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Contents : Metropolitan Housing and Communities Center August 2009 Targeting Chronically Homeless Veterans with HUD-VASH Mary Cunningham President Obama has made ending homelessness among veterans a national priority noting that his administration has a "zero tolerance policy for veterans falling into homelessness."1 Recently in an address to the National Coalition for Homeless Veterans Secretary of the Veterans Administration General Shinseki concurred stating "We have a moral duty to prevent and eliminate homelessness among veterans."2 A good place to target efforts is in the District of Columbia which has one of the highest rates of homelessness among veterans in the country (National Alliance to End Homelessness 2007). Recent city surveys identified hundreds of homeless veterans living on the street or in the shelter system. An overwhelming majority of these veterans is chronically homeless and suffers from high rates of mental illness and chronic and acute health problems that leave them at heightened risk of dying on the street. Many have been the victims of violent crimes since becoming homeless. Considering the scarcity of housing subsidies the Department of Veterans Affairs (VA) should use HUD-Veterans Affairs Supportive Housing (HUD-VASH) vouchers to help these chronically homeless veterans get back into permanent housing. Research shows that with the help of intensive services and a housing subsidy such as those provided through the HUD-VASH program even those with serious mental illness and substance use disorders can maintain permanent housing. Efforts to target HUD-VASH to chronically homeless veterans would contribute significantly to D.C. Mayor Fenty's commitment to end homelessness and could save taxpayers money. Providing chronically homeless veterans with permanent supportive housing will certainly help them access health care services and stabilize their housing situation. Inside: D.C. Chronically Homeless Veterans Have Serious Health Needs D.C. Homeless Veterans Are Highly Vulnerable Homelessness Is Costly ASH Is a Successful HUD-V Housing Model Slow Start for HUD-V ASH Lease-Up ASH Should Target HUD-V Veterans with High Needs Steps to Improve HUDV ASH Implementation Targeting Chronically Homeless Veterans Will Help End Homelessness D.C. Chronically Homeless Veterans Have Serious Health Needs The D.C. Department of Human Services (DCDHS) identified 537 homeless veterans sleeping in shelter transitional housing or on the street.3 The city and its partners surveyed these veterans about their current living situation as well as their physical and mental health problems.4 DCDHS used these data to prioritize homeless people for scarce permanent supportive housing resources and at the time helped 79 homeless veterans move into permanent supportive housing. Approximately 458 veterans identified through the survey remain on the street or in the shelter system. The survey data reveal that an overwhelming majority is Urban Institute a nonpartisan economic and social policy research organization 1 Metropolitan Housing and Communities Veterans living on the street and in shelter report serious health problems. chronically homeless with the average time spent homeless at seven years and the median at five years. Most of the veterans identified are middle-aged men but 6 percent are women. A small share (3 percent) is 35 years old or younger. Veterans identified through the survey are disproportionally African American (84 percent) and are frequent users of correctional institutions: 69 percent reported having been to jail and 32 percent reported having spent time in prison. Veterans living on the street and in shelter report serious health problems. Seventy percent reported at least one major health problem among them kidney disease liver disease heart disease stroke and HIV/AIDS (figure 1). Twentynine percent are tri-morbid meaning they reported mental health problems a serious medical condition and substance abuse issues (figure 2). Just over one-third (191 veterans) turn to VA hospitals and medical centers for health care (160 reported they have health care coverage from the VA). Over a third reported that they have sought emergency care in the past three months 51 percent of this group reported that they visited the emergency room one time 27 percent visited two times 11 percent visited three times and 12 percent visited four or more times (figure 3). These emergency room visits can be costly. D.C. Homeless Veterans Living on the Streets and in Shelter Are Highly Vulnerable After a wave of deaths among homeless people in Boston during the late 1990s Dr. Jim O'Connell of Boston's Healthcare for the Homeless program developed a method for identifying homeless people who are at a high risk of dying on the street (Hwang et al. 1998 O'Connell et al. 2005). He used this approach to monitor deaths among homeless people in Boston and develop appropriate interventions to prevent further deaths. Common Ground a nonprofit permanent supportive housing provider has used this tool commonly known as the vulnerability index in cities across the country including Los Angeles New Orleans Portland Santa Monica and New York City to prioritize people for permanent supportive housing.5 Using data from this survey we calculated the vulnerability index for homeless veterans in D.C. The vulnerability index score is the added total of how many risk qualifiers an individual has on a scale of 0 to 8. Risk factors include the following: FIGURE 1. Health Problems Reported by Homeless Veterans (N 537) At least one health problem Kidney disease/renal disease or dialysis Emphysema Cancer HIV/AIDS Tuberculosis Stroke Swollen or infected open wounds or ulcers on skin Asthma Diabetes History of frostbite hypothermia or immersion foot Difficulty controlling bodily functions Liver disease cirrhosis end-stage liver disease or hepatitis C Heart disease arrhythmia or irregular heartbeat Amputation or physical disability that limits mobility Sight or hearing impaired 0 70 4 5 5 6 9 10 12 13 14 16 16 18 20 24 26 10 20 30 40 50 60 70 % of veterans surveyed 80 2 Health problem reported Metropolitan Housing and Communities FIGURE 2. Mental Health and Substance Use Problems Reported by Homeless Veterans (N 537) Drug and TriMental Health Alcohol Abuse morbid Problems Total Tri-morbid Reports Any Mental Health Problems Currently or ever been treated for mental health problems Observed signs or symptoms of severe persistent mental illness Ever been taken to hospital against will Reports Drug or Alcohol Abuse Ever abused alcohol or been told you do Ever or currently use drugs Been treated for drug or alcohol abuse Reports a Serious Medical Condition Kidney disease/renal disease or dialysis 4 18 20 6 5 14 13 5 9 19 14 29 50 41 23 73 52 45 51 58 Serious Medical Condition Liver disease cirrhosis end-stage liver disease or hep-C Heart disease arrhythmia or irregular heartbeat HIV/AIDS Emphysema Diabetes Asthma Cancer Tuberculosis Observed signs or symptoms of serious physical health condition 0 10 20 30 40 50 60 70 80 % of veterans surveyed Tri-morbidity (mental health problem a serious health problem and substance use abuse) More than three hospitalizations or emergency room visits over a year More than three emergency room visits in the past three months 60 years or more of age HIV/AIDS Cirrhosis Kidney disease/renal disease or dialysis Cold weather injuries (frostbite immersion foot hypothermia) people are all too common.6 Thirty-nine percent of homeless veterans reported being the victim of a violent attack since becoming homeless. Homelessness Is Costly Supportive Housing Works and Can Be Cost-Effective Homelessness comes at an incredible cost to veterans and to society. Living for years on the street and in shelters has contributed to serious health problems among chronically homeless veterans. Without attention these health problems are costly: veterans enter and exit emergency rooms without proper long-term treatment. Many also cycle in and out of jails or prisons. Living on the street exacerbates health problems making it difficult to treat chronic illnesses such as cancer heart disease and cirrhosis of the liver. In addition to chronic health problems many veterans suffer from 3 Using this tool 46 percent of D.C. homeless veterans identified through the survey have one risk factor that increases their likelihood of premature mortality 30 percent have two risk factors and 17 percent have three or more risk factors (figure 4). In addition to serious health problems these veterans face violent streets where crimes against homeless Metropolitan Housing and Communities FIGURE 3. Health Care Coverage and Use among Homeless Veterans Reported health insurance (N 517) None 14% Medicaid 20% Where does veteran usually go for health care (N 537) VA 36% DC Alliance 23% Medicare 7% Other 64% Private 3% VA 30% Emergency room in the past three months (N 190)a Four times or more 8% Three times 11% One time 51% Two times 27% Inpatient hospital this past year (N 196)a Four times or more 11% Three times 10% One time 37% Providing permanent supportive housing under a housing-first umbrella to persons with mental illness or co-occurring disorders results in more days housed and for certain high-service users can be cost-effective. Two times 49% a Percentages do not add up to 100 because of missing values. weather-related injuries: 12 percent of veterans surveyed reported that they currently had swollen or infected open wounds or ulcers on their skin and 16 percent reported experiencing frostbite hypothermia or immersion foot (see figure 1). A growing body of evidence shows that providing permanent supportive housing under a housing-first umbrella to persons with mental illness or co-occurring disorders results in more days housed than comparison or control groups and for certain populations of high-service users can be cost-effective (Culhane Metraux and Hadley 2002 Kuhn and Culhane 1998). Housing-first helps chronically homeless FIGURE 4. Vulnerability Index for Homeless Veterans (N 537) 0-no risk factors 7.0% 6-six risk factors 0.2% 5-five risk factors 2.0% 4-four risk factors 3.0% 3-three risk factors 12.0% 2-two risk factors 30.0% 1-one risk factor 46.0% 4 Metropolitan Housing and Communities people gain immediate access to permanent housing linked with comprehensive services. Unlike linear models which emphasize emergency shelter and transitional housing programs that typically require sobriety and service plan compliance before permanent housing housingfirst uses a low-demand approach. Services are voluntary and typically include mental and physical health care substance use treatment or harm reduction counseling independent living skills and referrals to employment or vocational training. Nonprofit agencies provide services on site with mobile assertive community treatment (ACT) teams or through other models of care. Supportive housing models vary in structure (e.g. scattered site multiunit building) scale target population and tenant mix. Importantly the data show that for certain populations the costs of permanent supportive housing can be offset by savings in public services such as emergency room visits jail and hospital stays and mental health services that people who experience homelessness use while living on the street or in emergency shelter (Caton Wilkins and Anderson 2007 Culhane et al. 2002 Martinez and Burt 2006). Other studies show similar findings: one randomly controlled study of Pathways to Housing the program credited as one of the first housing-first models for chronically homeless adults showed that the treatment group (those who received permanent supportive housing under a housingfirst umbrella) reported spending less time homeless and more time stably housed than the control group (Tsemberis Gulcur and Nakae 2004). A study of two San Francisco permanent supportive housing sites found that 81 percent of residents remained in housing for at least one year and that housing placement reduced emergency department and inpatient services (Martinez and Burt 2006). Recent evidence from an evaluation of 1811 East Lake a supportive housing building operated by the Seattle Downtown Emergency Service Center shows that providing permanent supportive housing to chronically homeless alcoholics results in costs savings and can lead to reduced alcohol consumption (Larimer et al. 2009). Together this research debunks the notion that people experiencing homelessness need to be "housing ready" before placing them in permanent housing. HUD-VASH Is a Successful Housing Model for Homeless Veterans with High Service Needs HUD-VASH is a supportive housing program that links housing vouchers with case management and clinical services for homeless veterans "who would not be able to live independently without the support of case management."7 The program initially funded in 1992 provided a small pool of about 1 700 HUD-VASH vouchers to homeless veterans. In 2008 Congress significantly increased the program by providing $75 million of funding for 10 000 HUD-VASH vouchers and then an additional appropriation in the fiscal year 2009 budget for another 10 000. HUD awarded the first round of HUD-VASH (10 150 vouchers) in May 2008 to 132 Veterans Affairs medical centers (VAMCs) and 137 housing agencies across the country.8 This round of vouchers significantly expanded the eligibility for the program which was once limited to those homeless veterans with chronic mental illness or chronic substance use disorders. Chronically homeless veterans are a target population for HUD-VASH but homeless veterans with children homeless veterans who served in Operations Iraqi Freedom and Enduring Freedom female homeless veterans and other homeless veterans with "diminished functional capacity" who need case management are also eligible for the program (Smits and Kane 2009).9 HUD-VASH was initially modeled after the Housing Choice Voucher Program: participants are issued a voucher which they use to search for housing to rent from private-market landlords. Participants typically pay between 30 to 40 percent of their income toward rent and the government through local public housing authorities HUD-V ASH links housing vouchers with case management and clinical services for homeless veterans who are unable to live independently without case management. 5

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