Housing And Urban Development-Veterans Affairs Supportive Housing Research Articles

Rates and Predictors of Returns to Homelessness Among Veterans, 2018–2022

IntroductionThe progress made by the U.S. Department of Veterans Affairs (VA) towards ending veteran homelessness requires attention be paid to preventing returns to homelessness. MethodsUsing national VA data on 293,820 exits from a VA homeless program to a permanent housing destination between January 2018 thru December 2022, rates and predictors of returns to homelessness among veterans were examined. Analyses were conducted June-August 2023. A return to homelessness was operationally defined as a return encounter with a VA homeless program. Results5.8% of successful exits to permanent housing resulted in a return to homelessness within 6 months, 10.2% return within 12 months, and 16.7% return within 24 months. In the total sample, veterans who were male (hazard ratio [HR]= 1.47), widowed (HR= 1.29), had diagnoses of drug use disorder (HR= 1.40) or psychotic disorder (HR= 1.20), and had used more inpatient or urgent care services in the year prior (HR= 1.05-1.15) were at significantly greater risk of returning to homelessness. Many of these predictors remained significant in subgroup analyses of female veterans, veterans aged 65 or older, and veterans in the Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program. ConclusionsMost homeless veterans served by VA who exit to permanent housing do not return to homelessness within 2 years. The most critical period seems to be the first year, when 1 in 10 veterans return to homelessness. Knowledge of these risk factors may be important in planning secondary and tertiary prevention efforts for homelessness.

Actuarial prediction versus clinical prediction of exits from a national supported housing program.

The accurate identification of persons at risk of exiting permanent supportive housing could help maximize client success and minimize attrition and premature exits from such housing. Thus, in the present study, we developed and tested multivariable prediction models of negative and positive exits from the U.S. Department of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program using logistic regression and random forests. We compared the performance of these models with clinical predictions made by HUD-VASH program case managers. We selected a cohort of all 92,196 Veterans who entered HUD-VASH nationwide between October 1, 2014 and September 30, 2019, 70% of whom were randomly selected to serve as the development cohort and the remaining 30% of whom served as the validation cohort. Negative and positive exits were measured until September 30, 2019. A subset of 1,264 Veterans was used to compare performance of models with clinical judgment. Predictor variables included sociodemographic characteristics, health and behavioral health diagnoses, homeless/housing history, and VA service utilization history. Performance of models and clinical judgment were assessed using an array of metrics including area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, and positive predictive value. The logistic regression and random forest models had similar, modest performance in predicting negative and positive exits. These models were substantially more sensitive, yet far less specific in predicting exits than clinician ratings. Study findings highlight the challenges and tradeoffs in using actuarial models or case manager predictions to target interventions to Veterans at risk of exiting HUD-VASH. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

“Get people out of bad situations sooner”: exploring transgender and cisgender veterans’ experiences using permanent supportive housing

ABSTRACT Transgender veterans are more likely than non-transgender (i.e., cisgender) veterans to experience housing instability, and they may experience unique challenges in accessing permanent supportive housing (PSH). The objective of this study was to explore transgender and cisgender veterans’ experiences utilizing PSH through the U.S. Departments of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program. Between February and May 2018, 48 veterans (14 cisgender women, 17 cisgender men, 17 transgender individuals) completed an audio-recorded, semi-structured telephone interviews; all transgender individuals self-identified as transgender women. We used rapid identification of themes from audio recordings (RITA) to analyze the data. Half of the participants had been in HUD-VASH one to three years. Most respondents cited their case manager as a key facilitator in successfully becoming housed and identified lack of understanding the HUD-VASH admission processes and wait times as common barriers to housing. Other challenges included veterans’ inability to receive services until they were homeless and landlords’ reluctance to rent to veterans with histories of substance use. Transgender women veterans conveyed unique challenges related to sex-specific shelter experiences and incongruence of identification cards and gender expression.

Housing and Urban Development-Veterans Affairs Supportive Housing Vouchers and Veterans' Homelessness, 2007-2017.

Objectives. To determine what role the 88 000 Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) vouchers for permanent supportive housing among US veterans distributed between 2008 and 2017 played in the significant fall in veterans' homelessness over the same time period.Methods. Using a panel data set at the Continuum of Care level over the 2007 to 2017 period, we correlated changes in vouchers with permanent supportive housing units and measures of homelessness. To reduce concerns about omitted variables bias, we used a 2-stage least-squares procedure. The instrument is a Bartik-type shift-share variable. Specifically, for the cumulative vouchers received at the local level, we used the share of the nation's homeless veterans from the local level in the year before the HUD-VASH program multiplied by the cumulative number of vouchers distributed at the national level up to that point.Results. For each additional voucher, permanent supportive housing units increased by 0.9 and the number of homeless veterans decreased by 1.Conclusions. Our results indicate the HUD-VASH program worked as intended and veterans' homelessness would have risen substantially over the past decade without the program.

Applying the Housing First approach to single-site permanent supportive housing

ABSTRACTThis study explored how the U.S. Departments of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program applies Housing First principles in the context of ten single-site programs. Focus group discussions with 64 HUD-VASH staff and community partners explored how the programs were influenced by Housing First principles and specific strategies to implement these principles in a single-site setting. Focus group respondents described resourceful ways that the principles of Housing First were implemented in their programs specifically related to (1) housing choice and structure, (2) separation of housing and services, (3) service philosophy, and (4) service array. Several of the Housing First domains cite the importance of integrated housing and the provision of services off-site; it was of particular interest to learn how single-site programs address these issues logistically. Lessons learned from this study include the importance of leveraging the independent yet overlapping tasks of case management and property management to ensure functional – if not geographic – separation of housing and services; maintaining staff on-site to address Veterans’ needs; working with community service organizations to complement the array of service available to residents; and housing single-site programs in mixed-use buildings.

An evidence-based co-occurring disorder intervention in VA homeless programs: outcomes from a hybrid III trial

BackgroundEvidence-based treatment for co-occurring disorders is needed within programs that serve homeless Veterans to assist with increasing engagement in care and to prevent future housing loss. A specialized co-occurring disorders treatment engagement intervention called Maintaining Independence and Sobriety Through Systems Integration, Outreach and Networking - Veterans Edition (MISSION-Vet) was implemented within the Housing and Urban Development - Veterans Affairs Supportive Housing (HUD-VASH) Programs with and without an implementation strategy called Getting To Outcomes (GTO). While implementation was modest for the GTO group, no one adopted MISSION in the non-GTO group. This paper reports Veteran level outcome data on treatment engagement and select behavioral health outcomes for Veterans exposed to the MISSION-Vet model compared to Veterans without access to MISSION-Vet.MethodsThis hybrid Type III trial compared 81 Veterans in the GTO group to a similar group of 87 Veterans with mental health and substance use disorders from the caseload of staff in the non-GTO group. Comparisons were made on treatment engagement, negative housing exits, drug and alcohol abuse, inpatient hospitalizations, emergency department visits and income level over time, using mixed-effect or Cox regression models.ResultsTreatment engagement, as measured by the overall number of case manager contacts with Veterans and others (e.g. family members, health providers), was significantly higher among Veterans in the GTO group (B = 2.30, p = .04). Supplemental exploratory analyses between Veterans who received “higher” and “lower” intensity MISSION-Vet services in the GTO group failed to show differences in alcohol and drug use, inpatient hospitalization and emergency department use.ConclusionsDespite modest MISSION-Vet fidelity among staff treating Veterans in the GTO group, differences were found in treatment engagement. However, this study failed to show differences in alcohol use, drug use, mental health hospitalizations and negative housing exits over time among those Veterans receiving higher intensity MISSION-Vet services versus low intensity services. This project suggests that MISSION-Vet could be used in HUD-VASH to increase engagement among Veterans struggling with homelessness, a group often disconnected from care.Trial registrationClinicaltrials.gov, registration number: NCT01430741, registered July 26, 2011.

A cluster randomized Hybrid Type III trial testing an implementation support strategy to facilitate the use of an evidence-based practice in VA homeless programs

BackgroundThe Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program is one of the largest initiatives to end Veteran homelessness. However, mental health and substance use disorders continue to reduce client stability and impede program success. HUD-VASH programs do not consistently employ evidence-based practices that address co-occurring mental health and substance use disorders. This paper presents a study protocol to evaluate the implementation of an evidence-based, co-occurring disorder treatment called Maintaining Independence and Sobriety Through Systems Integration, Outreach, and Networking—Veterans Edition (MISSION-Vet) in HUD-VASH using an implementation strategy called Getting To Outcomes (GTO).Methods/designIn three large VA Medical Centers, this Hybrid Type III trial will randomize case managers and their clients by HUD-VASH sub-teams to receive either MISSION-Vet Implementation as Usual (IU—standard training and access to the MISSION-Vet treatment manuals) or MISSION-Vet implementation augmented by GTO. In addition to testing GTO, effectiveness of the treatment (MISSION-Vet) will be assessed using existing Veteran-level data from the HUD-VASH data monitoring system. This project will compare GTO and IU case managers and their clients on the following variables: (1) fidelity to the MISSION-Vet intervention; (2) proportion of time the Veteran is housed; (3) mental health, substance use, and functional outcomes among Veterans; and (4) factors key to the successful deployment of a new treatment as specified by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) model.DiscussionThis project is an important step for developing an implementation strategy to increase adoption of evidence-based practice use in VA homeless programs, and to further examine efficacy of MISSION-Vet in HUD-VASH. This project has important implications for program managers, policy makers, and researchers within the homelessness field. VA Central IRB approval for this study was granted in October 2011. The three sites were trained on MISSION-Vet and GTO in the first half of 2013. The first GTO planning meetings began after training occurred, between January 2013 and November 2013, across the three sites. The data collection—via a fidelity measure embedded into the VA Computerized Patient Record System—began as each site initiated MISSION-Vet, between April 2013 and January 2014.Trial registrationClinicalTrials.gov: NCT01430741

Neighborhood Outcomes of Formally Homeless Veterans Participating in the HUD-VASH Program

Research regarding how neighborhoods affect the people who live in them has grown in recent years. However, the neighborhood outcomes of formally homeless veterans have not received the attention this group warrants. This article examines the neighborhood outcomes of two groups of housing voucher holders. Using administrative data, this exploratory study finds that U.S. Department of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) voucher holders receiving comprehensive case management reside in higher quality neighborhoods than those who do not receive these services. Additionally, this effect seems to be a more critical factor for African Americans than Whites. Use of case managers with housing vouchers may improve African American residential outcomes in terms of neighborhood quality.

Homeless female U.S. veterans in a national supported housing program: comparison of individual characteristics and outcomes with male veterans.

As more women serve in the U.S. military, the proportion of females among homeless veterans is increasing. The current study compares the individual characteristics and 1-year outcomes of homeless female and male veterans in the Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program nationally. Administrative data on 43,853 veterans (10.69% females; 89.31% males) referred to HUD-VASH were analyzed for gender differences at baseline and over a 1-year period. Homeless female veterans were younger, had shorter homeless and incarceration histories, and were less likely to have substance use disorders than men. However, despite being less likely to report combat exposure, female veterans were more likely to have posttraumatic stress disorder. Homeless female veterans were also much more likely to have dependent children with them and to plan to live with family members in supported housing. Once admitted to HUD-VASH, there were no gender differences in attrition or main housing outcomes. Case managers were faster to admit female veterans to the program, reported better working alliances, and provided more services related to employment and income than male veterans. These findings suggest homeless female veterans may have certain strengths, including being younger, less involved in the criminal justice system, and more adept at relating to professional and natural supports; but special attention to noncombat trauma and family-oriented services may be needed.

Client satisfaction with a new group-based model of case management for supported housing services

Supportive housing typically offers rental subsidies and individual intensive community-based case management and has become a predominant service model for homeless adults. Alternative case management models have not been adequately explored. This study evaluates satisfaction with a novel group-intensive peer support (GIPS) model of case management for the Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program. A total of 95 HUD-VASH clients rated their satisfaction with services and responded to open-ended questions about what they liked best and least about the program. Quantitative and qualitative analyses compared clients who attended groups as part of the GIPS model and those who did not. No significant difference in satisfaction between group and non-group attenders were found. Clients reported what they liked best about the program was the staff; those who attended groups reported what they liked best was the social interaction and peer support. These findings suggest clients who attend groups for their primary source of case management may be as satisfied as those who receive only individual case management. GIPS offers a feasible and acceptable service model and should be further explored along with other alternative models of care in supportive housing services.

LIFE AFTER SUPPORTED HOUSING: A CASE SERIES OF FORMERLY HOMELESS CLIENTS IN THE DEPARTMENT OF VETERANS AFFAIRS‐SUPPORTIVE HOUSING (HUD‐VASH) PROGRAM 20 YEARS LATER

This article presents a case series of three formerly homeless clients who were in the Housing and Urban Development‐Veterans Affairs Supportive Housing (HUD‐VASH) program 20 years ago and describes their progress since. Clients were identified from a 1992 client roster at one of the original HUD‐VASH sites. Clients were interviewed and their medical records were reviewed. The case studies were characterized as “sustained involvement in subsidized housing,” “successful discharge followed by re‐engagement,” and “case management more important than the voucher.” These cases illustrate that, first, long‐term success in supported housing has not been defined, but perhaps social integration and self‐sufficiency should be a focus. Second, mental health and substance abuse treatment appear to be important in long‐term client success, but when and how they should be promoted remains unclear. Last, case management services may represent a crucial and necessary form of support for clients in supported housing programs.

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the risk factors for women,” Tsai said. Trauma in general may be a factor. Tsai and colleagues studied 581 homeless women veterans at 11 VA Homeless Women Veterans Program sites and found that women in the group had experienced a diverse array of trauma. For example, 82% said someone close to them had experienced a serious or lifethreatening illness, 67% reported having been raped, 61% had experienced a natural or manmade disaster, 53% had a friend or family member who was killed, 52% had been injured by a family member hitting or pushing them, and 27.7% had engaged in prostitution. Tsai said much of the trauma occurred before the women joined the military, and many remained at elevated risk of trauma after they returned home. He noted that some researchers theorize that people who have been traumatized may be at increased risk of further trauma in part because they may put themselves into potentially threatening situations. Homeless female veterans sometimes have a different set of needs than their male counterparts. Many have children and need to find housing that is suitable for children, explained Stephen Peck, MSW, of the nonprofit US Veterans Initiative. The majority of homeless female veterans have also experienced sexual trauma, which may make them less comfortable with participating in programs in which they are greatly outnumbered by men. Peck said his group found that many female homeless veterans declined to participate in their substance abuse program until the group developed a program specifically for women that allows women to attend day treatment as a cohort. Peck noted that his organization also offers on-site child care and a school with kindergarten through grade 8 to provide care and access to education for children whose mothers are seeking treatment. Tailoring interventions to the specific needs of subgroups of homeless vets may be crucial for both men and women, Tsai said. “Some individuals need more intensive services; some are able to do well on their own once they get housing,” he explained. Tsai recommended that physicians refer veterans at risk of homelessness to the VA, which he said is better equipped to handle issues surrounding homelessness and which is often free for veterans. The VA tries to make care as accessible as possible, not just at hospitals but also at outpatient clinics. The US Department of Housing and Urban Development–Veterans Affairs Supportive Housing (HUD-VASH) program provides vouchers to help homeless veterans find rental housing and also provides them with case management and clinical services (http://1.usa .gov/h52lnU).

HOUSING CHRONICALLY HOMELESS VETERANS: EVALUATING THE EFFICACY OF A HOUSING FIRST APPROACH TO HUD‐VASH

Rapidly placing homeless Veterans with severe mental illness into permanent housing is one important goal of the U.S. Department of Housing and Urban Development‐Veterans Affairs Supportive Housing (HUD‐VASH) program; however, no research has tested whether an explicit organizational alignment of this goal with revised practices could improve outcomes. A demonstration project initiated in 2010 to reform housing placement practices in a metropolitan area enabled researchers to compare an explicit “Housing First” program—offering immediate permanent housing without requiring treatment compliance, abstinence, or “housing readiness”—with a treatment‐first program for 177 homeless Veterans. The Housing First initiative successfully reduced time to housing placement, from 223 to 35 days, housing retention rates were significantly higher among Housing First tenants, and emergency room use declined significantly among the Housing First cohort. The results suggest that a national Housing First model for the VA would be associated with improved outcomes for Veterans experiencing homelessness.

Homeless veterans in supported housing: Exploring the impact of criminal history.

This article described the criminal histories of a multisite sample of homeless veterans enrolled in the Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program, presented a method of categorizing them, and compared outcomes among veterans with different criminal histories. A national dataset on a total of 1,160 participants over a 1-year period was analyzed. Cluster analyses were conducted on the criminal histories of participants and groups of participants were compared on program entry characteristics and outcomes. Before entry into the HUD-VASH program, 79% of participants had been charged with at least one criminal charge. The most common criminal charges were disorderly conduct, vagrancy, and public intoxication. At program entry, participants with more extensive criminal histories showed poorer status in employment, housing, substance abuse, and quality of life compared with participants with minor or no criminal histories. However, once enrolled in supported housing, there were no group differences in outcomes and all groups showed substantial improvements in housing. These findings suggest that most homeless veterans have had involvement in the criminal justice system, albeit mostly to a small extent. Supported housing programs, like HUD-VASH, that serve homeless veterans regardless of their criminal history should be supported.

Outcomes of a Group Intensive Peer-Support Model of Case Management for Supported Housing

Community-based intensive case management may be more intense than necessary and may be socially isolating for persons living in supported housing. This study evaluated a group intensive peer-support (GIPS) model of case management that was implemented in a supported housing program for homeless veterans with a broad range of psychiatric,substance use, and general medical problems. Group meetings led by case managers are the default mode of case management support, and individual intensive case management is provided only when clinically necessary. GIPS was implemented by the U.S. Department of Housing and Urban Development–Veterans Affairs Supportive Housing(HUD-VASH) program at one demonstration site in April 2010. The study used administrative data to compare outcomes, service delivery, and timing of housing acquisition among clients of the demonstration site one year before (N=102) and after (N=167) GIPS implementation and among clients of other HUD-VASH sites across the country before (N=9,659) and after (N=21,318) implementation of GIPS at the demonstration site. After adjustment for differences in baseline characteristics, the analyses found that GIPS implementation was associated with a greater increase in social integration ratings, a greater number of case manager services, and faster acquisition of Section 8 housing vouchers after program admission compared with outcomes at the same site before GIPS implementation and at the other sites before and after implementation. GIPS may be a viable service model of supported housing that represents a recovery-oriented approach that can be scaled up to address homelessness.

Conduct disorder behaviors, childhood family instability, and childhood abuse as predictors of severity of adult homelessness among American veterans

Despite US federal efforts to end and prevent homelessness among veterans, there has been limited examination of pre-military factors like childhood problems, associated with adult homelessness. This study examined childhood problems among homeless veterans and its relation to severity of homelessness and outcomes in supported housing. Using data from 1,161 homeless veterans at 19 sites enrolled in the Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program, three types of childhood problems were examined: conduct disorder behaviors, family instability, and childhood abuse. Multiple regressions were conducted to examine the association between childhood problems and severity of homelessness before supported housing, and childhood problems and outcomes after supported housing. About one-third reported conduct disorder behaviors, over half reported family instability, and 40% reported childhood abuse. Greater childhood problems were found in this sample compared to published samples of non-homeless veterans. Conduct disorder behaviors, family instability, and childhood abuse were each weakly associated with lifetime homeless episodes. One year after enrollment in the HUD-VASH program, past conduct disorder behaviors and family instability were not predictive of outcomes, except childhood abuse was related to less social support and lower quality of life. These findings demonstrate not only the potential impact of childhood abuse on social relationships and quality of life in adulthood, but also the resilience of homeless veterans from adverse childhoods to be successfully housed in a supported housing program.