2017 Issues   /   July 2017

‘Housing First’ Is Motto for VA Director Seeking to End Veteran Homelessness

USM By U.S. Medicine
July 7, 2017

By Steve Spotswood

WASHINGTON — In 2009, then-Secretary of Veterans Affairs Eric Shinseki unveiled the department’s ambitious five-year plan to end homelessness among veterans. One of the people brought in to implement that plan was Keith Harris, PhD, who stepped into the newly-created role of National Director of Clinical Operations for VA Homeless Programs.

While five years have come and gone and there are still thousands of veterans experiencing homelessness on any given night, much has been accomplished in that time, Harris said. He has helped shape how the VA addresses homelessness, turning many earlier ways of looking at the problem on their head.

 A clinical psychologist by training, Harris interned at the Palo Alto, CA, VAMC, which was both his gateway into VA and the first step in a career with a steep upward trajectory. “After four-to-five years of PhD programs and a year of internships, I realized the two best training experiences I had over that stretch were homeless-related. The first was a homeless youth program; the other was the homeless veterans program at Palo Alto,” Harris explained. “It was where I felt like I was having the greatest impact. The people we were serving felt like they needed help the most. It really ignited the passion I got into the field for in the first place.”

After his internship, Harris was hired into a hybrid position where he worked closely with the chief of Palo Alto’s homeless veterans service, doing research, training, and direct clinical work. Ten months after Harris was hired, his boss took early retirement and recommended Harris to take his place. Though he was the newest and youngest employee in the homeless veterans’ service, he took over as chief in 2004. He stayed in that role until 2010 when he was tapped to provide guidance and oversight to the clinical component of VA’s nationwide continuum of homeless programs.

When he started, Harris found the biggest challenges to be operational. It was impossible to determine the full quality of care that homeless veterans were receiving because the performance measurements were all wrong. “At the time, we had a very small number of very stale performance measures. A certain number of visits within a certain number of days, for example. And that was driving clinical behaviors.”

The first item on Harris’s extensive to-do list became creating a new set of measures. Those included questions such as: Are veterans going into permanent housing, and are existing housing programs resulting in housed veterans?

Volunteers from the Coast Guard hand out bagged lunches to Stand Down Against Homeless attendees at the Ralph H. Johnson VAMC. VA Photo by James Arrowood.

Exactly how individual VA systems met those goals was less of a concern to Harris. He wasn’t interested in micromanaging individual systems or facilities, since each one has different resources and different needs. “My philosophy is you set a general outcome and let people locally create a way to meet that.”

The second challenge was that there was too much money being funneled at the problem too quickly. The hiring budget far outpaced the department’s ability to recruit new employees. “You can’t send out money for upward of 500 case managers in a single year and expect them all to be hired on the spot. We had a large amount of unused money.”

Congress does not look favorably on services that don’t use their allocated resources, so Harris had to find ways to repurpose those funds for other needs for homeless veterans. “If you can’t hire a new case manager in that time, can you pay for a new vehicle for outreach workers?” he asked. “Can you repurpose that money for short-term beds? We were figuring out how to use and then track and manage all the funding we were given in a very short order, while also making the best use of it.”

While all this was occurring, Harris was working to develop a way that each VAMC could tally their resources and develop their own plan to end homelessness. He was turning a national goal into a thousand local ones. “We built a model that can be used by each medical center to assess the resources they had against the known need, and determine whether it would be sufficient.”

One central philosophical shift that Harris and everyone at the national office stressed to facilities across the country was: Housing First. This model prioritizes housing a veteran and then assists that veteran in accessing the care they need. It was a massive shift in mindset.

“Our goal is permanent housing, and it’s permanent housing as quickly as possible that’s appropriate for that veteran,” he noted. “You don’t follow a linear model and solve every problem that a veteran has before placing them in housing. You flip that on its head.” Once a veteran is housed, it becomes much easier to get them comprehensive and consistent clinical care, and to help them move forward in other social service programs.

 This nationwide shift in addressing veteran homelessness has led to considerable success. From 2010-2016, VA saw a nearly 50% reduction of homeless veterans on any given night. However, in some areas there is a danger that the numbers could trend upward again.

Officials in Los Angeles, which historically has one of the nation’s highest rates of homeless veterans, announced in March that the city’s overall homeless population jumped 23% over the previous year. Last year, Seattle announced that its homeless population was growing at twice the rate of its available homeless housing.   

Nationwide, the number of veterans entering into homelessness is outpacing VA’s ability to place them into housing. “At this point in the initiative, we expected the number of veterans entering homelessness in any given month would be much lower than when we started, and that is not the case,” Harris said. “There’s a very good case for it being at least as high as it’s ever been.”

One of the most frustrating facts with which Harris must wrestle is that much of the problem is out of VA’s hands. By the time VA is in a position to intervene with a veteran threatened by homelessness, a whole host of support networks have already failed. And while VA can place veterans into housing, vacancy is very low, especially in West Coast cities like Los Angeles and Seattle.

“VA is virtually unable to develop housing,” he explained. “For the most part, that’s something that has to be picked up by communities and the state, as well as developers and nonprofits.”

What the agency can work on is ensuring that veterans who they place into housing remain there. “Those that we’ve assisted into housing sometimes fall out of it. We haven’t done as good a job in supporting them,” Harris said. “That is probably our biggest single area of concern at this second. We’re focusing too much into getting them into housing and failing to help them do the things that will keep them there.”

Factors that affect whether a veteran remains housed include employment, financial viability, substance abuse, and the effects of isolation. “That can be a problem, especially if they came out of VA programs with a strong cohort around them, and then they’re placed in an apartment all by themselves,” he added. “Isolation can drive a lot of problematic behaviors.”

VA is committed to doing everything it can on its end to support veterans and ensure the time they spend homeless is as brief as possible, Harris said. But the goal of eradicating homelessness among veterans has to be one that the entire nation embraces. “It’s something that we as a country need to take ownership of.”     

Related Articles

Fibromyalgia Presents Differently in Male, Female Veterans

Research on fibromyalgia, a poorly understood, chronically disabling pain syndrome, generally has focused on its clinical presentation and treatment.

How Veterans Feel About Remote Management of Their Care

The VA is expanding remote management of patients to improve disease prevention and care.

U.S. Medicine Recommends

More From department of veterans affairs

Department of Veterans Affairs (VA)

Fibromyalgia Presents Differently in Male, Female Veterans

Research on fibromyalgia, a poorly understood, chronically disabling pain syndrome, generally has focused on its clinical presentation and treatment.

Department of Veterans Affairs (VA)

How Veterans Feel About Remote Management of Their Care

The VA is expanding remote management of patients to improve disease prevention and care.

Department of Veterans Affairs (VA)

Stick-on Monitors Help Warn of Heart Failure Exacerbation in VA Study

While implantable devices have shown promise in reducing rehospitalization for heart failure (HF), VA researchers sought to determine if options that are less expensive and non-invasive would have comparable results.

Department of Veterans Affairs (VA)

Legislation: Clinicians Must Be Involved in Formulary Design, Purchasing

Legislation to prevent VA from outsourcing creation of its drug formulary and to require more input from medical professions is being considered in Congress.

Department of Veterans Affairs (VA)

GAO: VA Needs Better Planning for ‘Complex’ Appeals System Overhaul

SYRACUSE, NY — Despite limited evidence to support the practice, testing for Helicobacter pylori (Hp) infection is recommended for work-up of unexplained iron deficiency anemia (IDA). A study published in the journal Gastroenterology Report sought... View Article

Facebook Comment

Subscribe to U.S. Medicine Print Magazine

U.S. Medicine is mailed free each month to physicians, pharmacists, nurse practitioners, physician assistants and administrators working for Veterans Affairs, Department of Defense and U.S. Public Health Service.

Subscribe Now

Receive Our Email Newsletter

Stay informed about federal medical news, clinical updates and reports on government topics for the federal healthcare professional.

Sign Up