» Back to Table of Contents

Research Highlight

Financial Support for Veterans Experiencing Housing Instability: Quantitative and Qualitative Evaluations of the Supportive Services for Veteran Families Program

Policy makers, patient advocates, and providers in VA as well as the broader community are recognizing and appreciating the intertwined relationship between housing and health. As a key health-related social need, stable housing can have important consequences on both physical and mental health outcomes. But poor health can contribute to challenges in maintaining stable housing due to rising health expenditures and employment difficulties. For these and many other reasons, ending Veteran homelessness has been a top VA priority for more than a decade. To reach this goal, VA employs several initiatives to support Veterans experiencing housing instability. One important program is Supportive Services for Veteran Families (SSVF).

SSVF Program and TFA

Through the SSVF program, VA partners with non-profit organizations (known as grantees) to provide housing-related services to Veterans who are either currently experiencing homelessness at the time of enrollment in SSVF or not currently homeless but at imminent risk of losing stable housing. In FY2021, SSVF awarded more than $630 million to 251 grantees that provided services to 81,043 Veteran households. SSVF services include case management, outreach, and assistance obtaining VA and non-VA benefits. In addition, a key component of SSVF is temporary financial assistance (TFA), which can be used by Veterans to pay rent, utility payments, security deposits, and other housing-related expenses. The average SSVF episode lasts 90 days with the Veteran receiving roughly $6,000 in TFA.

In the HSR-funded study “Measuring the Impact of the SSVF Program on Veteran Outcomes” (IIR 17-029), we performed both qualitative and quantitative assessments of the SSVF program. In our qualitative analyses, we interviewed four cohorts (10 leaders of national VA homeless service programs and homeless advocacy groups, 20 VA homeless service providers, 20 SSVF grantees, and 70 Veterans enrolled in the SSVF program). These interviews identified important insights from multiple perspectives into the integral role that SSVF played in VA’s response to the COVID-19 pandemic as well as both the strengths and the weaknesses of the program in fulfilling its primary goal of helping Veterans achieve stable housing.

In our quantitative analyses, we utilized VA electronic health record (EHR) data as well as data from the Homeless Management Information System (HMIS) to compare health, healthcare cost, and housing outcomes between TFA and SSVF recipients and control groups of non-recipients. Because structured EHR data for housing outcomes do not accurately identify a patient’s housing status longitudinally, we developed a natural language processing (NLP) system to capture long-term housing status from text notes. We have found that TFA is associated with higher rates of stable housing both immediately following exit from SSVF (using structured data in HMIS)1 as well as up to one year following exit (using housing status captured from unstructured VA data by our NLP system).²

In addition to these housing outcomes, we also found that TFA was associated with lower healthcare costs and lower rates of mortality and suicidal ideation. In a mixed methods study, we also found that several observable factors were associated with receiving TFA, including demographic (age, race, sex, and family composition) and socioeconomic (income, education, employment, and previous homelessness) characteristics.

Shallow Subsidies

With rental housing prices steadily increasing nationwide, VA realized that short-term and relatively small dollar amounts of assistance were insufficient to yield stable housing for many Veterans, especially those in high-cost areas. To remedy this, the shallow subsidy component of the SSVF program was launched in October 2019 in high cost of living areas including Los Angeles, San Diego, San Francisco, Oakland, San Jose, Santa Clara, Berkeley, Alameda, Washington, DC, New York City, Seattle, Honolulu, and Chicago. These shallow subsidies consist of a fixed amount set to 50 percent of rent for up to two years. To encourage long-term self-sufficiency and to avoid disincentivizing new employment, SSVF shallow subsidy recipients receive the subsidy for the full period, regardless of increases in household income. In recent years, VA has recognized that rent is increasingly unaffordable throughout the entire United States. For this reason, as of October 2021, the shallow subsidy component of SSVF is now available through any grantee regardless of geographic location.

In a follow-up HSR study entitled “Assessing an Initiative to Facilitate Long-Term Financial and Housing Stability in Vulnerable Veterans” (SDR 20-350), we extended our previous work to assess the impact of shallow subsidies on Veteran outcomes. While this study is still ongoing, we have several initial findings that are worth mentioning. For instance, we recently conducted a mixed methods study to identify Veteran characteristics that were predictive of receiving shallow subsidies from data collected by the organizations that administer this program to better understand how this new program is being implemented in real-world settings.³ We compared these observable characteristics with responses from grantee employees that described their reasons for allocating shallow subsidies.

We found that shallow subsidy receipt was positively associated with indicators of relative stability including having higher income, college education, and employer-provided health insurance. Similarly, indicators of relative instability such as having been homeless in the three years prior to SSVF enrollment were negatively associated with shallow subsidy receipt.

We have also conducted a preliminary analysis assessing the impact of shallow subsidies on Veteran outcomes, specifically VA healthcare costs and all-cause mortality. Using a propensity score matching approach, we selected a comparison group of SSVF enrollees in FY2020-FY2022 who did not receive shallow subsidies. We then compared healthcare cost outcomes between these two groups using a multivariable two-part regression model to compare healthcare cost outcomes and multivariable Cox proportional hazards regression models. We found that receiving shallow subsidies was associated with a $4,956 decrease in outpatient costs, a $3,542 decrease in inpatient costs, and a 49 percent decrease in the risk of mortality over a one-year follow-up period.

Future Directions

While our research to date has revealed valuable insights into the role that SSVF’s TFA and shallow subsidy services play in supporting the well-being of Veterans experiencing housing insecurity, many unanswered questions remain. For example, how do the documented benefits of TFA to Veterans (including reductions in mortality and suicidal ideation and improved rates of stable housing) compare to the costs of the program itself? In other words, are these beneficial outcomes sufficiently high to justify the budget outlay for these services? In addition, does the impact of TFA on Veteran outcomes vary by geographical region in the United States including urban vs. rural areas or by whether the Veterans enrolling in SSVF are in a sheltered vs. unsheltered living situation? Finally, while our previous analyses have assessed the impact of TFA on outcomes conditional on enrolling in SSVF, how do outcomes differ for Veterans enrolling in SSVF relative to Veterans experiencing housing instability who do not enroll in SSVF? Future research will focus on these and many other aspects of this important program.

Research Team: Thomas Byrne, PhD, MSW, Bedford VA Healthcare System; Alec Chapman, MS, VA Salt Lake City Healthcare System; Lillian Gelberg, MD, Greater Los Angeles VA Healthcare System; Stefan Kertesz, MD, Birmingham VA Healthcare System; Ann Elizabeth Montgomery, PhD, MPH, Birmingham VA Healthcare System; Jack Tsai, PhD, National Center on Homelessness among Veterans; Susan Zickmund, PhD, VA Salt Lake City Healthcare System

References

1. Nelson RE, Byrne TH, Suo Y, et al. “Association of Temporary Financial Assistance With Housing Stability Among US Veterans in the Supportive Services for Veteran Families Program,” JAMA Network Open 2021;4(2):e2037047.
2. Chapman AB, Scharfstein D, Byrne TH, et al. “Temporary Financial Assistance Reduced the Probability of Unstable Housing among Veterans for More Than 1 Year,” Health Affairs (Millwood) 2024;43(2):250-9.
3. Nelson RE, Byrne T, Suo Y, et al. “Shallow Subsidies for Veterans Facing Housing Barriers in the VA Supportive Services for Veteran Families Program,” Journal of Health Care for the Poor and Underserved. In press.