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VA National Center on Homelessness Among Veterans | U.S. Department of Veterans Affairs

Integrating Data and Sharing Research to End Veteran

Homelessness

National Alliance to End Homelessness

July 30, 2014


HUD-VASH Exit Study Preliminary Findings

~ Project Jointly Funded by HUD & VA

Meagan Cusack

Project Manager, HUD-VASH Exit Study

VA NATIONAL CENTER ON HOMELESSNESS AMONG VETERANS


HUD-VASH

HUD-VASH is a permanent supportive housing initiative conducted as an ongoing collaboration between these two agencies:

Department of Housing and Urban Development (HUD) Provides Veterans with Housing Choice Vouchers

US Department of Veterans Affairs (VA) Provides case management and outreach

HUD.gov

58,155 vouchers awarded since 2008


HUD-VASH Performance Targets

Measure Target FYTD

HUD-VASH vouchers that result in housing 90% 86.15%

Chronic homeless enrolled in HUD-VASH 65% 72.93%

Veterans housed within 90 days of entry 65% 62.65%

Negative exits 20% 17.75%

Homeless Services Scorecard (National - Report Period: 2014)


Negative HUD-VASH Exits

• Veteran did not comply with HUD-VASH case management

• Veteran was evicted from his/her HUD-VASH apartment by PHA or landlord and/or had other housing related issues or problems

• Veteran unhappy with HUD-VASH housing

• Veteran cannot be located

Homeless Services Scorecard Data Definitions


HUD-VASH Exit Study

Purpose: Identify reasons Veterans leave HUD-VASH prematurely and Veteran characteristics and program experiences that predict premature exit, including:

1) Barriers to accessing housing

2) Frequent causes of program exits

3) Housing destinations of Veterans who exit the program

4) Practices that lead to the long-term housing stabilization and well-being of participants

5) Patterns of exit that can inform efforts to prevent future exits


Study Site Descriptions Study Site VAMC Public Housing Authorities Vouchers*

Bedford Edith Nourse Rogers Memorial (Bedford) VAMC

Lynn Housing Authority Chelmsford Housing Authority Department of Housing & Community Development

407

Houston Michael E. DeBakey (Houston) VAMC

Houston Housing Authority Harris County Housing Authority

1,370

Los Angeles VA Greater Los Angeles HCS Housing Authority of the County of Los Angeles Housing Authority of the City of Los Angeles

4,025

Palo Alto Palo Alto HCS Housing Authority of the County of San Mateo County of San Joaquin Housing Authority County of Stanislaus Housing Authority County of Monterey Housing Authority Housing Authority of the County Santa Clara Alameda County Housing Authority Santa Cruz County Housing Authority

1,145

Philadelphia Philadelphia VAMC Housing Authority of the City of Camden Philadelphia Housing Authority

620

*Through FY13


Interview Data* Administrative Data Program Data

Study Group 1: Non-Leased Exiters Discharged before obtaining a lease with the voucher

Study Group 2: Leased-up Exiters Discharged after obtaining a lease with the voucher

Study Group 3: Stayers Obtained a lease with the voucher; leased housing unit with the voucher for 600+ days

*Includes Quantitative and Qualitative Components

Homeless Operations Management and Evaluations Systems (HOMES) Demographic, psychosocial, and health information

VA Medical Records Medical, substance abuse, and mental health diagnoses; frequency of use of VA medical, substance abuse and mental health services during program enrollment ; data on frequency of contact with HUD-VASH staff, and type of services provided

VA Case Management Teams Interviews with local VA case managers and review of Pre-Interview Questionnaire on program elements and program materials

HUD Public Housing Authorities Interviews with local PHAs and review of administrative plan and program materials

Data Collection Overview 1 2 3

Veteran Data


Preliminary Veteran Sample

Study Site Non-Leased Exiters

Leased-Up Exiters

Stayers Total

Target 40 total exiters 95 135

Bedford 1 5 16 22

Houston 3 6 86 95

Los Angeles 16 25 95 136

Palo Alto 21 22 81 124

Philadelphia 15 23 94 132

Total 56 81 372 509

Data collection will conclude July 31, 2014

Preliminary Interview Data


HUD-VASH Enrollment Process

3.73

3.36 3.61

3.93 3.95 4.12 4.04 4.01

4.19

1

2

3

4

5

Enrolling in the HUD-VASHprogram

Submitting applications toPHA*

Providing documentation ofidentity and income to

PHA*

Non-Leased Exiters Leased-Up Exiters Stayers

*Significance ≥.01

Very Difficult

Very Easy



HUD-VASH Housing Process

1.49 1.6

2.05 1.95 1.85

3.71 3.49

4 4.19

3.73 3.93

3.41

4.08 4.2

3.6

1

2

3

4

5

Finding listingsof available

apartments*

Finding anacceptableapartment

option*

Getting anapartment

inspected byPHA*

Being selectedas a tenant by a

landlord*

Obtainingmoney for rent,security deposit,

moving costs*



Very Difficult

Very Easy



Self-Reported Health Status

13%

36%

50%

2% 7%

35%

53%

5% 8%

30%

55%

7%

0%

10%

20%

30%

40%

50%

60%

Poor Fair Good or Very Good Excellent




Self-Reported Medical and Mental Health

55%

25%

41%

11%

46%

32%

59%

17%

57%

38% 39%

10% 0%

10%

20%

30%

40%

50%

60%

70%

Serious medicalproblems

Hospitalized forserious medical

problems

Serious mentalhealth problems*

Hospitalized forserious mental

health problems





“Troubled or Bothered” by Drugs or Alcohol while Enrolled in HUD-VASH*

66%

20%

5% 2% 7%

56%

19%

10% 7% 9%

68%

19%

10% 3% 1% 0%

10%

20%

30%

40%

50%

60%

70%

80%

Not at all Slightly Moderately Considerably Extremely





Self-Reported Drug or Alcohol Treatment while Enrolled in HUD-VASH

9%

14%

4%

0%

17%

10%

5%

15%

6%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

Inpatient only Outpatient only Both inpatient andoutpatient




0% 10% 20% 30%

Increase in income

Improvement in health, mental health or substance use condition

Difficulty paying rent

Worsening in medical, mental health or substance use condition

Difficulties with HUD-VASH case management/services

Difficulties with housing

Legal trouble

Offer from family or friends to move in to their housing

Leased-Up Exiters Non-Leased Exiters

Main Reason for Exit*


Neutral Exits

Negative Exits (~62% for both groups)


Positive Exits


Summary of Initial Findings

• Non-Leased Exiters found the enrollment process to be slightly more difficult and the housing process a lot more difficult than those who leased

• There seems to be a relationship, at least descriptively, between mental health and substance use and exiting housing

– Research team will control for other characteristics moving forward

• From Veteran reports, across all categories of exit, “negative” exits account for the same amount (~62%) of exits for those that do not lease and those that do; this rate is much higher than the HUD-VASH performance target and HOMES reports



Next Steps

• Analyze data for national HUD-VASH participants

• Develop study site descriptions and maps

• Analyze full study sample, including analysis of administrative records

• Code and analyze qualitative interviews

Final Report Outline with Preliminary Results September 30, 2014

Final Report December 31, 2014


Homelessness among Veterans Returning from Afghanistan & Iraq

Stephen Metraux, PhD


The number among this generation falling on hard times is rising sharply even as homelessness among veterans of all ages and conflicts has been on the decline, according to the VA. (USA Today 2014)


Homeless Veterans by Age Group (%)

0

5

10

15

20

25

30

18-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80 andolder

2000

2005

2010

Source: Unduplicated count of all Veterans who completed Form X (an intake form for those receiving services from VA's Health Care for Homeless Veterans Program) in each year from 2000-2010


OEF/OIF/OND Vets and VA Housing Services

0

5,000

10,000

15,000

Source: Various VA reports


(11,730 Veterans under age 30 in 2012)

Source: HUD’s 2012 Annual Homeless Assessment Report


5,694 of 310,685 (1.8%) recent Veterans had records of homelessness

5-year incidence rate of 3.7%

Source: S Metraux et al. “Risk factors for becoming homeless among a cohort of veterans who served in the era of the Iraq and Afghanistan conflicts.” American Journal of Public Health (November 2013).

24


Iraq and Afghanistan veterans are already turning up on the streets … And over time, the signature wounds of the current conflicts—psychological wounds and traumatic brain injuries—may contribute to higher rates of homelessness. (Iraq & Afghanistan Veterans of America 2009)


OEF/OIF deployment was associated with homelessness risk (OR=1.3)


26


PTSD was associated with homelessness risk in OEF/OIF deployed veterans

(OR=1.2 for men & OR=1.6 for women)

18% of recent Vets who left military with a behavioral health disorder comprised 44% of those who became

homeless

Source: S Metraux et al. “Risk factors for becoming homeless among a cohort of veterans who served in the era of the Iraq and Afghanistan conflicts.” American Journal of Public Health (November 2013). 27


OEF/OIF/OND Veterans N=15,502

Vietnam Veterans N=19,713

Alcohol Use Disorder (Q44a)

34.0% 41.0%

Drug Use Disorder (44b) 31.3% 30.3%

Alcohol or Drug Disorder (44a or 44b)

46.9% 50.7%

Military-related PTSD (44g)

49.5% 20.4%

Schizophrenia (44d) 1.8% 4.9%

Affective Disorder (44j) 40.8% 35.8%

Experienced Combat (Q19)

73.5 42.8%

Source: VA’s Homeless Management and Evaluation System (HOMES)


Veterans ages 25 to 34 … experienced significant increases in poverty rates over the [past] decade. (National Center for Veterans Analysis and Statistics, 2011) Though the overall unemployment rate among America's 21m veterans in November (7.4%) was lower than the national rate (8.6%), for veterans of Iraq and Afghanistan it was 11.1%. (Economist 2011)


The 44% of recent Veterans in the lowest pay grades accounted for 72% of those who became homeless.


30


Among 15,102 homeless veterans who were deployed in Iraq or Afghanistan:

- 40% reported full time work (including military)

- 15% reported part time work

- 12% reported being disabled

as primary work pattern over the previous 3 years.



Among 15,102 homeless veterans who were deployed in Iraq or Afghanistan:

- 37% reported no income

- 50% reported income under $326

- 70% reported income under $950

over the previous 30 days.



Other Factors

• Relationships (family, friends, partners)

• Money Management

• Legal Issues

• Military Experiences

• Experience with VA Services

• Transitioning From Military

• Use of Mainstream Services


Research Agenda • Dynamics of homelessness – numbers and trajectories

• Risk factors for homelessness – service-related and antecedent factors

• Service use patterns in VA and mainstream systems

• Forecasting future demand and services need


Universal And Repeated Screening For Homelessness And Risk In The Veterans Health Administration

Ann Elizabeth Montgomery, Thomas Byrne, & Jamison Fargo


Agenda

• Overview of Homelessness Screening Clinical Reminder (HSCR)

• Annual prevalence of homelessness and risk among Veterans responding to the HSCR

– Predictors of positive screens

• Rescreens

– Odds of resolving housing instability


HSCR: Primary Questions • For the past 60 days, have you been living in stable housing

that you own, rent, or stay in as part of a household? – Yes Question 2

– No Homeless, refer to VHA Homeless Program

• Are you worried or concerned that in the next 60 days you may not have stable housing that you own, rent, or stay in as part of a household? – Yes At risk, refer to social work services

– No Screener complete (negative)


HSCR: Administration Schedule • Administered annually in outpatient primary care clinics,

including mental health and social work – Semi-annual rescreening for Veterans who screen positive

• Exclusions: – Patient already receiving services through VHA Homeless Program

– Patient is long-term resident of nursing home or long-term care facility

– Patient declines screening or is unable to respond


October 1, 2012 – September 30, 2013

• 4,307,764 Veterans accessing outpatient care completed the HSCR

– 0.8% screened positive for homelessness

– 1.0% screened positive for risk

– 98.2% screened negative

• 17,720 Veterans responded to a rescreen


Demographics Characteristics Homeless At Risk Negative

N 36,081 (0.8%) 41,540 (1.0%) 4,230,143 (98.2%)

Gender Female 1.1% 1.6% 97.4%

Male 0.8% 0.9% 98.3%

Age <35 1.7% 1.8% 96.5%

35–44 1.5% 1.9% 96.7%

45–54 1.8% 2.0% 96.1%

66–64 1.3% 1.4% 97.3%

65+ 0.2% 0.3% 99.5%


Screening Location

0.7%

0.5%

1.1%

0.9%

0.0% 0.5% 1.0% 1.5%

At Risk

Homeless

Not Rural Rural

• 4 of 5 screens take place in primary care

• Rates of positive screens are highest in: – Social work

– Mental health/substance abuse clinics


Predictors of Initial Positive Screen

• Younger than 60 years

• Male

• Hispanic or Black*

• Service in eras other than OEF/OIF/OND

• No service-connected disability and Medicaid-eligible*

• Responded to the HSCR in settings other than primary care (social work, mental health, substance abuse clinic)*

• Responded to the HSCR in non-rural locations

*More likely to screen positive for homelessness than risk


Rescreens

• 22.8% of the 77,621 Veterans who screened positive during FY 2013 responded to a subsequent screen 6–12 months after the initial screen

– 80.5% resolved their homelessness

– 87.7% resolved their homelessness risk


Changes in Screening Disposition

85.0%

5.3%

4.8%

3.0%

1.9%

Resolved housing instability(N=15,060)

Persistently homeless(N=937)

Persistently at-risk(N=849)

Newly homeless(N=530)

Homelessness to risk(N=344)

• Resolved housing instability – positive initial screen and negative rescreen

• Persistently homeless – positive for homelessness on initial screen and rescreen

• Persistently at risk – positive for risk on initial screen and rescreen

• Newly homeless – positive for risk on initial screen and homelessness on rescreen

• Homeless to risk – positive for homelessness on initial screen and positive for risk on rescreen


Odds of Rescreening Disposition* Characteristics

Persistently Homeless

Persistently At Risk

Newly Homeless

Homeless to Risk

Accept referral + NS + +

Older age - + NS NS

Male + NS NS NS

Black race + + + +

<50% service-connected** + + + +

Screening location Mental health + + NS +

Substance abuse + + + +

Rural location - NS NS NS

*Relative to resolved housing instability; **includes not service-connected/VA pension; NS = not significant


Future Work • Evaluate comparative effectiveness of interventions to

support Veterans’ resolution of housing instability – Assess effectiveness of the HSCR at linking Veterans with services

and Veterans’ perceptions of the effectiveness

• Medical, mental, and behavioral health comorbidities associated with persistent homelessness and risk

• In-depth analysis of Veterans with repeated positive screens (i.e., 3 or more)


SSVF: Year 2 Results and Community Characteristics

Dan Treglia, MPP

Thomas Byrne, PhD


SSVF Overview • Prevention and Rapid Rehousing

• Operated through Community-based organizations

• Eligibility criteria targeting those most in need of SSVF assistance


FY 2012 FY 2013 FY 2014

US States and Territories Served

40 and DC 49, DC, and Puerto

Rico 50, DC, Puerto Rico,

Virgin Islands

CoC's Served n/a 261 (62%) 375 (89%)

Grantees 85 151 319

Households served 21,111 39,930 n/a

Funding Level

$59,313,413 Actual Expenditures

$99,043,780 Actual Expenditures

$299,056,370 Budgeted


SSVF Year 2 Populations

Children 45% of households had at least 1 child

Female Veterans

15% of Veterans were female

OEF/OIF 17% of Veterans served in OEF/OIF

Very low income

Majority (76%) had incomes below 30% of AMI

Disability Slightly more than half had disabling condition


SSVF Services

• In community & VA 1.Outreach

• Careful assessment of needs • Housing stability plan

2. Case management

• Health care • VBA benefits (education/vocational,

pensions)

3. Assistance in obtaining VA benefits

• Legal assistance, credit counseling • Income support (e.g. TANF, SNAP, etc.)

4. Assistance in obtaining mainstream benefits

• Rental assistance, utility payments, security deposits, moving costs, emergency supplies, child care, transportation

5. Temporary Financial Assistance


http://www.va.gov/HOMELESS/ssvf/docs/SSVFUniversity/SSVF_Annual_Report_FY_2013.pdf Available at :

http://www.va.gov/HOMELESS/ssvf/docs/SSVFUniversity/SSVF_Annual_Report_FY_2013.pdf


Households Served by Assistance Type

Nearly 100,000 (97,979) people served in FY ‘12 & ‘13


Distribution of Temporary Financial Assistance


Evaluating Program Outcomes

• Divide exiters by household and assistance type

• Assess “survival rates”

• Regression models to examine Veteran, SSVF program & community factors associated with SSVF outcomes


Exit Type by Assistance and Household Type


Survival Curves

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

1 31 61 91 121 151 181 211 241 271 301 331 361

Prevention - Singles Prevention - Families

Rapid Re-housing - Singles Rapid Re-housing Families

One Year Survival Rates

Prevention - Families: 95% Prevention - Singles: 90% RR- Families: 93% RR - Singles: 88%


Regression: Veteran Characteristics Rapid Rehousing Prevention

Families Singles Families Singles

Age Group (18-30 is reference)

30-44 + +

44-54 + + +

54-61 + + +

62+ +

Male + +

Hispanic

Race (white is reference)

Black +

Other Race

Disabling Condition + +

History of Homelessness + + +


Regression: Program Factors Rapid Rehousing Prevention


Exited in FY 2013 + + + +

Participation length>90 days

Legal services

Housing search services

Rental assistance + +

Security deposit +

Utility payment

Moving costs

Exit destination (compared to temporary with family/friends)

HUD-VASH - - - -

Other permanent - - - -

Other/Unknown - -


Regression: Community Characteristics

Rapid Rehousing Prevention


Median Rent (in $100s)

% Vacant Housing Units -

Percent Renter Households

Percent Rent Burdened Households


Conclusions and Next Steps • Models did not find any relationship between

community characteristics and SSVF success

• Much greater influence from personal characteristics and programmatic needs

• Advance SSVF evaluation and integrate into the research on Rapid Re-housing

• In depth interviews with Veterans to better understand what’s working and what’s not

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