Commentary Challenges Findings in Previous Study on Housing First Approach for Homeless Veterans
In the past year, there has been an impressive reduction in the number of Veterans who are homeless– down to about 50,000 in 2014 from 75,609 at a single point in time during 2009. This decline is due, in part, to the provision of housing for more than 74,000 Veterans over the last four years through a collaboration between the Department of Housing and Urban Development (HUD) and VA. Recently, VA adopted an evidence-based approach to housing and recovery known as "Housing First," which includes: removing traditional pre-conditions to housing (i.e., completing substance abuse treatment), providing extensive support for recovery, and delivering support services according to the Veteran's choice. However, in 2013 an article was published (Westermeyer and Lee) about a study that offered a skeptical view of both Housing First as a recovery approach and HUD-VASH as a program. Results showed that in a 16-person quasi-experimental study, 8 Veterans who entered VA's permanent supportive housing did poorly, while 8 Veterans who remained in more traditional treatment did well. However, this Commentary suggests that the study was problematic, both in its conceptualization of the matters it sought to address – and in its science.
One of the critical questions regarding this study's conceptualization concerns the actual treatment availability for the HUD-VASH clients in this case series. The Housing First approach requires recovery services to engage clients and reduce substance-use related harms; however, there are no data to suggest these services were available to the eight clients in this study. Another important issue concerns the potential for bias. The Veterans in this study were the first eight placed in apartments, thus, they are a pseudo-random sample. Moreover, the availability of complete one-year follow-up data for all eight comparators raises the question of whether they represent "retained clients" rather than a pseudo-random sample of entrants to more traditional programs. Another concern is the poor outcomes for the initial HUD-VASH Veterans: job loss (5/8), re-addiction (8/8), and loss of housing (7/8). While poor outcomes are more common than advocates would like, most Housing First research suggests they are not so prevalent as reported by these eight clients. For example, an analysis of more than 29,000 HUD-VASH clients found no effect of substance use disorder on housing success (Tsai et al, 2014). Despite these limitations, the 2013 study highlights pressing challenges in the adoption of Housing First, including the necessity for strong resource supports for clinical care in combination with leadership actions necessary to foster institutional change.
Drs. Kertesz, Austin, and Pollio are part of the Birmingham VA Medical Center. Dr. VanDeusen Lukas and Ms. Holmes are part of HSR&D's Center for Healthcare Organization and Implementation Research, Boston, MA.
Kertesz S, Austin E, Holmes S, Pollio D, and VanDeusen Lukas C. Housing First and the Risk of Failure: A Comment on Westermeyer and Lee (2013). Commentary: The Journal of Nervous and Mental Disease. July 2015;203(7):559-62.