Getting To Outcomes® in Services for Homeless Veterans 10 Steps for Achieving Accountability

Housing programs vary widely in their philosophies, design, and provided support services. Careful consideration should be given when designing housing programs to make sure that they meet the needs and preferences of the intended tenants. Segregated group homes have often been used to provide housing to people with serious mental illness, although people with serious mental illness prefer integrated, regular housing (Carling, Randolph, Ridgway, & Blanch, 1987; Brown, Ridgway, Anthony, & Rogers, 1991 as cited in SAMHSA, 2003). Veterans with substance use disorders may initially require low-demand housing (see Housing First program below) in order to encourage them to engage in services. Providing housing to homeless individuals has been shown to increase retention in substance abuse treatment, but these individuals these individuals will not do as well when housing requires participating in high intensity services (Orwin, Mogren, Jacobs, & Sonnefeld, 1999 as cited in SAMHSA, 2003). Programs that combine affordable, independent housing with flexible, supportive services have been shown to be most successful at establishing housing stability, and improving mental health and recovery from substance abuse (SAMHSA, 2003).

VA's Homeless Providers Grant and Per Diem Program is offered by the Department of Veterans Affairs Health Care for Homeless Veterans (HCHV) Programs to fund community agencies providing services to homeless Veterans. The purpose is to promote the development and provision of supportive housing and/or supportive services with the goal of helping homeless Veterans achieve residential stability, increase their skill levels and/or income, and obtain greater self-determination. Only programs with supportive housing (up to 24 months) or service centers (offering services such as case management, education, crisis intervention, counseling, services targeted towards specialized populations including homeless women Veterans, etc.) are eligible for these funds.

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  Consumers should have a choice from a range of housing options from low-demand housing to transitional and permanent supportive housing.
  
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  Consumers should have control over their living environment
  
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  Flexible supportive services should be customized to the needs of individual clients
  
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  Receiving services should not be required to maintain housing
  
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  Services, such as mental health treatment, substance abuse treatment, legal services, and income support, should be integrated.
  

• The National Alliance on Mental Illness (NAMI) has produced a housing toolkit. The toolkit provides guidance and information on expanding housing opportunities for people with mental illnesses. The fifteen fact sheets provide detailed information about resources available to finance the creation of new housing and new ways to think about housing options. In addition there are four background briefs to provide a framework for assessing housing needs and housing solutions. These materials are organized so that they can be reviewed as a whole for overall knowledge about housing or individually for information about specific funding programs or housing types. The toolkit is available from the NAMI website:

http://www.nami.org/Content/ContentGroups/Policy/housingtoolkit.pdf

Brown, M.A., Ridgway, P., Anthony, W.A., & Rogers, E.S. (1991). Comparison of outcomes for clients seeking and assigned to supported housing services. Hospital and Community Psychiatry, 42(11), 1150-1153.

Burt, M.R., Hedderson, J., Zweig, J., Ortiz, M.J., Aron-Turnham, L., & Johnson, S.M. (2004). Strategies for Reducing Chronic Street Homelessness. Washington, DC: U.S. Department of Housing and Urban Development, and The Office of Policy Development and Research.

Carling, P.J., Randolph, F., Ridgway, P., & Blanch, A. (1987). Housing and Community Integration for People with Psychiatric Disabilities. Burlington, VT: Center for Community Change Through Housing and Support.

Orwin, R.G., Mogren, R.G., Jacobs, M.L., & Sonnefeld, L.J. (1999). Retention of homeless clients in substance abuse treatment: Findings from the National Institute on Alcohol Abuse and Alcoholism Cooperative Agreement Program. Journal of Substance Abuse Treatment 17(1-2), 45-66.

Substance Abuse and Mental Health Services Administration. (2003). Blueprint for Change: Ending Chronic Homelessness for Persons with Serious Mental Illnesses and Co-Occurring Substance Use Disorders. DHHS Pub. No. SMA-04-3870, Rockville, MD: Center for Mental Health Services, SAMHSA.

Historically, supportive housing emerged as a response to several emerging issues including a greater desire for independent housing by clients with mental illness, and a realization that affordable, permanent housing, with supports, was a path to decreasing homelessness.

In supportive housing, the tenant typically pays between 30%-50% of their income towards rent, ideally not more than 40%. The tenant in supportive housing has a lease or occupancy agreement, and the housing is considered permanent, as long as the conditions of the lease are met. Supportive housing often involves a working partnership between the service providers and the property managers.

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   Increase housing stability
   
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   Decrease symptoms of mental illness
   
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   Decrease substance use
   

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  Positive Impacts on Health. Decreases of more than 50% in tenants’ emergency room visits and hospital inpatient days; decreases of more than 80% in tenants’ use of emergency detoxification services; and increases in the use of preventive health care services.
  
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  Positive Impacts on Employment. Increases of 50% in earned income and 40% in the rate of participant employment when employment services are provided in supportive housing, and a significant decrease in dependence on entitlements – a $1,448 decrease per tenant each year.
  
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  Positive Impacts on Reducing or Ending Substance Use. A one-year study found that 56.6% of those living independently remained sober, 56.5% of those living in a halfway house remained sober, and 57.1% of those living in an unsupported SRO remained sober – while 90% of those living in supportive housing remained sober.
  

The seven dimensions are:

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  Dimension #1: Administration, Management, and Coordination
  

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  Dimension #2: Physical Environment
  

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  Dimension #3: Access to Housing and Services
  

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  Dimension #4: Supportive Services Design and Delivery
  

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  Dimension #5: Property Management and Asset Management
  

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  Dimension #6: Tenant Rights, Input, and Leadership
  

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  Dimension #7: Data, Documentation, and Evaluation
  

(Corporation for Supportive Housing, 2009)

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  Session I: Understanding the Issues Your Tenants Face, including topics of addiction, and typical issues of supported housing tenants.
  
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  Session II: The Housing Context, including rights and rules around housing, and offering support services to tenants.
  
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  Session III: The Effective Tool Kit, including building relationships with tenants, service planning with tenants, conflict resolution and issues of eviction.
  

Corporation for Supportive Housing. (2009). The Seven Dimensions of Quality for Supportive Housing. New York, NY: Corporation for Supportive Housing.

National Housing Conference. (2006). Ending Homelessness Among Veterans Through Permanent Supportive Housing. Washington, DC: Author.

Rog, D. (2004). The Evidence on Supported Housing. Psychiatric Rehabilitation Journal, 27(4), 334-344.

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  Homelessness is first and foremost a housing problem and should be treated as such
  
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  Housing is a right to which all are entitled
  
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  People who are homeless or on the verge of homelessness should be returned to or stabilized in permanent housing as quickly as possible
  
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  Issues that contribute to homelessness can best be addressed once housed
  

The Housing First model has several important delivery components. These include providing emergency services when needed and a complete assessment of housing needs, resources, and services necessary to sustain housing. Housing placement services are also provided, including financial assistance, and advocacy and assistance in facing barriers to housing. In many cases, time limited case management is also a part of Housing First programs. The Housing First approach has been used extensively with populations with severe mental illness and substance abuse histories.

1. Decrease the time people are homeless

2. Increase housing stability

Some current VA programs, such as the HUD/VASH program, have similarities to the Housing First Model, but research has not yet been done using a true Housing First model specifically with Veterans.

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  Initial crisis intervention involving identifying the family’s immediate needs and helping to meet them during the transition period.
  
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  Housing search to help participants obtain permanent housing, including clarifying housing needs, helping develop rental resumes, assisting in obtaining housing subsidies, providing one-on-one and group tenant education workshops, and negotiating lease terms with and on behalf of clients.
  
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  Home-based case management to stabilize participants once they are re-housed by linking participants with mainstream social services, ensuring children are enrolled and attending school, providing crisis management assistance, and helping participants work toward case management goals developed at the outset of program participation.
  
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  Direct financial assistance to assist with move-in and other costs associated with becoming rehoused, such as current and previous utility bills, moving costs, rental deposits, furniture, and other goods.
  

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  Establish a cross-functional team to spearhead the Housing First change process
  
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  Develop a shared vision, and clarify the scope of change
  
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  Do an organizational self-assessment to determine agency strengths and challenges for a change process
  
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  Develop a time line for implementation, including staffing issues, policies and procedures, community collaboration and funding information.
  
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  Determine who will manage the change process
  
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  Initiate the Housing First project, and monitor and revise as needed
  
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  Evaluate outcome and process indicators for the project.
  

Lanzerotti, L. (2004). Housing First for Families: Research to Support the Development of a Housing First Training Curriculum. Washington, DC: National Alliance to End Homelessness.

National Alliance to End Homelessness. (2009). Organizational Change: Adopting a Housing First Approach. Washington, DC: Author. Retrieved June 14, 2010, from http://www.endhomelessness.org/content/article/detail/2489

Tsemberis, S., Gulcur, L., & Nakae, M. (2004). Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal Of Public Health, 94(4), 651-656.