Engaging Veterans with Lived Experience of Homelessness

HSR&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 2020 Issue:

• Introduction: Causes for homelessness among Veterans are complex and important in developing effective interventions.
• Engaging Veterans: Three innovative programs use Community Engaged Research and Human Centered Design practices to include Veterans with experiences of homelessness in intervention development.
• Impacts: Veterans provide vital input that informs and guides development of initiatives.
• Lessons Learned: Engaging Veterans iteratively from the outset is key and should be considered a long-term investment.

Introduction

Experiencing homelessness, or being at risk for homelessness, is a particularly difficult situation for Veterans. Veteran homelessness is associated with PTSD, substance use disorder (SUD), lack of social support, limited income, and difficulty transitioning to civilian life. Research has found that more than 50% of homeless Veterans had a diagnosed mental disorder before becoming homeless, and up to 90% had a mental disorder diagnosis after experiencing homelessness. In 2017, the U.S. Department of Housing and Urban Development (HUD) reported that more than 40,000 Veterans were experiencing homelessness on any given night. Although that number represents a 45 percent decline between the years 2009–2017, addressing Veteran homelessness remains a priority in VA. Homelessness is complex and not easily pinned to a single issue or simple intervention. Underlying causes vary, and these are important to developing responsive interventions. Over the last decade a growing recognition of the importance of developing studies and interventions with individuals and not simply for them has led to an expansion of “engaged research” models in health services.

The US Centers for Disease Control defines Community-Engaged Research as “the process of working collaboratively with groups of people affiliated by geographic proximity, special interests, or similar situations with respect to issues affecting their well-being.” Human Centered design (HCD) is an approach developed to help organizations create products, services, and processes focused on the needs of those who will use and benefit from them. Health services researchers and program developers have adopted this evolution in culture such that many now build their projects around Veteran Engagement Groups, going straight to the source for development and revision of products and services. VA has invested considerable resources in developing products to promote engagement in research and in human-centered design, such as the SERVE and Human Centered Design toolkits. Additionally, VA’s Innovation Ecosystem helps VA researchers and staff improve research, care, and services using these approaches.

Engaging Veterans

Three innovative initiatives led by HSR&D researchers employed community-engaged research and HCD practices to engage Veterans with lived experience of homelessness throughout the process of research to implementation. Their goal was to ensure programs, products, and interventions created for Veterans were useful, straightforward, and relevant.

Cards for Connection are functional playing cards that were created as a novel way to share resources with Veterans who may not have consistent access to the internet or a reliable place to store paper handouts. The cards have unique fronts with either a critical phone number or a brief coping skill, and come enclosed in a plastic case with a mini permanent marker. The perspectives of Veterans who had experienced homelessness, or who worked with homeless Veterans, were critical to this project’s human-centered design process. Through qualitative interviews and focus groups, Veterans’ input guided the prototype cards. Two thousand decks were distributed among 3 project sites, where they were met with great interest. Additional Veteran feedback via focus groups at those sites and an anonymous postcard included in each deck led to revisions and distribution at additional sites. As of this writing, 15,000 decks have been distributed across the nation and 10,000 more decks are available from the Rocky Mountain MIRECC for Suicide Prevention.

The Cards for Connection initiative employed Community Engaged Research and Human-Centered Design methods. Photo: VAntage Point Contributor

Connecting Veterans with VHA Homeless Programs is a graphic medicine booklet that follows Barry and Kenya, two Veterans experiencing housing instability, as they meet Norm, a VA Homeless Outreach Coordinator. Norm helps Barry and Kenya learn about available resources to help them resolve their housing issues. The booklet, which was developed with guidance from an Advisory Committee that included Veterans with lived experience of homelessness, helps Veterans understand available services and benefits, as well as where to find assistance.

The NCHAV Homeless Veteran Research Engagement Panel (HV-REP) is comprised of 6 to 15 Veterans with lived experience of homelessness who vary by age, gender, race/ethnicity, homeless status, and geographic area of residence. Members provide feedback, opinions, and recommendations to NCHAV-funded researchers. They discuss study ideas, review and comment on study instruments and other materials, and assist with interpretation and dissemination of findings. Their input contributes to investigators’ understanding of issues surrounding homelessness and the development of interventions designed to assist those experiencing homelessness. It was established in October of 2019 and got to work quickly, holding its first meeting in November.

Impacts

Cards for Connection: The project team saw critical phone numbers and coping skills as the most important content of cards, yet in Veteran feedback from all phases (development, testing, evaluation), Veterans indicated their favorite cards were the positive affirmation cards with messages such as, “I am worth it.” Veterans said that the positive affirmations resonated most because they so rarely hear things like that. The cards, originally intended specifically for homeless outreach programs, have now been distributed in a wide variety of settings, including inpatient and outpatient programs, group therapy sessions (where each person takes a card and demonstrates the skill or talks about what it means to them), residential living facilities, and Veterans Service Organizations. After using the cards, one Veteran wrote to the project lead and said, “Gratitude for the PTSD playing cards. I never thought they would have such a truly beneficial effect. Now you are the hero to Veterans.”

Connecting Veterans with VHA Homeless Programs: Researchers initially thought the booklet would have a narrative/story arc of a Veteran resolving their housing issues. Veteran feedback indicated it was more important to highlight a person getting set on the pathway through mindset (wanting help), connecting to VA Homeless Program staff who could help them navigate available services, and advocating for themselves (be empowered). The content and format of the booklet was entirely changed by this feedback.

Panels from the Connecting Veterans with VHA Homeless Programs graphic medicine booklet

HV-REP: Five NCHAV investigators presented their research to the group in the first year. Veteran members of the group have been enthusiastically engaged in conversations about healthcare services, outreach challenges and strategies, and intervention ideas. Given the speediness of HV-REP’s launch, researchers generally presented on existing studies.  In year 2, the group will have an opportunity to provide input on newly funded studies and provide consultation early in the research development process. NCHAV will gather feedback from Veterans about their experiences serving on the panel and from VA investigators about changes to their research methods, data collection instruments, and other aspects of the research based on Veteran input.  

Lessons Learned

• It is important to have a clear sense of goals for Veteran input.
• Going back to Veterans consistently, flexibly, and at each step of the process – not for a stamp of approval or checking off a box when decisions have already been made but seeking real input that can change direction - enriches the product.
• Engagement initiatives may begin with less intensive input from Veterans, but over time they should grow to repeat engagement and ongoing feedback. Room to grow and evolve is important.
• Projects such as Cards for Connection and Graphic Medicine are demonstrations of how Veteran input at every step can improve the product. Multiple opportunities for input from Veterans resulted in significant changes and improvements in content and direction. These projects can serve as models for larger Veteran engagement.
• These efforts are valuable and should be considered long-term investments. Funding must be consistent - to provide time for research/design teams to work with Veterans - in order to see the fruits of engagement. The SERVE toolkit has tips.

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