Successes and Challenges On the Path to Housing First: The Department of Veterans Affairs' Expansion of Supportive Housing

Objective:  Veterans in the United States experience homelessness at a rate disproportionate to the civilian population, with an estimated 62,619 veterans homeless in 2012.  In 2009, President Obama and the Secretary of the US Department of Veterans Affairs (VA) declared homelessness among veterans a “national tragedy” and set policy towards an ambitious goal of ending veteran homelessness by 2015.  The primary strategies towards implementing this policy were an increase in the number of total housing certificates available to chronically homeless veterans, and adoption of a “Housing First” (HF) model¹ of service delivery.  This qualitative study examined successes and challenges faced by VA facilities undertaking this endeavor in 2012.   

Methods: A purposive sample of eight VA facilities was selected for inclusion, with consideration of the overall number of homeless individuals in the local community, the number of vouchers allocated to the facility, demographic characteristics of patients in the facility’s Health Care for Homeless Veterans programs, and geographic region. A multidisciplinary team used a semi-structured protocol to interview leadership, mid-level managers, and front-line service providers at each facility (N = 95 interviews). A narrative was created for each site detailing the response to the policy change incorporating all the interviews. The team used a structured analysis framework to assess operational, contextual, and organizational influences on this effort.   Based on iterative reviews of all analytic summaries, team members identified key factors in the transition to the HF approach

Results:  Key facilitators of success included a forceful communication of goals by national leadership, use of performance metrics, resource expansion, and highly-committed middle managers. Challenges included variations in rental markets and local Public Housing Authorities, as well as logistic hurdles. Organizationally, a tight linkage between middle managers and national leadership conferred advantages but left open an opportunity for a greater role by VA facility leaders. Direct service was overwhelmingly provided by licensed clinical social workers, as were a substantial proportion of mid-level management.

Conclusions:  The VA’s path towards ending homelessness in veterans highlights the influential impact of national impetus, resource expansion, logistical challenges, and organizational relationships in efforts to end homelessness for a nationally prioritized population.  Examining the processes through which increased housing resources are deployed in diverse local settings provides insight into barriers and innovative solutions that can inform other agencies/communities embarking on a similar goal.  Ongoing attention is required to address specific logistic and organizational barriers and to negotiate changes with community partners. For social workers conducting case management, training is required both in harm reduction and motivational interviewing models, and managing a clinical tension between pushing housing as the nationally-measured objective versus a veteran-centered acceptance of goals that may not include permanent, independent housing.   

¹Tsemberis S, Gulcur L, Nakae M: Housing First, consumer choice, and harm reduction for homeless individuals with a dual diagnosis. American Journal of Public Health 94:651-6, 2004