Timing and Momentum in VA’s Path Toward Housing First

To the Editor: When U.S. Secretary of Veterans Affairs (VA) Eric Shinseki first announced the bold goal to end homelessness among veterans, he explained that “a goal of zero homeless veterans sure sounds like an absolute, but unless we set ambitious targets for ourselves, we would not be giving this our very best efforts” (1). This striving toward an absolute somewhat parallels the VA’s path toward another kind of absolute, the Housing First model, which prescribes immediate housing without any prerequisites for sobriety or treatment.

The May issue included a qualitative study by Austin and colleagues (2) that described the VA’s experiences in adopting the Housing First model. The authors made an admirable effort in highlighting some of the organizational and logistical challenges in implementing Housing First in the country’s largest integrated health care system. The authors aptly called it VA’s “path” toward Housing First, because change based on the model has been gradual rather than radical. It is also hard to pinpoint a universal starting point, because some VA Supportive Housing (VASH) programs have followed Housing First principles for a longer period than others.

What the authors implicitly acknowledge, but perhaps should be stated more explicitly, are the macro-level forces supporting the move toward Housing First. The Housing First model had been promoted nationwide outside the VA since the late 1990s and early 2000s, but the VA did not initiate a demonstration project of Housing First until 2010 and did not make the model official policy until 2012. With the momentum of the VA’s five-year plan to end homelessness among veterans, implementation of this new service model quickly garnered resources and support. It is hard to predict what would have happened to the Housing First model in the VA without the plan to end homelessness.

So there may be a lesson there for the practice and science of implementation. The role of timing may have been a crucial ingredient in the adoption of the Housing First model. Timing can also be conceptualized as readiness for change and is essential for implementation (3). At the time, the number of vouchers being issued to VASH programs was increasing dramatically, and thus there was considerable pressure and scrutiny on programs to distribute these housing vouchers to veterans. This type of environment may have been particularly conducive for the principles of Housing First because it allowed case managers to focus on voucher disbursement and housing placement.

However, it may be important to consider some potential, unintended negative consequences. Because of high client-to-staff ratios and the intense focus on housing veterans, case management and follow-up support for veterans may have fallen to the wayside after the veterans were housed, which has led to the development of alternative case management models to facilitate peer support and social integration (4).

As the VA enters the final two years of the five-year plan to end homelessness among veterans, one wonders whether the VA will continue to strive toward absoluteness in housing homeless veterans.