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Articles   |    
VA’s Expansion of Supportive Housing: Successes and Challenges on the Path Toward Housing First
Erika Laine Austin, Ph.D.; David E. Pollio, Ph.D.; Sally Holmes, M.B.A.; Joseph Schumacher, Ph.D.; Bert White, D.Min., M.B.A.; Carol VanDeusen Lukas, Ed.D.; Stefan Kertesz, M.D., M.Sc.
Psychiatric Services 2014; doi: 10.1176/appi.ps.201300073
View Author and Article Information

Dr. Austin and Dr. Kertesz are with the U.S. Department of Veterans Affairs (VA) Birmingham Medical Center, Birmingham, Alabama (e-mail: erika.austin@va.gov). Dr. Austin is also with the Division of Infectious Diseases, University of Alabama at Birmingham. Dr. Pollio is with the School of Social Work, University of Alabama, Tuscaloosa. Ms. Holmes, Dr. White, and Dr. Lukas are with the VA Center for Healthcare, Organization and Implementation Research, Boston. Ms. Holmes and Dr. Lukas are also with the Department of Health Policy and Management, Boston University. Dr. Schumacher is with the Division of Preventive Medicine, University of Alabama at Birmingham, where Dr. Kertesz is also affiliated.

Copyright © 2014 by the American Psychiatric Association

Abstract

Objectives  The U.S. Department of Veterans Affairs (VA) is transitioning to a Housing First approach to placement of veterans in permanent supportive housing through the use of rental vouchers, an ambitious organizational transformation. This qualitative study examined the experiences of eight VA facilities undertaking this endeavor in 2012.

Methods  A multidisciplinary team interviewed facility leadership, midlevel managers, and frontline staff (N=95 individuals) at eight VA facilities representing four U.S. regions. The team used a semistructured interview protocol and the constant comparative method to explore how individuals throughout the organizations experienced and responded to the challenges of transitioning to a Housing First approach.

Results  Frontline staff faced challenges in rapidly housing homeless veterans because of difficult rental markets, the need to coordinate with local public housing authorities, and a lack of available funds for move-in costs. Staff sought to balance their time spent on housing activities with intensive case management of highly vulnerable veterans. Finding low-demand sheltering options (that is, no expectations regarding sobriety or treatment participation, as in the Housing First model) for veterans waiting for housing presented a significant challenge to implementation of Housing First. Facility leadership supported Housing First implementation through resource allocation, performance monitoring, and reliance on midlevel managers to understand and meet the challenges of implementation.

Conclusions  The findings highlight the considerable practical challenges and innovative solutions arising from a large-scale effort to implement Housing First, with particular attention to the experiences of individuals at all levels within an organization.

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Figure 1 Recruitment and placement in housing of an HUD-VASH clienta

aSteps shown are for a hypothetical client who is interested in and eligible for the U.S. Department of Housing and Urban Development and VA Supportive Housing program (HUD-VASH). The steps are derived from a composite of work processes at 8 sites. HCHV, Health Care for Homeless Veterans; PHA, local public housing authority

Figure 2 Simplified overview of organizational management of the HUD-VASH programa

aThe reporting hierarchy and relationships affecting the U.S. Department of Housing and Urban Development and VA Supportive Housing program (HUD-VASH) as reflected in interviews conducted at 8 sites (February to December 2012). The Veterans Health Administration is divided regionally into 23 Veterans Integrated Service Networks (VISNs), each with a homeless program coordinator who is guided by national VA leadership. The predominant flow of expectations and information is from top VA leaders to middle managers at each facility.

Anchor for Jump
Table 1Personnel interviewed (N=95) at eight VA facilities
Table Footer Note

a Categories include individuals for whom a title was created to match their role in the organization. Titles are excluded to protect confidentiality of study sites.

Table Footer Note

b HCHV, Health Care for Homeless Veterans

Table Footer Note

c HUD-VASH, U.S. Department of Housing and Urban Development and U.S. Department of Veterans Affairs (VA) Supportive Housing

Anchor for Jump
Table 2Characteristics of eight U.S. Department of Veterans Affairs (VA) study sitesa
Table Footer Note

a All values are approximate to protect the confidentiality of study sites.

Table Footer Note

b HUD-VASH, U.S. Department of Housing and Urban Development and VA Supportive Housing

Table Footer Note

c Includes both veteran and nonveteran homeless individuals

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