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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
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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


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



2012 Annual Homeless Assessment Report: Volume 1. 2012 Point-in-Time Estimates of Homelessness. Washington, DC, US Department of Housing and Urban Development, Office of Planning and Community Development, 2012
Baggett  TP;  O’Connell  JJ;  Singer  DE  et al:  The unmet health care needs of homeless adults: a national study.  American Journal of Public Health 100:1326–1333, 2010
[CrossRef] | [PubMed]
Kertesz  SG;  Hwang  SW;  Irwin  J  et al:  Rising inability to obtain needed health care among homeless persons in Birmingham, Alabama (1995–2005).  Journal of General Internal Medicine 24:841–847, 2009
[CrossRef] | [PubMed]
Parker  RD;  Albrecht  HA:  Barriers to care and service needs among chronically homeless persons in a housing first program.  Professional Case Management 17:278–284, 2012
[CrossRef] | [PubMed]
McGuire  J;  Gelberg  L;  Blue-Howells  J  et al:  Access to primary care for homeless veterans with serious mental illness or substance abuse: a follow-up evaluation of co-located primary care and homeless social services.  Administration and Policy in Mental Health and Mental Health Services Research 36:255–264, 2009
[CrossRef] | [PubMed]
Remarks by Secretary Eric K Shinseki. National Summit on Homeless Veterans, Washington, DC, November 3, 2009. Washington, DC, United States Department of Veterans Affairs, Office of Public and Intergovernmental Affairs, 2009. Available at www.va.gov/opa/speeches/2009/09_1103.asp
O’Connell  MJ;  Kasprow  WJ;  Rosenheck  RA:  Differential impact of supported housing on selected subgroups of homeless veterans with substance abuse histories.  Psychiatric Services 63:1195–1205, 2012
[CrossRef] | [PubMed]
O’Connell  MJ;  Kasprow  W;  Rosenheck  RA:  Rates and risk factors for homelessness after successful housing in a sample of formerly homeless veterans.  Psychiatric Services 59:268–275, 2008
[CrossRef] | [PubMed]
Ridgway  P;  Zipple  AM:  The paradigm shift in residential services: from the linear continuum to supported housing approaches.  Psychosocial Rehabilitation Journal 13:20–31, 1990
Tsemberis  S:  Housing First: The Pathways Model to End Homelessness for People With Mental Illness and Addiction .  Center City, Minn,  Hazelden, 2010
Tsemberis  S;  Gulcur  L;  Nakae  M:  Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis.  American Journal of Public Health 94:651–656, 2004
[CrossRef] | [PubMed]
Sadowski  LS;  Kee  RA;  VanderWeele  TJ  et al:  Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial.  JAMA 301:1771–1778, 2009
[CrossRef] | [PubMed]
Tsai  J;  Mares  AS;  Rosenheck  RA:  A multi-site comparison of supported housing for chronically homeless adults: “Housing first” versus “residential treatment first.” Psychological Services 7:219–232, 2010
[CrossRef] | [PubMed]
Cheng  A-L;  Lin  H;  Kasprow  W  et al:  Impact of supported housing on clinical outcomes: analysis of a randomized trial using multiple imputation technique.  Journal of Nervous and Mental Disease 195:83–88, 2007
[CrossRef] | [PubMed]
Larimer  ME;  Malone  DK;  Garner  MD  et al:  Health care and public service use and costs before and after provision of housing for chronically homeless persons with severe alcohol problems.  JAMA 301:1349–1357, 2009
[CrossRef] | [PubMed]
Srebnik  D;  Connor  T;  Sylla  L:  A pilot study of the impact of housing first–supported housing for intensive users of medical hospitalization and sobering services.  American Journal of Public Health 103:316–321, 2013
[CrossRef] | [PubMed]
Mares  AS;  Rosenheck  RA:  A comparison of treatment outcomes among chronically homelessness adults receiving comprehensive housing and health care services versus usual local care.  Administration and Policy in Mental Health and Mental Health Services Research 38:459–475, 2011
[CrossRef] | [PubMed]
Housing First and Rapid Re-Housing as Key Strategies in Ending Homelessness and Creating Results in 10 Year Plans. Resolution adopted at the 2008 annual meeting of the United States Conference of Mayors, Miami, Fla, June 20–24, 2008
 Housing First .  Washington, DC,  National Alliance to End Homelessness, 2010
Goering  PN;  Streiner  DL;  Adair  C  et al:  The At Home/Chez Soi trial protocol: a pragmatic, multi-site, randomised controlled trial of a Housing First intervention for homeless individuals with mental illness in five Canadian cities.  BMJ Open 1:e000323, 2011
[CrossRef] | [PubMed]
Hwang  SW;  Stergiopoulos  V;  O’Campo  P  et al:  Ending homelessness among people with mental illness: the At Home/Chez Soi randomized trial of a Housing First intervention in Toronto.  BMC Public Health 12:787, 2012
[CrossRef] | [PubMed]
VHA Handbook 1162.05. Housing and Urban Development (HUD)–Department Of Veterans Affairs Supported Housing (VASH) Program. Washington, DC, US Department of Veterans Affairs, Veterans Health Administration, Sept 14, 2011. Available at www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2446
Policy Directive from William Schoenhard, Deputy Under Secretary for Heath for Operations and Management, Veterans Health Administration, US Department of Veterans Affairs. Internal communication to all VISN leadership, Oct 15, 2012
2011 Annual Homeless Assessment Report: Volume 1. 2011 Point-in-Time Estimates of Homelessness. Washington, DC, US Department of Housing and Urban Development, Office of Planning and Community Development, 2011
Kasprow  WJ;  Cuerdon  T;  DiLella  D  et al:  Health Care for Homeless Veterans Programs: 23rd Annual Report .  West Haven, Conn,  Department of Veterans Affairs, 2010
VanDeusen Lukas  C;  Engle  RL;  Holmes  SK  et al:  Strengthening organizations to implement evidence-based clinical practices.  Health Care Management Review 35:235–245, 2010
[CrossRef] | [PubMed]
Lukas  CV;  Holmes  SK;  Cohen  AB  et al:  Transformational change in health care systems: an organizational model.  Health Care Management Review 32:309–320, 2007
[CrossRef] | [PubMed]
Glaser  B;  Strauss  A:  The Discovery of Grounded Theory: Strategies for Qualitative Research .  New York,  Aldine DeGruyter, 1967
Miles  M;  Huberman  A:  Qualitative Data Analysis , 2nd ed.  Thousand Oaks, Calif,  Sage, 1994
O’Connell  M;  Kasprow  W;  Rosenheck  RA:  National dissemination of supported housing in the VA: model adherence versus model modification.  Psychiatric Rehabilitation Journal 33:308–319, 2010
[CrossRef] | [PubMed]
Marlatt  GA;  Larimer  ME;  Witkiewitz  K:  Harm Reduction: Pragmatic Strategies for Managing High-Risk Behaviors , 2nd ed.  New York,  Guilford, 2012
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