keep them housed, and providing the supports necessary to allow them to recover and be productive members of their communities.


I n November of 2009, Secretary of Veterans Affairs (VA)
Eric Shinseki set out the ambitious goal of ending homelessness among veterans in 5 years [1]. At the time, approximately 1 in 3 homeless people were veterans [2,3], despite only 12% of the population having served in the military. In many communities, homelessness-and specifically veteran homelessness-had become an institutionalized fixture in the urban landscape. With this very public and ambitious Cabinet-level policy announcement came focus and timesensitive urgency, which galvanized thinking and planning and mobilized resources in an unprecedented manner.
In addition to bringing resources that greatly expanded existing program capacity, the charge to end veteran homelessness also ushered in new thinking and approaches as to how this would be done. Using the federal strategic plan for ending homelessness, "Opening Doors: Federal Strategic Plan to Prevent and End Homelessness" [4], as the framework, VA both greatly expanded capacity and introduced several policy changes to how programs would be constructed, purposed, and operationalized. This included 4 significant policy shifts.
First, a "no wrong door" policy was enacted, meaning that homeless veterans could go through multiple channels or portals to access care and services needed to gain permanent housing.
Second, the focus shifted to permanent housing; the goal was no longer to simply get homeless veterans off of the streets, but rather to get them into permanent housing of their own so that they were no longer homeless. The Housing and Urban Development (HUD) Veterans Affairs Supportive Housing (VASH) program, which now supports over 69,000 vouchers, reflects this approach.
Third, Housing First policies were implemented. Previously, much of the program and housing support for homeless persons was contingent on their achieving sobriety, getting a job, or meeting other key milestones. Unfortunately, too many individuals dropped out prior to meeting these threshold requirements, resulting in a cohort of chronically homeless veterans. Housing First instead provides noncontingent housing, with the intent of engaging the veteran in needed supportive services and treatments once they are housed [5,6]; this results in significantly improved outcomes [7,8].
Finally, VA emphasized the importance of community partnerships in reaching this goal; no longer could this be seen as an insular process. These partnerships have included several initiatives such as working with local community Continuums of Care, partnering in First Lady Michele Obama's Mayor's Challenge, cosponsoring the 25 City Initiative, and making grants to local agencies to provide direct services. The result was a much more enhanced infrastructure and capacity for identifying who is homeless, intervening early to prevent homelessness, rapidly rehousing those who become homeless, and keeping veterans housed.
Within this framework of new policies and approaches, several new programs were launched, and the capacity of existing programs was increased. These programs can be organized into 5 main categories: prevention; outreach and engagement; housing, with an emphasis on low-threshold or noncontingent housing; enhanced treatment and services; and individual sustainment and self-sufficiency initiatives.

Prevention
Prevention programming is embodied in the Supportive Services for Veteran Families (SSVF) initiative, which provides grants to local community agencies to provide temporary support and assistance to veterans and their families who may be at imminent risk of becoming homeless or may have just become homeless. During this past fiscal year, the SSVF program provided assistance to more than 122,000 individuals, including over 14,000 veteran households.

Outreach and Engagement
Outreach and engagement are provided through several different venues, reflecting a "no wrong door" philosophy both within VA and the community. Three specific programs reflect both in-reach strategies, for identifying and engaging those veterans coming to VA who may need help, and outreach strategies within our communities. VA now has a clinical screener for homelessness and homeless risk that is applied to all veterans seeking ambulatory care [9]. Last year, more than 4.2 million veterans were screened, and 50,000 were identified as being either homeless or at risk for becoming homeless. These individuals are then referred to facility-based homeless programming to create a seamless transition to needed services.
Among outreach efforts, VA Health Care for Homeless Veterans conducts their own street outreach and sponsors community-based "Stand Downs," weekend events that put veterans in touch with a host of different programs and connect them with needed care and services. In 2014, such events brought more than 80,000 homeless veterans in touch with a host of different programs. Additionally, VA has developed Community Resource and Referral Centers located in community settings frequented by homeless persons as an alternative portal for accessing care and services.

Housing Assistance and Programming
Housing assistance and programming are obviously core to the VA strategy of ending homelessness and are provided through several different programs: SSVF temporary support and assistance; grant-per-diem transitional housing, which often provides the bridge needed to stabilize veterans on their way to permanent housing or support them while they participate in a treatment program; the HUD-VASH program noted earlier; and the VA Domiciliary Care Program, which provides more intensive support to frail and infirm veterans.
Coupled with this support is an increased focus on lowering thresholds for moving into housing, consistent with VA's Housing First policy. This is reflected in Safe Haven housing, which is intended for veterans with significant challenges complying with housing rules, as well as those with lowdemand grant-per-diem and HUD-VASH vouchers.

Supportive Services and Clinical Care
Keeping veterans housed and providing the necessary supportive services and clinical care often requires a continuum of services and approaches that extend beyond what can be provided in traditional care settings at VA medical facilities or in the community. The VA Homeless Program Office has developed several population-tailored care models that facilitate this process of treatment engagement and care delivery for veterans as they continue to stabilize and recover. Homeless Patient Aligned Care Teams (H-PACTs) are VA-based/staffed care models that provide an integrated, open-access model that incorporates primary care, mental health, and addiction services along with homeless programming in a single setting [10]. Assertive community treatment (ACT) teams provide intensive, often street-based, mental health care support for veterans who are unable or unwilling to come to a facility for care. The Veterans Justice Outreach Initiative has several programs that support veterans in the criminal justice system who are either homeless or at high risk for becoming homeless; these programs facilitate their engagement in services and care, either as an alternative to incarceration or following incarceration to assist in their community transition [11,12]. Finally, the Homeless Veterans Dental Program provides targeted assistance and dental care to homeless veterans [13]. Additionally, all homeless veterans being placed in HUD-VASH housing are assigned case managers who are trained in specific skill areas necessary to effectively monitor and manage veterans' care needs and reduce recidivism.

Income Stability and Supports
Taking the long view, several initiatives sponsored by the VA Homeless Program are addressing veterans' ability to stay housed with regards to income stability and supports. The VA actively works with veterans to help them return to the workforce. Currently over 50% of veterans leaving the grant-per-diem program are employed at the time of their discharge (personal communication, Keith Harris, PhD, director of clinical operations for VHA Homeless Program Office). The grant-per-diem program, which is funded by VA and managed by local community organizations, provides up to 2 years of housing and supportive services to homeless veterans. VA has also launched the Homeless Veterans Community Employment Services program, in which community employment coordinators embedded within homeless programs serve as liaisons with employers in the community to assist in job placement. For veterans with disabling conditions, every regional office has either a homeless veteran outreach coordinator or a homeless veteran claims coordinator who is responsible for case management and for expediting veterans' claims for disabilities and pension.

Program Results
Taken together, this continuum of programming, care, and services has yielded unprecedented results. Since 2009, VA has housed more than 200,000 veterans in permanent housing. Further, according to the annual Point-In-Time (PIT) count, which reflects a one-night head count of self-identified homeless veterans, there has been a 33.2% reduction in homeless veterans since 2010, including a nearly 40% reduction in unsheltered homeless veterans [14]. These findings are particularly notable in that they occurred in the context of a deep recession, high unemployment rates, and a housing crisis marked by record numbers of foreclosures.
Moving forward into the next 5 years, there are sev-eral substantial challenges that will need to be addressed in order to maintain these gains. While progress has been made, the ultimate goal of ending veteran homelessness has not yet been met, and more work is needed. Critical to this initiative is the leadership and organizational commitment to continue to innovate, adopt evidence-based practices [4][5][6][7][8][10][11][12], and implement a total quality improvement philosophy and capacity. Several initiatives and pilot projects underway at the National Center on Homelessness Among Veterans are helping to move us towards a more efficient and effective approach. These initiatives are using predictive analytics, critical time interventions, and hot-spotter algorithms, and they are evaluating the best practices in housing and care delivery that will help drive our next steps. Sustaining focus when mission fatigue and competing interests become more prominent, as well as cultivating a nimble and adaptive culture within an organization and bureaucracy the size of VA, is critical to the success of this effort and will require ongoing focus and attention. The commitment by VA leadership and the administration, the collaboration with federal partners at HUD, the leadership from the US Interagency Council on Homelessness, and strong bipartisan Congressional support have all been critical and will remain so in the upcoming years. Maintaining the enhanced capacity and continuum of programming that have been built up over these past 5 years is equally important. As more communities reach a stage where they are effectively managing the inflow to homelessness with programs and supports, there will be a natural tendency to lose a sense of urgency or moral imperative and to assume that programs can be cut back or eliminated.
Finally, the evolving demographic characteristics of veterans and veteran homelessness suggest 4 subpopulations that will likely need increased attention, programming, and program capacity over the next several years: veterans from the post-9/11 era who served in the Iraq and Afghanistan theaters [15]; female veterans, who disproportionately experience poverty and who are currently serving in the military at record levels [16]; aging veterans, who experience accelerated aging and a higher chronic disease burden when they are homeless [17]; and those veterans most prone to recidivism and a return to homelessness. Each group will require an intensified and tailored focus as well as proactive planning to develop models that can identify, intervene, prevent, and quickly support those in need. Without this, any gains made will be in jeopardy.
It is also important to note that-barring eradication of poverty, substance abuse, mental illness, disability, domestic violence, housing crises, job loss, and all the other drivers of homelessness-people, including veterans, will still become homeless and need help. Rather than falling victim to a cynic's view that homelessness can never truly be ended, we need to instead consider what is needed, practically and realistically, for a community to truly end homelessness. This means having the resources in place to be able to iden-tify who is homeless or at risk for becoming homeless and being able to prevent homelessness from occurring. It also means, when homelessness cannot be prevented, being able to respond with immediacy and resources so that no one ever has to stay on the streets or in a shelter because of a lack of available housing. Finally, it means having the commitment and capacity to support people in their recovery so they never have to return to homelessness and poverty. Communities like New Orleans and Houston have demonstrated an ability to end veteran homelessness in their cities by knowing who the homeless veterans are in their communities, by having an individualized plan for each veteran to move him or her into permanent housing, and by having the housing stock and resources to make it happen. This is what it ultimately means to end homelessness: when a community, with support from and in partnership with VA and other state and federal agencies, can do what is needed so that the national disgrace of having veterans ending up on the streets becomes a historical footnote.