Housing First on a Large Scale: Fidelity Strengths and Challenges in Va's Hud-Vash Homelessness Program

Introduction/purpose:  Housing First (HF) is an evidence-based intervention that offers permanent supportive housing for highly-vulnerable homeless individuals without requiring clients to meet preconditions related to treatment completion or treatment success. Housing First has gained favor in multiple countries, based in part on research evidence. To date, there has been little research to show which aspects of Housing First are most difficult to implement once Housing First is executed outside the confines of funded research demonstrations. Since 2009, the US Department of Veterans Affairs (VA), in collaboration with the Department Housing and Urban Development (HUD), has distributed nearly 80,000 rental vouchers, requiring that a Housing First approach should govern this program. This offers a naturalistic window to study fidelity when Housing First is adopted on a large scale. This presentation describes strengths and shortfalls in attaining Housing First fidelity.

Methods: We assessed progress toward fidelity in Housing First in 8 VA Medical Centers twice, one year apart, conducting 170 interviews with staff/leadership.  We operationalized Housing First based on 20 criteria grouped into 5 domains: (1) no preconditions related to sobriety or treatment; (2) efforts are made to rapidly offer permanent housing in a community/noninstitutional setting, (3) prioritization of the most vulnerable, (4) sufficient supportive services, and (5) a modern recovery philosophy. A consensus scoring approach was used to rate each Vas at both time periods.  Scores ranged between 4 (high fidelity) and 1 (low fidelity) on all 20 criteria and averaged into the 5 domains, and were compared between the two data collections.

Results:  There was discrepancy between HF domains for which high fidelity was readily attained and those for which it was not. Notably, fidelity at follow-up was high (3.63) for the “no preconditions” domain, and for the focus on rapidly offering permanent housing (3.28), both of which represent building blocks of the HF philosophy. Fidelity was less consistent for “prioritization of the most vulnerable” and substantively lower for domains related to provision of sufficient supportive services (2.51) and adoption of a modern recovery philosophy (2.44). Interviews suggested that operational issues such as shortfalls in staffing and staff training likely hindered fidelity in these latter two domains.

Conclusions and Implications:  The VHA HF program was implemented in response to national goals for ending veteran homelessness and it faced challenges likely to apply outside the context of research demonstration projects. This study observed greater progress on removal of preconditions and on rapid placement into permanent housing units, but lower levels of progress in assuring adequate supportive services and in deployment of a modern recovery philosophy. Real-world and large-scale implementation of Housing First is likely to require significant additional investment in service support to assure that results are concordant with those found in research.