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Older Formerly Homeless Veterans Living in HUD-VASH HousingHSR&D’s monthly publication Veterans’ Perspectives highlights research conducted by HSR&D and/or QUERI investigators, showcasing the importance of research for Veterans – and the importance of Veterans for research. In the November 2019 Issue:
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IntroductionHousing OptionsProvided through HUD (Housing and Urban Development) project-based housing (Section 8) offers rental assistance to low-income households for privately owned and managed rental units. Also provided through HUD, tenant-based housing vouchers increase housing choices in affordable privately-owned rental housing for low-income families.Veterans represent 10% of all homeless persons and approximately 20% of homeless Veterans are older than 55 years of age.1 In 2015, the National Center on Homelessness among Veterans convened a panel to discuss growth rates and special needs of the older homeless Veteran population. The panel anticipated an upward trend in the numbers of older Veterans (60+ years of age) who are homeless, from the current 17,000, to 22,000 by 2025.2 This population has substantial geriatric physical health conditions, mental health conditions, and substance use disorders.3 To help meet the physical and behavioral health needs of aging homeless Veterans, the panel recommended better integration of VA and community healthcare, social services, and housing programs to enable Veterans to age in place for as long as possible and avoid nursing home care. 2 However, the best way to achieve the housing and wrap-around services (things done for the homeless outside of housing, i.e., treating mental health conditions) for this age group is not known. Project-based housing (PBH) may help improve physical and behavioral health due to the social support and community engagement it is believed to provide, as compared to tenant-based housing. There is some evidence, though limited, that group housing confers a reduced risk of subsequent homelessness, compared to independent apartment living,4 but there is no evidence on this topic for an older Veteran population. HSR&D Investigators Collaborate to Provide New InsightsHSR&D investigators Cathy St. Pierre, PhD, NP, RNC, and Thomas Byrne, PhD, MSW, with the Edith Nourse Rogers Memorial Veterans Hospital, and Justeen Hyde, PhD, Shawn Dunlap, MA, and Keith McInnes, ScD, MSc, and Russell Schutt, PhD, part of HSR&D’s Center for Healthcare Organization & Implementation Research (CHOIR), and colleagues, worked with the VA National Center on Homelessness among Veterans to compare Veterans’ experience with government housing assistance, particularly project-based housing (PBH) as opposed to tenant-based housing (TBH). From left to right: Cathy M. St. Pierre, PhD, APRN, FNP-BC, FAANP; D. Keith McInnes, ScD; Shawn Dunlap, MA; Justeen Hyde, PhD; Thomas Byrne, PhD; Russell Schutt, PhD; Max Winer, LICSW, MPH Study focusVA National Center on Homelessness among VeteransThe VA National Center on Homelessness among Veterans promotes recovery-oriented care for Veterans who are homeless – or at risk of being homeless. As part of this mission, the Center works in partnership with HSR&D’s Center for Healthcare Organization and Implementation Research (CHOIR); Center of Innovation for Complex Chronic Healthcare (CINCCH); Center for Health Equity Research & Promotion (CHERP); and the Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0), in addition to QUERI (Quality Enhancement Research Initiative) programs and initiatives, such as Bridging the Care Continuum.This qualitative study focused on four themes:
A fifth theme emerged, not specifically asked about in the interview, concerning substance use history. Investigators conducted in-depth interviews with 30 Veterans in the U.S. Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) program (25 males and 5 females; average age 63). Thirteen of the Veterans in this study were living in PBH and 17 in TBH within the North Shore (Massachusetts) and Boston metropolitan areas. Prior to entering HUD-VASH, the average length of homelessness was four years -- on the streets or “couch surfing.” Many Veterans had lived in a Single Residency Occupancy (SRO) building or a group setting with other Veterans. Veterans noted that they were unaware of the HUD-VASH housing prior to meeting a Veteran representative or other community leaders. Although Veterans can choose between PBH and TBH, many selected a housing voucher based on the quickest availability. Overall, the Veterans verbalized satisfaction with their choice of housing. “I was living in the woods in (town), where I was working. I didn’t even know there was a Veterans’ housing program until a Catholic priest told me about it.” – Veteran study participant “I guess I became homeless in 2012, technically, and in 2013 I was living in my sister’s living room. And I hadn’t been aware of any Veterans’ benefits at all, that I was eligible for. I found out about VASH through a contact who told me about benefits that I was eligible for.” – Veteran study participant Social engagement“It’s community. I feel safer around vets than ‘regular’ people…like we all take care of each other.” —Veteran living in project-based housing Social engagement was a complex issue, independent of the type of housing Veterans chose. PBH was a positive factor here. As one Veteran explained, “It’s community. I feel safer around vets than ‘regular’ people…like we all take care of each other.” This may be even more important today, as attacks on the homeless have increased in the United States.5,6,7 The dangers of being homeless also are being experienced by the indigent in other countries; for example, the homeless in England and Wales are 15 times more likely to be assaulted, with nearly half having been intimidated or threatened with violence.8 Thus, being among people who understand that experience is helpful, particularly for older male and female Veterans who may feel more vulnerable to physical violence. Many homeless Veterans in the study also discussed the social activities available to them in the different types of housing programs, and some would participate in these activities, but a significant number stated that they did not take part by choice or due to problems with anxiety. The most common social activity cited was attending a therapeutic horse farm weekly. Support from Case Managers“I came to realize that my case worker frequently checking in with me was a good thing and helped me to stay on track with what I needed to do.” —Veteran living in project-based housing Veterans verbalized very positive feelings regarding the help and support that they received from their HUD-VASH case managers. Some Veterans described their case managers as their “life line” and felt that they could reach out to them as needed. Some of the Veterans living in PBH stated that they had initially been upset that they would have to meet frequently with their case managers. As one of the Veterans put it, “I didn’t need to be watched over,” but later said, “I came to realize that my case worker frequently checking in with me was a good thing and helped me to stay on track with what I needed to do.” Most Veterans in both PBH and TBH received medical care on a regular basis, either within the VA health care system or in their own community setting. Veterans ranged in age from 56 to 82 and had an average of five medical diagnoses and two mental health diagnoses each. The most common medical diagnosis was hypertension (47%), while the most common mental health diagnosis was substance use disorder at 56%. Most Veterans struggled with sobriety. This was consistent with Veterans living in both PBH and TBH. The most common substance used was alcohol, followed by marijuana, and a combination of drugs. The major issues raised were maintaining sobriety for a significant period; having periods of substance use and sobriety – and cycling in and out of both frequently; and high-frequency of substance use. This also was an issue for Veterans who did not have SUD. As one Veteran living in PBH stated: “I am very disappointed over the people smoking, drinking, carrying on… I pray that the community gets it turned around quickly.” Study outcomes and themesMost Veterans struggled with sobriety. This was consistent with Veterans living in both PBH and TBH. The outcome of this qualitative study highlighted several areas to be addressed within the HUD-VASH program, including:
As noted previously, substance use disorders also were a common theme among Veterans in both types of housing. Although there are many mental health programs of recovery and support available, not many of the Veterans interviewed were actively engaged in these programs. Veterans’ use of behavioral health services was more limited. Although many briefly discussed their behavioral health issues, most were not actively engaged in utilizing behavioral health services either in the VA healthcare system or in the community. It was not clear why they were not using services, although some of the Veterans using TBH mentioned transportation issues as one factor. Moving forward, study investigators would like to expand the focus of their research to formally include substance use disorders and social engagement among Veterans living in a HUD-VASH housing setting. The goal would be to identify and investigate both the challenges and opportunities in maintaining sobriety for formerly homeless Veterans, including the stigma Veterans attach to utilizing mental health services to support recovery and sobriety. Investigators also emphasize the need to better understand their patterns of socialization and how to create more social engagement opportunities to meet their needs. Study implicationsOverall, the Veterans who were interviewed were very happy with the HUD-VASH housing program in general – and the support they receive from the VASH Social Workers. Most of them cited that their VASH social workers were a real asset in helping them to maintain their housing vouchers and appreciated the ongoing, regular contact that they received from them. Veterans also were very satisfied with the type of housing that they were living in, whether TBH or PBH. They often commented on how happy/satisfied they were with their apartment and the locations of their housing. More Veterans speak about HUD-VASH—“The VASH filter process “really rocks. I feel comfortable speaking with my VASH Social Worker.” – Veteran study participant “I like my VASH Social Worker and feel that he is trustworthy.” This Veteran study participant went on to state that in the past, she had issues in working with male professionals but is now more open due to the relationship of trust that she has with her male VASH Social Worker. “Having more of these (PBH) even in different states, I don’t know if they have them, but it helped me out. But a lot of guys don’t know that it’s a program either. They’re confused about that. Because when I came here, I knew it was a program. Like, I knew it was a program to help you get adjusted…. but I wanted to continue in a program atmosphere, I needed the structure, or I wanted the structure.” —Veteran who lived in project-based housing “I have a gorgeous garden apartment with no stairs and a driveway that leads to my front door. It’s a place made in heaven.” —Veteran living in tenant-based housing “This is not what I expected. I didn’t expect this much. I got six rooms. I don’t even use them all. I have no complaints so far. I’ve very satisfied (in apt. for one year). …Well, (town name) It is great. It’s like a quaint rural town, and it’s not too far down the road.” —Veteran living in tenant-based housing “And the building’s nice, people are nice, everything, you know, I mean, face it. We all got beautiful one-bedroom apartments, all brand spanking new General Electric appliances right out of the carton from the factory.” —Veteran living in project-based housing “I’m by myself (previously shared a place with 3-4 roommates). If I want to work out, I can work out. If I want to play music on the TV, I can play music on the TV. If I want to open windows, I can open windows. I only must take care of me. I got a person that helps me with the cleaning and stuff. She gives me rides to where we need to go, to appointments and stuff.” —Veteran living in tenant-based housing References:
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