Housing First is a clinical approach to providing permanent supportive housing for homeless individuals. It departs from traditional approaches in removing traditional preconditions for housing support, and in emphasis on community-based recovery support services. The approach emphasizes selection of the most vulnerable potential clients rather than persons who are easiest to accommodate. The expansion of Veterans Affairs' Supportive Housing program, in collaboration with the US Department of Housing and Urban Development (HUD-VASH) progressively adopted Housing First during a period of expansion to accommodate over 80,000 Veterans. The objectives of this study were to: (a) Identify organizational facilitators and barriers to implementation of Housing First in a VA context through qualitative data collection among 8 VA Medical Centers; (b) Disseminate easily accessible description of concrete actions available to VA facilities and VHA leaders seeking to implement Housing First programs with available housing vouchers; (c) Compare homeless vulnerability indicators (homeless chronicity health diagnoses, utilization history) among veterans who entered HUD-VASH to those who did not. Each phase of the study has sought to deliver actionable information to VA and non-VA leadership on ending homelessness.
The objectives of this study are to: (a) Identify organizational facilitators and barriers to implementation of Housing First in a VA context through qualitative data collection among 8 VA Medical Centers that differ in the degree of adoption of Housing Firstt; (b) Disseminate easily accessible description of concrete actions available to VA facilities and VHA leaders seeking to implement Housing First programs with the use of presently available housing vouchers; (c) Compare homeless vulnerability indicators (homeless chronicity, homelessness immediately preceding referral, health diagnoses, utilization history) among veterans at the 8 VA Medical Centers under site . Each phase of the study has sought to deliver actionable information to VA and non-VA leadership on ending homelessness.
This project has four phases. In Phase I we conducted expert panels with VA leadership involved in housing homeless veterans along with nationally-known experts on homelessness. Deliberations guided tailoring of the organizational assessment tool used in the subsequent phase of the study. Phase II entailed in-person and telephone interviews with leadership, mid-level management, and front-line staff involved in housing homeless veterans at eight VA facilities throughout the country. Phase III uses client-level data to assess the prevalence and possible prioritization of medical and social vulnerabilities of homeless veterans who are provided permanent housing. Lastly, Phase IV is ongoing and involves dissemination of results to guide future VA housing policy based on the best practices identified through the expert panels, organizational assessments, and client-level data analysis. We are focused on finalizing an additional policy paper for national leadership and one additional scientific manuscript.
Across 6 peer-reviewed papers, numerous white papers and public presentations, we have identified strengths and challenges of the Housing First effort to date. As a whole this research profiles the largest Housing First undertaking in the world, and reveals concrete actions available to VA leaders, and to any person or group seeking to advance Housing First.
Housing First implementation is correlated with elements of organizational transformation that reflect leadership and resources
Among 8 VA Medical Centers (VAMCs), we found that Housing First fidelity scores correlated strongly with the degree to which leaders and middle managers showed principles of organizational transformation through their own actions. These principles included communicating impetus for the change to Housing First with local VAMC leaders either reinforcing or soft-pedalling the ambitious national goal to end Veteran homelessness. They included success at integrating effort across organizational units and vertically between management and staff layers. To a striking degree, success or failure depended on mid-level managers who in their skill at transmitting challenges both up and down their command chain and across service lines.
Front Line Staff have unique insights and spoke frequently of caseloads being too high
We identified many challenges faced by front-line staff as they attempted to house veterans. These included housing markets, coordination with Public Housing Authorities, the need for supplemental funds as veterans moved into housing, and high caseloads. The latter hindered efforts to provide appropriate support for challenging clientele. With regard to the level of support needed to house especially vulnerable veterans, front-line staff spoke of the difficulty of balancing housing tasks and clinical case management in this particularly complicated population.
Chronically homeless Veterans were prioritized, but other vulnerable Veterans were not
Because Housing First often involves selecting the "most vulnerable" for permanent housing, we checked if in VA HUD-VASH programs moved in this direction during the period 2011-2014 We found (a) there was increased emphasis on acceptance of chronically homeless individuals; (b) there was little to no evidence of increased focus on selecting persons with medical or mental vulnerabilities into HUD-VASH. The latter finding runs counter to expectation for Housing First.
Overall, there is solid adoption and implementation of many Housing First philosophies
Despite some shortfalls, we generally found that there was solid adoption and implementation of many Housing First principles, especially in VAMCs with committed leadership. As mentioned previously, high caseloads of front line staff has hindered efforts to provide comprehensive support services, and we are advised from homeless program leadership that this is an are targeted for improvement.
1. Manuscripts: To date, three peer-reviewed manuscripts have been published and two more are accepted. Publications appeared in journals ranging from Psychiatric Services to Journal of General Internal Medicine. A perspective commentary informed by this VA study, is slated for publication in New England Journal of Medicine on December 1, 2016.
2. White Papers: In fall 2012 we offered a written summary of our findings for VACO and HUD-VASH national leadership, which was well-received .In March, 2015, we developed a 2-page newsletter-style White Paper. This was provided to VHA National Homeless HUD-VASH Director Jesse Vazzano, VHA National Director of Clinical Operations Keith W. Harris, and Direct of VHA Homeless Programs Lisa Pape, and Director of the National Center on Homelessness Among Veterans Thomas O'Toole.
3. National/International Presentations: Major study findings were reviewed for the Research Council of the National Alliance to End Homelessness in an oral presentation in April of 2015. Findings were also presented in Melbourne Australia at the Victorian Council on Human Services, jointly sponsored by two local universities.
4. Study findings were presented in a large multi-VISN regional training for HUD-VASH leadership held in Atlanta, April of 2015
5. Email correspondence of August 5, 2015 shows that VHA National Director of Clinical Operations Lisa Pape sent a detailed written briefing regarding this project to VHA Undersecretary Shulkin and received a strong and enthusiastic response.
6.Previously we have reported the following dissemination/impact: Results were presented at several national conferences, including an oral panel presentation at the International Homelessness and Housing Research conference in Philadelphia in June 2013, co-sponsored by VA's National Center on Homelessness Among Veterans. Our work won an award for Best Abstract at the 2013 AMERSA conference. We have presented numerous aspects of our work over several years at the Society of General Internal Medicine (2013, 2014, 2015, 2016), the AcademyHealth Annual Research Conference (2014, 2015, 2016), and the Association for Medical Education and Research in Substance Abuse (2013, 2016).
- Austin EL, Pollio DE, Kertesz SG. Ethnographic Observation of a Housing First Approach to Case Management at Four VA Medical Centers. Psychiatric services (Washington, D.C.). 2016 Dec 1; 67(12):1384-1385.
- Kertesz SG, Baggett TP, O'Connell JJ, Buck DS, Kushel MB. Permanent Supportive Housing for Homeless People - Reframing the Debate. The New England journal of medicine. 2016 Dec 1; 375(22):2115-2117.
- Kertesz SG, Austin EL, Holmes SK, Pollio DE, Schumacher JE, White B, Lukas CV. Making housing first happen: organizational leadership in VA's expansion of permanent supportive housing. Journal of general internal medicine. 2014 Dec 1; 29 Suppl 4:835-44.
- Austin EL, Kertesz S, Tsemberis S. Timing and momentum in VA's path toward Housing First: in reply. Psychiatric services (Washington, D.C.). 2014 Jun 1; 65(6):836-7.
- Austin EL, Pollio DE, Holmes S, Schumacher J, White B, Lukas CV, Kertesz S. VA's expansion of supportive housing: successes and challenges on the path toward Housing First. Psychiatric services (Washington, D.C.). 2014 May 1; 65(5):641-7.
- Kertesz SG, Austin EL, Holmes SK, Pollio DE, VanDeusen Lukas C. Housing First and the Risk of Failure: A Comment on Westermeyer and Lee (2013). [Editorial]. The Journal of nervous and mental disease. 2015 Jul 1; 203(7):559-62.
- Kertesz SG. Housing, Housing Vouchers and the H-SOLVE Study. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; Washington, DC.