Study Suggests VA's "Housing First" Approach to Helping Homeless Veterans Presents Several Challenges

BACKGROUND:
There were an estimated 62,619 homeless Veterans in 2012. A primary tool in the effort to end homelessness among Veterans is VA's supportive housing (VASH) program, which provides permanent rental vouchers and case management services to homeless Veterans, in collaboration with the U.S. Department of Housing and Urban Development (HUD). In addition, over the past three years VA has shifted toward a Housing First (HF) approach to its HUD-VASH program, pivoting away from the traditional approach (often termed "Treatment First"), which emphasized housing readiness prior to awarding rental vouchers. This qualitative study examined the experiences of eight VA facilities that were at varying stages of HF adoption in 2012. Investigators conducted 95 interviews to explore how personnel at all levels of the organization (front-line, middle management, leadership) – and from four regions in the U.S. – experienced the transition to HF, which was formally rearticulated as VA policy in late 2012. Questions assessed how HUD-VASH programs were managed at each facility, as well as the influence of organizational factors in advancing VA's goal of ending homelessness among Veterans through intensified efforts to provide permanent housing.

FINDINGS:

• Front-line staff faced challenges in rapidly housing homeless Veterans due to difficult rental markets, the need to coordinate with local public housing authorities, and a lack of available funds for move-in costs. Finding interim sheltering options for Veterans waiting for housing (i.e., with no expectations of sobriety or treatment participation) also presented a significant challenge to the implementation of HF.
• Staff struggled to balance the time spent on housing search activities with intensive case management of highly vulnerable Veterans; this tension is acute immediately after the release of vouchers, when facilities are closely monitored on the speed with which the vouchers are used.
• Facility leadership supported HF implementation through resource allocation, performance monitoring, and reliance on mid-level managers to meet the challenges of implementation.
• The authors suggest that HF cannot successfully proceed unless VA is able to secure housing in discrete geographies and markets. Moreover, securing housing while simultaneously advancing the recovery agenda for each Veteran remains an ambitious undertaking.

LIMITATIONS:

• Insights could have been missed by not interviewing HUD-VASH program participants.
• Findings describe efforts at eight facilities in various stages of transition to HF at a specific point in time. Follow-up interviews are currently being conducted to assess programmatic changes following the late 2012 reiteration of HF as VA policy.

AUTHOR/FUNDING INFORMATION:
This study was funded by HSR&D (SDR 11-233). Drs. Austin and Kertesz are part of the Birmingham VAMC, Birmingham, AL. Ms. Holmes and Drs. White and VanDeusen Lukas are part of HSR&D's Center for Healthcare Organization and Implementation Research, Boston, MA.

Austin E, Pollio D, Holmes S, Schumacher J, White B, VanDeusen Lukas C, and Kertesz S. VA’s Expansion of Supportive Housing: Successes and Challenges on the Path toward Housing First. Psychiatric Services January 15, 2014;e-pub ahead of print.