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

CTI involves three distinct phases, carried out over nine months. In the first phase, during the first 3 months, the case manager makes home visits, and meets with the client and new community providers. The case manager provides support and guidance for both the client and the new care givers. In the next four months, a second “tryout” phase is devoted to testing and adjusting the system of support. The case manager works to increase the client’s problem solving skills, and observes how the client’s support network is operating. Finally, in the last two months, the final “transfer of care” phase occurs, where a gradual process allows a total transfer of care to the new community providers. This phase often includes a party or formal recognition of the transfer of care.

1. 
   To prevent homelessness among individuals being discharged from shelters, hospitals, and other instutions into the community.
   
2. 
   To strengthen individual's long-term ties to services, family, and friends.
   

66% Alcohol abuse

51% Drug abuse

54% Serious psychiatric diagnosis

39% Dual diagnosis

58% Health/physical

Homeless Veterans with serious mental illnesses and/or co-occurring substance use disorders have complex problems that require comprehensive treatment. Although their need for treatment is often higher than Veterans with housing, they face more difficulties accessing the services they need. Some of the barriers to engaging homeless Veterans in treatment include: social isolation, distrust of authorities and service providers, geographic instability, and multiplicity of treatment needs (Zerger, 2002).

The Homeless Veteran Dental Program was established by the Veterans Administration in 1992. In surveys listing and ranking the 10 highest unmet needs for homeless Veterans, dental care was consistently ranked by homeless Veterans as one of their top 3 unmet needs, along with long-term permanent housing and childcare. Dental problems, such as pain and/or missing teeth can be tremendous barriers in seeking and obtaining employment. Studies have shown that after dental care, Veterans report significant improvement in perceived oral health, general health and overall self-esteem, thus, supporting the notion that dental care is an important aspect of the overall concept of homeless rehabilitation.

1. 
   To allow individuals with severe mental illness to remain in the community and avoid institutionalization.
   
2. 
   To decrease symptoms from mental illness
   
3. 
   To decrease substance use
   

who are at high risk of institutionalization and other adverse outcomes.

1. 
   To help people overcome ambivalence and commit to change.
   
2. 
   To increase treatment engagement.
   

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 et al., 1987; Brown et al., 1991). 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 will not do as well when housing requires participation in high intensity services (Orwin et al., 1999). 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.

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.

1. 
   Increase housing stability
   
2. 
   Decrease symptoms of mental illness
   
3. 
   Decrease substance use
   

• 
  Homelessness is first and foremost a housing problem and should be treated as such
  
• 
  Housing is a right to which all are entitled
  
• 
  People who are homeless or on the verge of homelessness should be returned to or stabilized in permanent housing as quickly as possible
  
• 
  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

Although many homeless individuals qualify for Federal income and entitlement programs, such as SSI, many are not enrolled. Benefits counseling can help with enrollment by providing information about benefits and eligibility, helping gather required documentation, filing applications, and mounting appeals, if necessary.

For those who want to work, offering employment at the earliest stages of engagement may be effective to develop trust, motivation, and hope (Cook et al., 2001; Min, Wong, & Rothbard, 2004). Fear of losing public entitlements, especially healthcare and Social Security Administration (SSA) cash benefits, can inhibit people from seeking work. Many Federal benefit programs have changed policies to remove barriers to work, but eligible recipients remain largely unaware of these changes. Benefits counseling can help homeless individuals navigate employment opportunities without sudden loss of needed benefits.

Integrating employment services with clinical treatment through multidisciplinary teams has been found to be superior to providing services separately, especially in regards to consumer engagement and retention (Bond, 2004). Integrating these services can be difficult, however, due to conflicting staff perspectives on treatment priorities, the importance of employment, and how services should be integrated. Cross-training in mental health and employment issues, creating protocols for communication among staff, and providing opportunities for program planning can help address these barriers (Quimby et al. 2001).

VA’s Supported Employment (SE) program consists of competitive employment with therapeutic supports integrated into treatment. The focus of SE as currently implemented in the VA is to assist Veterans with psychosis and other serious mental illness gain access to meaningful competitive employment. The principles of SE have been found to be broadly effective. A full description of SE follows on the next page, so consideration can be given to how SE principles may be integrated into other employment programs or used with other populations.

VHA has provided specialized funding to support Veterans Benefits Counselors as members of HCMI and Homeless Domiciliary Programs as authorized by Public Law 102-590. These specially funded staff provide dedicated outreach, benefits counseling, referral, and additional assistance to eligible Veterans applying for VA benefits. VBA has also instituted new procedures to reduce the processing times for homeless Veterans' benefits claims.

In contrast to other approaches to vocational rehabilitation, SE de-emphasizes prevocational assessment and training and puts a premium on rapid job search and attainment. The job search is conducted at a pace that is comfortable for consumers and is not slowed down by any programming prerequisites.

People with serious mental illnesses differ from one another in terms of the types of work they prefer, the nature of the support they want, and the decision about whether to disclose their disability to the employer or coworkers. SE programs respect these individual preferences and tailor their vocational services accordingly.

In addition to appreciating the importance of consumer preferences, SE programs recognize that most consumers benefit from long-term support after successfully attaining a job. Therefore, SE programs avoid prescribing time limitations on services. Instead employment specialists help consumers become as independent and self-reliant as possible.

The overriding philosophy of SE is the belief that every person with a serious mental illness is capable of working competitively in the community if the right kind of job and work environment can be found. Rather than trying to sculpt consumers into becoming “perfect workers,” through extensive prevocational assessment and training, consumers are offered help finding and keeping jobs that capitalize on their personal strengths and motivation. Thus, the primary goal of SE is not to change consumers but to find a natural “fit” between consumers’ strengths and experiences and jobs in the community.” (SAMHSA Evidence Based Practices Kit for Supported Employment, Module 1, 2009, pp. 2-3)

1. 
   Increase consumers participation in competitive employment
   
2. 
   Increase consumers self-esteem