2023 HSR&D/QUERI National Conference

4129 — Enhancing VA’s preparedness for disease epidemics that disproportionately impact unsheltered homeless Veterans

Lead/Presenter: Ronald Calderon,  COIN - Los Angeles
All Authors: Calderon RA (Center for the Study of Healthcare Innovation, Implementation and Policy), Nazinyan M (Center for the Study of Healthcare Innovation, Implementation and Policy) McCoy MR (Center for the Study of Healthcare Innovation, Implementation and Policy) Gabrielian SE (Center for the Study of Healthcare Innovation, Implementation and Policy)

Veterans experiencing unsheltered homelessness, i.e., living outdoors or other places not intended for sleeping, are disproportionately vulnerable to disease epidemics, including the coronavirus 2019 (COVID-19) pandemic. Beyond higher burdens of morbidity and mortality, physical distancing regulations dramatically shifted the delivery of VA housing and social services from in-person to virtual modalities. To enhance VA’s preparedness for future disease epidemics that impact unsheltered Veterans, we conducted a pilot project to understand the experiences and needs of this vulnerable population during the first year of the COVID-19 pandemic.

We conducted 18 semi-structured, in-person and over the phone interviews (45-60 minutes each) with Veterans who experienced unsheltered homelessness in Los Angeles during the first year of the pandemic; Veterans were recruited from a parent USC/RAND study of homeless service utilization and housing outcomes among unsheltered Veterans conducted pre-pandemic, augmented by additional Veterans recruited from homeless services at the VA Greater Los Angeles. Interviews queried Veterans’ experiences using housing and social services since the pandemic’s onset and identified perceived gaps in care.

Program and policy adaptations to transitional housing and residential rehabilitation programs, spurred by the pandemic, led to prominent feelings of loneliness and social isolation while using these services; comradery with other Veterans was described a central impetus to use these services outside of pandemic times, and it was challenging for participants to find value in these programs when physical distancing and other requirements were enforced. A portion of participants endorsed the value of a novel VA-sanctioned tent encampment, on medical center grounds, that provided safe-comping in an outdoor community with fewer COVID-19 restrictions than other transitional housing options. Though participants perceived threat from COVID-19, they prioritized their housing concerns over this threat, and were distressed by decreased access to housing services because of public health precautions. Participants described longer than usual wait times to enter housing programs due COVID-19 testing requirements, fewer transportation options, and a mismatch between their needs and available resources (e.g., they were offered motel vouchers, but needed fundamental supportive services and skills training to stay housed). Many participants desired in-person health care services and legal and vocational services, struggling with the transition to virtual modalities; they wanted guidance and assistance with technology used during the pandemic.

Physical distancing precautions resulting from the COVID-19 pandemic worsened vulnerabilities and care experiences of Veterans experiencing unsheltered homelessness. A safe-camping site was an important innovation that provided a safe and flexible environment for Veterans who struggled to tolerate changes to other homeless services during the pandemic. Though many VA services transitioned well to virtual care, some of the most vulnerable Veterans struggled to use technology during the pandemic and desired access to ongoing in-person services.

Veteran perspectives about their needs and challenges during to the COVID-19 pandemic can inform quality improvement about how to accommodate unsheltered homeless Veterans with continuous services during this pandemic and future disease epidemics