» Back to Table of Contents

Research Highlight

Improving Care for Veterans Experiencing Homelessness Engaged in a Tiny Home Community

In April 2020, the COVID-19 pandemic prompted VA Greater Los Angeles (VAGLA) leadership to create a first-of-its-kind emergency safe camping environment known as the Care, Treatment, and Rehabilitation Service (CTRS) for Veterans experiencing homelessness (VEHs). CTRS allowed Veterans to shelter outdoors in a low-barrier sanctioned tent encampment on the West Los Angeles VA grounds. Many reasons existed for starting CTRS. First, for VEHs, the pandemic posed profound health risks and curtailed access to services. Second, Los Angeles has the nation’s largest unsheltered population. Third, when other shelter options closed in response to the pandemic, Veterans increasingly congregated in tents adjacent to VAGLA, necessitating a quick response. In this context, CTRS provided a safe camping option, including onsite hygiene facilities (e.g., toilets, hand-washing stations, showers) and three meals a day for VEHs who chose not to live in mainstream VA transitional housing. Moreover, research suggested that the outdoor nature of encampments lessened the risk for COVID-19 transmission. Although the rationale for CTRS was clear, no paradigms for VA sanctioned encampments existed. Furthermore, the initiative’s scope and goals – beyond providing temporary housing, food, and hygiene resources – were poorly defined.

Given CTRS’s novelty, its staff and leadership desired iterative quality improvement (QI). We conducted ethnography within CTRS, participating in and observing the daily routines of residents and staff. We also interviewed Veterans and staff about how to improve the encampment and its service offerings. By developing relationships with both Veterans and staff (e.g., social workers and peer specialists), we created a QI feedback loop with frequent recommendations offered to multiple stakeholders. The QI team leveraged its partnerships with CTRS staff and VEHs, stakeholders at a research center housed at VAGLA’s academic affiliate, VA clinicians, and local national VA homeless program leadership to propose improvements at CTRS. These partnerships were critical for enacting change at CTRS and facilitated staff buy-in and participation.

Overall, our QI efforts highlighted the need for more stable units to replace the tents, a desire for primary and mental healthcare delivery within the encampment, and increased Veteran engagement. This low- barrier-to-entry sanctioned encampment proved popular for VEH, many of whom were leaving the streets for the first time in years, if not decades. However, nearly all Veterans interviewed in the tent encampment endorsed transforming the tents to tiny shelters – and encouraged their expansion across Los Angeles and other VA facilities nationwide – as an important resource to help end Veteran homelessness. By March 2022, tiny homes (8’x 8’ lockable cabinswith electricity, heat, and air-conditioning, see Figure 1) replaced tents, and have grown today to over 120 shelters and twelveadditional “drop-in” shelters for Veterans who are not participants in the program but require overnight emergency shelter. An additional 40 interviews were performed with Veterans in the tiny home community, to enable ongoing QI and understand Veteran preferences as the community transformed.

Veterans appreciated the security of locked, private tiny homes in a community of Veterans who have had similar experiences. One Veteran expressed this sentiment, telling us that “having a secure place, a safe place is very important to me...and then having Veterans that are in a similar situation as I am with my PTSD or my substance use is also important because I can engage with them and they understand where I’m coming from.” For many Veterans, tiny shelters were the first stable housing they had experienced in upwards of a decade or more. One Veteran told us, “I can actually have my own place. Because I’ve been on the streets so long…I can clean up, wash my clothes, and feel better.”

As the tents transformed into tiny homes, VAGLA developed, in partnership with CTRS management, an on-site medical team (including a primary care physician, nurse practitioner, psychiatrist, and occupational therapist) to offer regular primary and mental healthcare at the community itself. Veterans appreciated this team’s harm reduction approach to substance use, furthered by a parallel philosophy fostered by CTRS staff themselves. As one Veteran told us, “When I relapse, I don’t lose everything. I don’t lose my housing. [When you] lose everything and that just makes you go deeper into your addiction.” Clinicians with the on-site medical team “met Veterans where they are” by establishing relationships and getting to know Veterans before offering services. One Veteran described this for us: “[They have helped a] great deal because they come out and they talk with you. They make sure you’re okay. If you need anything, you can get in contact with them. I think it’s a big, big deal.”

Qualitative data with CTRS residents also led to the development of a Veteran-led resident council – the Veteran Engagement Committee – which meets weekly to discuss Veterans’ experiences in the community and offers suggestions to CTRS leadership for improvement. Veterans highly value this council, expressing the importance of amplifying VEH voices when developing programs that cater to their needs. One Veteran said, “I think that it’s a good way for Veterans that live here to feel that they have a voice and to get heard…I think that helps a lot that you get the feedback. Because if you don’t live here, you don’t know what some of the frustrations are.” Committee feedback has led to substantive changes at CTRS, including adding coffeemakers, outdoor tables, water dispensers, designating a women’s-only row, beginning a Veteran-run art class, and increased medical services (e.g., on-site phlebotomy). In November 2023, VA Secretary McDonough paid a virtual visit to Veterans on the council and spoke to them about their recovery and housing goals.

Our data suggest that a low-barrier, harm reduction approach to transitional housing that offers Veterans a private, safe space to work on health and housing at their own pace fills an important gap in VA’s continuum of homeless services. Importantly, these spaces may benefit from offering an outlet for Veterans to regularly provide feedback on QI efforts, partnered with QI scientists and operational leaders in feedback loops. In the words of one Veteran, CTRS has helped a vulnerable group of Veterans become “whole again…so that they can live on their own.”

References

1. McCoy, M, et “Improving a Sanctioned Homeless Encampment for Veterans During COVID-19 Through Multi-level Partnerships,” Psychiatric Services 2024; 75(1):94-7.
2. Kalofonos, I, McCoy, M. “Purity, Danger, and Patriotism: The Struggle for a Veteran Home during the COVID-19 Pandemic,” Pathogens 2023;12(3):482.
3. Lynch, KA, McCoy, M, Gabrielian, S. “Veterans Finding Community and a “Home” Within an Emergency Housing Environment,” Journal of Primary Care & Community Health 2023;14, 21501319231180448.