HUD-VASH Exit Study

Final Report

U.S. Department of Housing and Urban Development | Office of Policy Development and Research

HUD-VASH EXIT STUDY

FINAL REPORT

September 2017

Prepared for

U.S. Department of Housing and Urban Development

Prepared by

Ann Elizabeth Montgomery, VA National Center on Homelessness Among Veterans

Meagan Cusack, VA National Center on Homelessness Among Veterans

ACKNOWLEDGMENTS

The authors acknowledge the following individuals and teams that were integral to this project:

•  The Veterans who agreed to participate in the study;

•  The U.S. Department of Housing and Urban Development (HUD) for sponsoring the

study, as well as the HUD staff who assisted in its development and completion,

especially Elizabeth Rudd from the Office of Policy Development and Research and staff

from each of the participating housing authorities: Chelmsford Housing Authority, Harris

County Housing Authority, Housing Authority of Monterey County, Housing Authority

of the City of Camden, Housing Authority of the City of Los Angeles, Housing Authority

of the County of Los Angeles, Housing Authority of the County of Santa Clara, Houston

Housing Authority, Lynn Housing Authority, Massachusetts Department of Housing and

Community Development, and Philadelphia Housing Authority; and

•  The U.S. Department of Veterans Affairs (VA) and the staff of the HUD-VA Supportive

Housing case management teams affiliated with each study site: Edith Nourse Rogers

Memorial Veterans Hospital, Michael E. DeBakey VA Medical Center (VAMC),

Philadelphia VAMC, VA Greater Los Angeles Healthcare System, and VA Palo Alto

Health Care System.

In addition, we acknowledge the local research staff at each study site who assisted with data

collection:

•  Bedford—David Smelson and Brittany Walker.

•  Houston—Marilyn Hinojosa-Lindsey, Laura Marsh, and Takeisha Plowden.

•  Los Angeles—Sonya Gabrielian and Nupur Nanda.

•  Palo Alto—Mona Bazzi, Dan Blonigen, David Howard, and Luisa Manfredi-Batki.

•  Philadelphia—Nora Hunt-Johnson and Janna Manjelievskaia.

We thank the staff from the University of Pennsylvania’s Mixed Methods Research Lab who

aided with the coding and reporting of qualitative findings: Aderinola Adejare, Aneeza Agha,

and Rosemary Frasso.

We also recognize staff from the VA National Center on Homelessness Among Veterans who

assisted in important ways throughout the design, analysis, and reporting of the study: Thomas

Byrne, Dennis Culhane, Ashley DiSilvestro, Jamison Fargo, Bessie Flatley, Thomas O’Toole,

Jonathan Rajkumar, Christopher B. Roberts, Dan Treglia, and Irene Wong.

Finally, the authors acknowledge Vince Kane and Mark Johnston, who originally conceived of

this study, and their tireless efforts to end Veterans’ homelessness.

DISCLAIMER

The contents of this report do not necessarily represent the views of the U.S. Department of

Veterans Affairs, the U.S. Department of Housing and Urban Development, or the United States

Government.

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PREFACE

The HUD-VA Supportive Housing (HUD-VASH) program serves hard-to-house, homeless

Veterans and their families with deep housing subsidies and intensive supportive services. HUD-

VASH, a collaboration between the U.S. Department of Housing and Urban Development and

the Department of Veterans Affairs, has grown from a small program serving fewer than 2,000

Veterans in 2008 to a major program with the capacity to serve more than 87,000 Veterans in

2017. With 87,864 VASH vouchers in circulation in April 2017, the program contributed

substantially to the 47-percent decline in the number of homeless Veterans since 2010.

The HUD-VASH exit study takes a close look at how the HUD-VASH program was

implemented in four different sites, focusing most on the 2011-to-2014 period, supplemented

with administrative data covering 2008 to 2014. HUD-VASH served more than 7,000 clients

during this time at the four sites. Researchers surveyed more than 500 Veterans and conducted

indepth interviews with 110 Veterans to enhance information that could be derived from

administrative data. The study analyzes how Veterans moved through the program from

homelessness to stable housing and why Veterans exit the program. By better understanding why

Veterans leave the program, we can inform and improve efforts to house this population.

The report finds that about one-half of Veterans who exited the program during the observation

period simply no longer needed its intensive support, but a substantial minority of exiters would

probably benefit from continued case management services and housing assistance—the key

program features. This need is especially strong among Veterans who exit the program before

accessing housing. The report describes program successes and offers concrete recommendations

for program improvement. In particular, it describes promising practices for serving the Veterans

with the greatest barriers to housing stability. This careful analysis of the characteristics of

exiters from the program should inspire current and future efforts to better address the needs of

the homeless veteran population.

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MESSAGE FROM THE U.S. DEPARTMENT OF

VETERANS AFFAIRS

In 2010, the U.S. Interagency Council on Homelessness (USICH) presented the White House

and Congress with Opening Doors: Federal Strategic Plan to Prevent and End Homelessness,

which represented the collaborative effort of 19 federal agencies. A primary goal of this plan was

to prevent and end Veteran homelessness. Since then, the number of Veterans experiencing

homelessness has decreased 47 percent, due in large part to a key collaboration between the U.S.

Departments of Housing and Urban Development (HUD) and Veterans Affairs (VA).

HUD and VA collaborated on a number of significant efforts to address Veteran homelessness

by providing homelessness prevention and rapid re-housing assistance through the Veterans

Homelessness Prevention Demonstration Program, advocating for community efforts to end

Veteran homelessness through the Mayors Challenge to End Veteran Homelessness, and

permanently housing Veterans through the HUD-VA Supportive Housing (HUD-VASH)

program. HUD-VASH is one of the most effective tools for ending Veteran homelessness.

HUD-VASH is jointly funded and implemented by HUD and VA. HUD provides a permanent

housing subsidy through the Housing Choice Voucher (HCV) program and VA provides case

management and other supportive services to assist formerly homeless Veterans in accessing and

maintaining housing. Although the program was originally established in 1992, since the release

of Opening Doors the number of HUD-VASH vouchers has increased more than 60 percent, and,

as of FY 2016, 85,097 vouchers are available across the country to house formerly homeless

Veterans, some who go on to live independently.

HUD and VA commissioned this study to learn more about how and why Veterans exit the

HUD-VASH program, the role that HUD and VA resources play in Veterans’ abilities to access

and maintain housing with a HUD-VASH voucher, and facilitators and barriers to successful

collaboration between HUD and VA in the administration of the program. Exploring multiple

perspectives—Veterans and staff from both HUD and VA—and a wide array of data, this study

found that HUD-VASH is successful at retaining Veterans in housing and that those who exit the

program often do so because they accomplished their goals and rarely return to VA homeless

programs. The study also found that the committed partnership between HUD and VA

contributed to more streamlined internal processes and flexible program requirements,

contributing to Veterans’ rapid access to housing and long-term housing stability.

This project underscores the importance of interagency collaboration and validates much of our

joint efforts during these past several years.

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TABLE OF CONTENTS

Executive Summary ..................................................................................................................... xiv

Chapter 1: Introduction and Overview of Study ..............................................................................1

Background ................................................................................................................................1

Previous Research ......................................................................................................................3

Overview of Study .....................................................................................................................6

This Report.................................................................................................................................7

Chapter 2: Methods ..........................................................................................................................8

Study Site Selection ...................................................................................................................8

Veteran Sample Selection ..........................................................................................................8

Data Collection ........................................................................................................................14

Data Analysis ...........................................................................................................................16

Chapter 3: Characteristics of HUD-VASH Participants ................................................................18

Demographics ..........................................................................................................................18

Military History .......................................................................................................................20

Medical Conditions and Mental or Behavioral Health Conditions ..........................................20

Descriptive Background Characteristics ..................................................................................21

Summary ..................................................................................................................................22

Chapter 4: Features of Study Sites .................................................................................................24

Population Data ........................................................................................................................24

Homelessness and Housing Context ........................................................................................24

HUD-VASH Voucher Allocation ............................................................................................26

HUD-VASH Processes ............................................................................................................27

Study Site Processes ................................................................................................................27

Study Site Outcomes ................................................................................................................33

Summary ..................................................................................................................................35

Chapter 5: Program Engagement and Housing Process ................................................................37

Time to Placement in Permanent Housing ...............................................................................37

Living Situation Prior to HUD-VASH & Source of Referral .................................................39

HUD-VASH Enrollment Process ............................................................................................42

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HUD-VASH Housing Process .................................................................................................48

Facilitators and Barriers ...........................................................................................................50

Housing Satisfaction ................................................................................................................57

Program Satisfaction ................................................................................................................60

Summary ..................................................................................................................................61

Chapter 6: VA Case Management .................................................................................................62

Frequency of VA Case Management Contacts ........................................................................62

VA Case Management Satisfaction .........................................................................................64

Facilitators and Barriers ...........................................................................................................65

Summary ..................................................................................................................................71

Chapter 7: VA Health Services Use...............................................................................................73

VA Health Services Use during Housing Process ...................................................................73

VA Health Services Use Before and After Exit .......................................................................74

Self-Reported Health in HUD-VASH .....................................................................................75

Summary ..................................................................................................................................78

Chapter 8: Exits from HUD-VASH ...............................................................................................79

Frequency & Timing of Exits ..................................................................................................79

Administrative Data .................................................................................................................80

Characteristics Predicting Exit .................................................................................................88

Profiles of Exiters ....................................................................................................................89

Veterans’ Status After Exit ......................................................................................................93

Returns to Homelessness .........................................................................................................93

Summary ..................................................................................................................................95

Chapter 9: Program Facilitators and Barriers ................................................................................97

Facilitators................................................................................................................................97

Barriers ...................................................................................................................................101

Recommendations ..................................................................................................................106

Summary ................................................................................................................................114

Chapter 10: Conclusions ..............................................................................................................116

HUD-VASH is Successful .....................................................................................................116

Veterans Leave HUD-VASH Housing for a Variety of Reasons ..........................................116

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Some Veterans Never Use their HUD-VASH Vouchers .......................................................117

Facilitators and Barriers .........................................................................................................118

Opportunities for Program Improvements .............................................................................119

Strengths and Limitations ......................................................................................................123

Next Steps ..............................................................................................................................124

Appendix A: Glossary..................................................................................................................125

Appendix B: Terms ......................................................................................................................127

Appendix C: Methods ..................................................................................................................129

Veteran Interview Materials ..................................................................................................129

Staff Interview Materials .......................................................................................................146

Quantitative Variables and Analyses .....................................................................................156

Qualitative Coding Dictionary ...............................................................................................169

Appendix D: Study Respondents .................................................................................................180

Study Respondent Subsample ......................................................................................................180

Demographics ........................................................................................................................181

Military History .....................................................................................................................183

Medical and Mental or Behavioral Health Conditions ..........................................................183

Representativeness of Study Respondent Subsample ............................................................184

Appendix E: Houston Site Description ........................................................................................186

Housing Context ....................................................................................................................186

VA Case Management ...........................................................................................................187

Houston Housing Authority ...................................................................................................195

Harris County Housing Authority ..........................................................................................199

Step-by-Step Processes ..........................................................................................................203

Appendix F: Los Angeles Site Description .................................................................................209

Housing Context ....................................................................................................................209

VA Case Management ...........................................................................................................210

Housing Authority of the City of Los Angeles ......................................................................217

Housing Authority of the County of Los Angeles .................................................................223

Step-by-Step Processes ..........................................................................................................228

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Appendix G: Palo Alto Site Description ......................................................................................231

Housing Context ....................................................................................................................231

VA Case Management ...........................................................................................................232

Housing Authority of the County of Santa Clara ...................................................................246

Housing Authority of Monterey County ................................................................................250

Step-by-Step Processes ..........................................................................................................254

Appendix H: Philadelphia Site Description .................................................................................260

Housing Context ....................................................................................................................260

VA Case Management ...........................................................................................................261

Philadelphia Housing Authority ............................................................................................269

Housing Authority of the City of Camden .............................................................................273

Step-by-Step Processes ..........................................................................................................277

Appendix I: Supporting Data .......................................................................................................280

Characteristics of HUD-VASH Participants ..........................................................................280

Features of Study Sites...........................................................................................................286

Program Engagement and Housing Process ..........................................................................289

VA Case Management ...........................................................................................................295

VA Health Services Utilization .............................................................................................296

Exits from HUD-VASH .........................................................................................................301

Appendix J: References ...............................................................................................................312

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LIST OF EXHIBITS

Summary Exhibit 1 Veteran Data Sources and Sample Sizes  ......................................................xv

Summary Exhibit 2 Reasons for Exits Reported by VA Case Managers, HUD-VASH

Participants ................................................................................................................................. xviii

Summary Exhibit 3 Profiles of Leased-Up Exiters, HUD-VASH Participants ........................... xix

Summary Exhibit 4 Profiles of Nonleased Exiters, HUD-VASH Participants .............................xx

Summary Exhibit 5 Overview of HUD-VASH Processes .......................................................... xxii

Exhibit 2.1 Study Group Pathways Into and Out of HUD-VASH ..................................................9

Exhibit 2.2 HUD-VASH Participant Count ...................................................................................10

Exhibit 2.3 Year of Program Admission, HUD-VASH Participants .............................................11

Exhibit 2.4 Days in HUD-VASH, by Quartile, HUD-VASH Participants ....................................11

Exhibit 2.5 Years in HUD-VASH Housing, HUD-VASH Participants ........................................11

Exhibit 2.6 Study Site Recruitment and Enrollment  .....................................................................12

Exhibit 2.7 Study Respondent Count .............................................................................................13

Exhibit 2.8 Qualitative Respondent Count ....................................................................................13

Exhibit 2.9 Administrative Data Sources and Variables ...............................................................14

Exhibit 3.1 Age, HUD-VASH Participants ...................................................................................18

Exhibit 3.2 Race and Ethnicity, HUD-VASH Participants ...........................................................18

Exhibit 3.3 Marital Status, HUD-VASH Participants ...................................................................19

Exhibit 3.4 VA Enrollment Priority Group, HUD-VASH Participants ........................................19

Exhibit 3.5 Period of Service and Combat Exposure, HUD-VASH Participants  .........................20

Exhibit 3.6 Medical Conditions and Mental/Behavioral Health Conditions, HUD-VASH

Participants  ....................................................................................................................................21

Exhibit 3.7 Background Characteristics, Qualitative Respondents ...............................................21

Exhibit 4.1 Adult Population, 2013  ..............................................................................................24

Exhibit 4.2 Homeless Population, 2009–2014  ..............................................................................25

Exhibit 4.3 Veteran Homeless Population, 2009–2014  ................................................................25

Exhibit 4.4 Proportion Sheltered/Unsheltered Veteran Homeless, 2014  ......................................26

Exhibit 4.5 Rental Market, 2013 ....................................................................................................26

Exhibit 4.6 HUD-VASH Voucher Allocation, 2008-2014  ...........................................................26

Exhibit 4.7 Overview of HUD-VASH Processes ..........................................................................27

Exhibit 4.8 Houston HUD-VASH Processes .................................................................................28

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Exhibit 4.9 Los Angeles HUD-VASH Processes ..........................................................................29

Exhibit 4.10 Palo Alto HUD-VASH Processes .............................................................................31

Exhibit 4.11 Philadelphia HUD-VASH Processes ........................................................................32

Exhibit 4.12 HUD-VASH Days to Placement in Permanent Housing, 2009–2014  .....................33

Exhibit 4.13 VA Performance Measures, 2014  ............................................................................34

Exhibit 4.14 Ease of HUD-VASH Enrollment Process, Study Respondents  ...............................34

Exhibit 4.15 Ease of HUD-VASH Housing Process, Study Respondents ....................................35

Exhibit 5.1 Days to Placement in Permanent Housing, HUD-VASH Participants  ......................37

Exhibit 5.2 Summary of Multiple Regression Analyses, HUD-VASH Participants .....................38

Exhibit 5.3 Living Situation at Voucher Receipt, Study Respondents .........................................39

Exhibit 5.4 Living Situation at Apartment Selection, Study Respondents ...................................40

Exhibit 5.5 Living Situations, Qualitative Respondents ................................................................40

Exhibit 5.6 Exposure to Program/Referral Source, Qualitative Respondents  ..............................40

Exhibit 5.7 Ease of HUD-VASH Enrollment Process, Study Respondents ..................................41

Exhibit 5.8 Enrollment Process Experiences, Qualitative Respondents ........................................42

Exhibit 5.9 Negative Program Orientation Experiences, Qualitative Respondents .......................43

Exhibit 5.10 Program Rules and Regulations, Qualitative Respondents .......................................46

Exhibit 5.11 Ease of HUD-VASH Housing Process, Study Respondents  ...................................47

Exhibit 5.12 Number of Apartments Visited During Housing Search, Study Respondents .........48

Exhibit 5.13 Services Received During Housing Process, Study Respondents  ...........................49

Exhibit 5.14 Services Received During Move-In, Study Respondents  ........................................50

Exhibit 5.15 HUD-VASH Housing Process Facilitators and Barriers, Qualitative

Respondents ...................................................................................................................................51

Exhibit 5.16 Housing Satisfaction While in HUD-VASH and After Exit, Study

Respondents  ..................................................................................................................................58

Exhibit 5.17 HUD-VASH Housing Satisfaction Experiences, Qualitative Respondents  .............59

Exhibit 6.1 VA Case Management Requirements .........................................................................62

Exhibit 6.2 Frequency of VA Case Management During Housing Process, HUD-VASH

Participants ....................................................................................................................................63

Exhibit 6.3 Frequency of VA Case Management Following Move-In, HUD-VASH

Participants ....................................................................................................................................63

Exhibit 6.4 Self-Reported Number of Monthly Meetings With VA Case Manager, Study

Respondents  ..................................................................................................................................64

Exhibit 6.5 VA Case Management Satisfaction, Study Respondents ...........................................64

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Exhibit 6.6 VA Case Management Facilitators and Barriers, Qualitative Respondents ...............65

Exhibit 7.1 Monthly Outpatient Visits During Housing Process, HUD-VASH Participants

........................................................................................................................................................73

Exhibit 7.2 Inpatient Stays and Emergency Care During Housing Process, HUD-VASH

Participants ....................................................................................................................................74

Exhibit 7.3 Monthly Outpatient Visits Before and After Exit, HUD-VASH Participants  ...........75

Exhibit 7.4 Inpatient Stays and Emergency Care Before and After Exit, HUD-VASH

Participants ....................................................................................................................................75

Exhibit 7.5 Self-Reported Health Status, Study Respondents ......................................................76

Exhibit 7.6 Self-Reported Medical and Mental Health Problems, Study Respondents ................76

Exhibit 7.7 Self-Reported Being “Troubled” by Drugs/Alcohol, Study Respondents .................77

Exhibit 8.1 Days Between Receipt of Voucher and Exit, HUD-VASH Participants ...................80

Exhibit 8.2 Reasons for Exits Reported by VA Case Managers, HUD-VASH Participants ........81

Exhibit 8.3 Reasons for Exits Identified by Housing Authority and VA Staff ..............................82

Exhibit 8.4 Main Reason for Exit Reported by Leased-up Exiters, Study Respondents ...............84

Exhibit 8.5 Main Reason for Exit Reported by Nonleased Exiters, Study Respondents ...............84

Exhibit 8.6 Reasons for Exit, Qualitative Respondents ................................................................85

Exhibit 8.7 Logistic Regression Modeling Exits from HUD-VASH, HUD-VASH

Participants ....................................................................................................................................89

Exhibit 8.8 Profiles of Leased-Up Exiters, HUD-VASH Participants  .........................................90

Exhibit 8.9 Profiles of Nonleased Exiters, HUD-VASH Participants ...........................................90

Exhibit 8.10 Latent Class Analysis of Leased-up Exiters, HUD-VASH Participants ...................91

Exhibit 8.11 Latent Class Analysis of Nonleased Exiters, HUD-VASH Participants ...................92

Exhibit 8.12 Avoiding Returns to VA Homeless Programs 360 Days After Exit, HUD-

VASH Participants ........................................................................................................................93

Exhibit 8.13 Cox Proportional Hazards Survival Analysis for Time to Return to

Homelessness Within 360 Days, HUD-VASH Participants ..........................................................94

Exhibit 9.1 Program Facilitators Identified by Housing Authority and VA Staff .........................98

Exhibit 9.2 Program Facilitators Identified by Qualitative Respondents ......................................99

Exhibit 9.3 Program Barriers Identified by Housing Authority and VA Staff  ...........................102

Exhibit 9.4 Program Barriers Identified by Qualitative Respondents  ........................................103

Exhibit 9.5 Recommendations Identified by Housing Authority and VA Staff  .........................107

Exhibit 9.6 Recommendations Identified by Qualitative Respondents .......................................110

Exhibit C.1 Administrative data ..................................................................................................157

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Exhibit C.2 Survey Respondent Data ..........................................................................................163

Exhibit D.1 Study Respondent Count ..........................................................................................180

Exhibit D.2 Year of Program Admission, Study Respondents ....................................................180

Exhibit D.3 Days in HUD-VASH, by Quartile, Study Respondents ...........................................181

Exhibit D.4 Years in HUD-VASH Housing, Study Respondents ...............................................181

Exhibit D.5 Age, Study Respondents ..........................................................................................181

Exhibit D.6 Race and Ethnicity, Study Respondents ...................................................................182

Exhibit D.7 Marital Status, Study Respondents...........................................................................182

Exhibit D.8 VA Enrollment Priority Group, Study Respondents ................................................183

Exhibit D.9 Period of Service and Combat Exposure, Study Respondents .................................183

Exhibit D.10 Medical and Mental or Behavioral Health Conditions, Study Respondents ..........184

Exhibit I.1 Sample Details, HUD-VASH Participants, by Study Group  ....................................280

Exhibit I.2 Demographics, HUD-VASH Participants, by Study Group  .....................................281

Exhibit I.3 Military History, HUD-VASH Participants, by Study Group  ..................................282

Exhibit I.4 Medical and Mental or Behavioral Health Conditions, HUD-VASH

Participants, by Study Group .......................................................................................................282

Exhibit I.5 Sample Details, HUD-VASH Participants, by Study Site .........................................283

Exhibit I.6 Demographics, HUD-VASH Participants, by Study Site ..........................................283

Exhibit I.7 Military History, HUD-VASH Participants, but Study Site ......................................284

Exhibit I.8 Medical and Mental or Behavioral Health Conditions, HUD-VASH

Participants, by Study Site ...........................................................................................................285

Exhibit I.9 Adult Population, 2013 ..............................................................................................286

Exhibit I.10 Homeless Population, 2009-2014 ............................................................................286

Exhibit I.11 Rental Market, 2013 ................................................................................................287

Exhibit I.12 HUD-VASH Program Characteristics .....................................................................288

Exhibit I.13 Days to Placement in Permanent Housing, HUD-VASH Participants ....................289

Exhibit I.14 Multiple Regression Analysis for Days Between Admission and HA

Referral, HUD-VASH Participants ..............................................................................................289

Exhibit I.15 Multiple Regression Analysis for Days Between HA Referral and Receipt of

Voucher, HUD-VASH Participants .............................................................................................290

Exhibit I.16 Multiple Regression Analysis for Days Between Receipt of Voucher and

Move-in, HUD-VASH Participants .............................................................................................290

Exhibit I.17 Multiple Regression Analysis for Days Between Admission and Receipt of

Voucher, HUD-VASH Participants .............................................................................................291

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Exhibit I.18 Multiple Regression Analysis for Days Between Admission and Move-in,

HUD-VASH Participants .............................................................................................................291

Exhibit I.19 Living Situation During HUD-VASH Housing Process, Study Respondents .........292

Exhibit I.20 HUD-VASH Enrollment and Housing Process, Study Respondents ......................292

Exhibit I.21 Housing Selection, Study Respondents ...................................................................293

Exhibit I.22 Services Received During Housing Process and Move-in, Study Respondents ......293

Exhibit I.23 Housing Satisfaction While in HUD-VASH and After Exit, Study

Respondents .................................................................................................................................294

Exhibit I.24 Program Satisfaction, Study Respondents ...............................................................294

Exhibit I.25 Frequency of VA Case Management .......................................................................295

Exhibit I.26 VA Case Management Satisfaction, Study Respondents ........................................295

Exhibit I.27 VA Services Utilization, HUD-VASH Participants ................................................296

Exhibit I.28 Self-reported Health in HUD-VASH, Study Respondents ......................................300

Exhibit I.29 Logistic Regression Modeling Exits from HUD-VASH (Leased-up Exit vs.

Stay), HUD-VASH Participants ..................................................................................................301

Exhibit I.30 Logistic Regression Modelings Exits from HUD-VASH (Nonleased vs.

Leased-up Exit), HUD-VASH .....................................................................................................301

Exhibit I.31 Reasons for Exits Reported by VA Case Managers, HUD-VASH

Participants ...................................................................................................................................302

Exhibit I.32 Reasons for Exits Identified by Housing Authority and VA Staff ..........................302

Exhibit I.33 Reasons for Exits, Study Respondents ....................................................................303

Exhibit I.34 Latent Class Analysis of Leased-up Exiters, HUD-VASH Participants .................308

Exhibit I.35 Latent Class Analysis of Nonleased Exiters, HUD-VASH Participants .................309

Exhibit I.36 Veterans’ Status Post-exit ........................................................................................310

Exhibit I.37 Cox Proportional Hazards Survival Analysis for Time to Return to

Homelessness Within 360 Days, HUD-VASH Participants ........................................................311

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INTRODUCTION AND RESEARCH PURPOSE

Opening Doors: Federal Strategic Plan to Prevent and End Homelessness was released in 2010.

This plan included ending Veteran homelessness as one of its top priorities. In fact, homelessness

among Veterans declined by nearly 47 percent, from 74,087 in 2010 to 39,471 in 2016. The U.S

Department of Housing and Urban Development (HUD)–U.S. Department of Veterans Affairs

(VA) Supportive Housing (HUD-VASH) program played a key role in this achievement. HUD-

VASH provides permanent supportive housing (PSH) to homeless Veterans. To qualify for

HUD-VASH, Veterans must be eligible for VA health care and meet the homeless definition

established by the McKinney-Vento Homeless Assistance Act. 1 The PSH component links subsidized housing with supportive services such as mental and behavioral health care.

HUD and the VA jointly implement the HUD-VASH program. VA clinicians provide case

management to Veterans and refer Veterans to the partner public housing authority for housing.

The housing authority issues Housing Choice Vouchers (HCVs) to HUD-VASH program

participants to lease rental units within the private market. In addition, a small number of HUD-

VASH participants live in project-based PSH. The HCV subsidizes the portion of rent that

exceeds 30 percent of a Veteran’s income.

Congress expanded the HUD-VASH program significantly in 2008, with $635,000,000 in new

vouchers funded between fiscal years 2008 and 2016. With this support, HUD and VA

transformed HUD-VASH from a small program serving fewer than 2,000 Veterans into a major

program with the capacity to serve more than 87,000 Veterans in 2016. As part of the effort to

improve program effectiveness, HUD and VA initiated the HUD-VASH exit study in 2012 to

develop a better understanding of how and why Veterans exit the program.

RESEARCH METHODOLOGY

This study addressed a series of research questions at the participant level:

•  Is HUD-VASH successful and what are the facilitators of success?

•  What are the reasons that Veterans exit the HUD-VASH program, and do Veterans who

exit before leasing up have different reasons than Veterans who exit after leasing up?

•  What Veteran characteristics or program antecedents (for example, housing stability,

frequency of supportive services, mental health status, and substance use) predict whether

Veterans exit the program, the type of exit, and length of stay in the program?

•  What are Veterans’ patterns of VA medical, mental or behavioral health, and homeless

services use before, during, and after participation in the HUD-VASH program?

•  What are common barriers that prevent Veterans from using HUD-VASH vouchers to

obtain housing or that make remaining in permanent housing difficult?

1 Pub. L. 100-77, July 22, 1987.

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The study also addressed program-level questions regarding implementation and collaboration:

•  What community factors affect the success of local housing authorities and VA medical

centers in administering the program?

•  How do HUD and VA work together to implement HUD-VASH at the community level?

•  To answer the research questions, the VA National Center on Homelessness Among

Veterans studied HUD-VASH programs in four U.S. cities: Houston, Texas; Los

Angeles, California; Palo Alto, California; and Philadelphia, Pennsylvania. As shown in

summary exhibit 1, the research team collected and analyzed administrative data on 7,383

Veterans, surveyed 508 Veterans, and conducted indepth, qualitative interviews with 110

Veterans. Data were complemented by site visits and interviews with program staff.

Summary Exhibit 1. Veteran Data Sources and Sample Sizes

Stayers

Leased-Up Exiters

Nonleased Exiters

Total N

2,788

3,088

1,507

VA administrative data

7,383

(38%)

(42%)

(20%)

370

80

58

Survey data

508

(73%)

(16%)

(11%)

56

28

26

Qualitative interviews

110

(51%)

(25%)

(24%)

VA = U.S. Department of Veterans Affairs.

Source: VA Homeless Operations Management and Evaluation System

The administrative data gathered from VA medical records, as well as the VA Homeless

Operations Management and Evaluation System (HOMES), included information such as

demographics, diagnoses and frequency of VA healthcare visits, case management, HUD-VASH

program enrollment start and exit dates, and reasons for exiting HUD-VASH case management

recorded by case managers. The research team used administrative data to describe Veterans’

characteristics, their paths through the program, and use of VA services. The researchers

analyzed the data to identify types of exiters, factors predicting exit, and profiles of exiters.

Administrative data also enabled researchers to identify potential respondents for the study’s

survey and open-ended qualitative interviews.

A survey of 508 Veterans, conducted either in person or by telephone, and indepth interviews

with 110 Veterans contextualized the findings from VA administrative data. Researchers

examined the following themes in the survey questions:

•  Housing and homelessness history.

•  Experiences with the HUD-VASH housing process.

•  Housing satisfaction.

•  Relationships with case managers.

•  Medical and mental health conditions.

•  Substance use status.

•  Reasons for program exit.

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Researchers also gathered program-level information through qualitative interviews with local

housing authority staff and VA case managers.

To determine why Veterans exit the HUD-VASH program, the study examined three categories

of program participants:

1.  Stayers—Veterans who obtained a lease with a HUD-VASH voucher and remained in the

housing unit with the voucher for 600 days or longer and had not exited the program at

the time of selection into the study.

2.  Leased-up exiters—Veterans who exited HUD-VASH after leasing a housing unit.

3.  Nonleased exiters—Veterans who exited HUD-VASH after obtaining a voucher but

before leasing a housing unit.

Exit from the HUD-VASH program was defined as exit from VA case management as recorded

by case managers in the VA administrative data.

MAJOR FINDINGS

Successes of HUD-VASH

A major success of the HUD-VASH program was that among both stayers and leased-up exiters,

87 percent remained in the program for at least 1 year and 60 percent for at least 2 years. Of

those who exited, nearly 93 percent of leased-up exiters and 90 percent of nonleased exiters did

not return to VA homeless programs during the observation period.

Veteran Respondents. |  Most of Veteran survey respondents indicated that HUD-VASH met

their needs (96 percent of stayers, 90 percent of leased-up exiters, and 88 percent of nonleased

exiters). Furthermore, during the qualitative interviews, Veterans indicated that maintaining a

relationship with VA case managers was important and that VA peer support specialists provided

valuable support from someone who shared their experience. As indicated by Veterans, the

following facilitated successful outcomes in the HUD-VASH program:

•  Cooperative landlords who waived screening processes or application fees.

•  Move-in assistance.

•  Quick move-in processes.

•  Supportive VA case managers.

•  Ability to meet requirements imposed by the HUD-VASH program and property owners.

•  Lists of available housing.

Program Staff.  | At the program level, relationships with community partners and the ability to connect Veterans to community resources contributed to successful outcomes. The following

common themes and activities, as articulated by program staff, contribute to the program’s success:

•  Collaboration with community partners to identify Veterans in need of assistance.

•  Connecting Veterans to community resources.

•  HUD-VASH boot camps as workshops to learn how to better respond to Veterans’ needs.

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•  Program flexibility.

•  Reliance on VA specialists for employment and peer support.

•  Building trust between Veterans and program staff.

•  Promoting Veteran independence so that Veterans can rebuild rental and credit history.

Reasons for Exiting HUD-VASH

Veteran Respondents (Leased-Up Exiters and Nonleased Exiters).  | Among the leased-up

exiters interviewed (N=74), the most common reason for exiting the program was an increase in

income—a positive outcome for 27 percent of leased-up exiters. Another 11 percent indicated

they left to move in with family or friends. The remaining 62 percent of leased-up exiters

indicated reasons for exit such as worsening medical or mental health, difficulty paying rent,

eviction, and dissatisfaction with the neighborhood.

Nonleased exiters (N=53) often indicated that difficulty in finding housing was the main reason

for exiting the program prior to moving into an apartment. Of nonleased exiters, 23 percent

indicated that having the voucher revoked was the main reason for their exit, and 21 percent

reported difficulty with housing, citing examples such as dissatisfaction with available

apartments, inability to find an apartment to rent with the voucher, and insufficient funds to pay

for the security deposit or furniture. Most of the remaining nonleased exiters indicated reasons

for exit such as getting an offer to move in with family or friends, worsening medical or mental

health, difficulty with HUD-VASH case management, and legal trouble; 13 percent indicated

exiting for the positive reasons of increased income and improved health.

Program Staff.  | Staff from local housing authorities and VA case management teams described their perspectives as to why leased-up and nonleased exiters left the program. The main reasons

identified by program staff are as follows:

•  Incarceration.

•  Increase in income, which can make Veterans ineligible for the program.

•  Lease or program violations.

•  Loss of contact.

•  Lack of motivation to complete the process required to access housing.

•  Withdrawal because Veterans may no longer need case management.

Case Managers.  | When a Veteran exits HUD-VASH, VA case managers record in HOMES 1 of

the 12 reasons listed in summary exhibit 2 to indicate why the Veteran ended his or her involvement

in HUD-VASH case management. According to VA case managers, the most common reason

for exit among leased-up exiters is that the Veteran accomplished his or her goals or obtained

access to services and no longer needed the program. Eviction or selecting other housing were

also identified frequently, although fewer than 1 in 10 leased-up exiters were considered to have

left the program for either of those reasons. Nonleased exiters were more evenly split across exit

categories. VA case managers indicated that a common reason for nonleased exiters to leave the

program was that they were no longer interested in participating, followed by the case manager

being unable to locate the Veteran or the Veteran selecting other housing.

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Summary Exhibit 2. Reasons for Exits Reported by VA Case Managers, Percent of HUD-

VASH Participants

Accomplished goals/no longer needs program

1.9

42.5

Cannot be located

3.0

16.6

Deceased

1.2

8.7

Evicted by HA or landlord or other housing issues

0.1

9.1

Found/chose other housing

8.1

14.2

3.7

Incarcerated

3.6

No longer financially eligible

4 6.9.0

No longer interested in participating in HUD-VASH

5.7

21.9

Noncompliance with HUD-VASH case management

2.7

10.1

1.6

Too ill to participate in HUD-VASH

1.7

Transferred to another HUD-VASH program site

1.5

2.1

Other

8.4

20.0

Leased-Up Exiters

Non-Leased Exiters

HUD-VASH = U.S. Department of Housing and Urban Development (HUD)-U.S. Department of Veterans Affairs (VA) Supportive Housing.

Note: N = 4,925, including 3,070 leased-up exiters and 1,855 nonleased exiters.

Source: VA Homeless Operations Management and Evaluation System

Veterans’ Characteristics

About 90 percent of Veterans who participated in HUD-VASH programs at each of the study

sites were men, regardless of the study group. Other characteristics varied among the study

groups. Most stayers and leased-up exiters identified as Black and non-Hispanic, whereas most

nonleased exiters identified as White and non-Hispanic.

Leased-up exiters were more likely than others to have a medical or mental or behavioral health

condition, and nearly one-half of them received HUD-VASH vouchers while living in a

supportive environment. Before program entry, leased-up exiters used emergency and acute care

more frequently than stayers, but use declined after program entry. HUD-VASH participants

with a service-connected disability2 were 37 percent more likely to leave HUD-VASH after obtaining housing, perhaps indicating that they had sufficient income to live independently.

Compared with Veterans who accessed HUD-VASH housing, nonleased exiters tended to have

deployed during the period after September 11, 2001, serving in Operations Enduring Freedom,

Iraqi Freedom, or New Dawn. Nearly one-third of nonleased exiters received vouchers at a time

when they were literally homeless. They received less frequent VA case management between

referral to the housing authority and voucher receipt and reported finding the housing process

more difficult. Nonleased exiters were the most likely to report poor health during their time in

the program and used emergency and acute care more frequently both before and after entry than

did Veterans who moved into housing. Among exiters, Veterans with a diagnosis of post-

traumatic stress disorder were more likely to exit before moving into housing.

2 A disability incurred during military service is termed a  service-connected disability and may entitle a Veteran to disability compensation, a monetary benefit paid to Veterans who the VA determines to be disabled by an injury or illness incurred or aggravated during active military service.

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Researchers used demographic, health, and exit data about Veterans to conduct a series of latent

class analyses that grouped study sample members into subgroups. The latent class analyses

included variables that describe Veterans’ demographic and clinical characteristics and case

managers’ characterizations of reasons for exit. Results of these analyses describe the

heterogeneity among exiters. Summary exhibits 3 and 4 describe the subgroups of leased and

nonleased exiters, arranged in order from most to least successful exits. Subgroups with most of

the Veterans exiting the program because they had accomplished their goals or become

financially ineligible are considered more successful than subgroups for whom negative exit

reasons such as eviction or incarceration are more common.

Summary exhibit 3 describes five classes of leased-up exiters. This analysis suggests that about

one-half of leased-up exiters left the program for positive reasons, based on case managers’

characterization of reasons for exit. The first three classes can be considered successful, because

most Veterans left HUD-VASH for reasons such as accomplishing goals or making too much

money to qualify for the program. The smallest and least successful class had high needs with

little income and used acute or intensive services more frequently. This class tended to exit the

program for reasons such as noncompliance or incarceration.

Summary Exhibit 3. Profiles of Leased-Up Exiters, HUD-VASH Participants

Demographics

Clinical Characteristics

Reasons for Exit

Accomplished goals

Class 1

Younger female, SC

Low rates of chronic medical and

(20.9%)

disability

behavioral health conditions.

Found other housing

Financially ineligible

Class 2

Older male, no SC

Low rates of chronic medical and

(16.4%)

disability

behavioral health conditions.

Accomplished goals

Class 3

Middle-aged male and  High rates of behavioral health

Accomplished goals

(16.6%)

female, SC disability

conditions or substance abuse problems;

chronic medical conditions.

Financially ineligible

Accomplished goals

Class 4

Loss of contact with VA

Older male, no SC

Low rates of chronic medical and

Incarceration

(32.2%)

disability

behavioral health conditions.

Noncompliance

Eviction

Loss of contact with VA

Class 5

Older male, no SC

High rates of chronic medical and

behavioral health conditions; inpatient  Incarceration

(13.9%)

disability

care.

Noncompliance

Eviction

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing. SC = Service-connected.

Note: N = 2,959.

As shown in summary exhibit 4, researchers identified three profiles of nonleased exiters. About

one-fourth of nonleased exiters were younger, female Veterans who left the program for positive

reasons. Nonleased exiters in class 3 had high rates of medical, mental, and substance use

conditions and typically left the program due to illness or incarceration.

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Summary Exhibit 4. Profiles of Nonleased Exiters, HUD-VASH Participants

Demographics

Clinical Characteristics

Reasons for Exit

Class 1

Found housing elsewhere

Younger female, SC

Few medical, mental and behavioral

(25.2%)

disability

health, or substance abuse problems.

Were no longer interested in

HUD-VASH

Class 2

Older male, no SC

Some medical problems, but few mental  Typically did not accomplish goals

(44.9%)

disability

and behavioral health or substance

abuse problems.

Younger to middle-

High rates of medical, mental and

Loss of contact with VA

Class 3

aged male, no SC

behavioral health, or substance abuse

(29.9%)

disability or more than  problems. Use of inpatient care prior to  Illness

50% disability

exit.

Incarceration

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing. SC = Service-connected.

Note: N = 1,307.

Veterans’ Patterns of VA Services Use

The research team examined Veterans’ patterns of use of VA medical and mental health services

before entry into the program and, if applicable, after exit from the program. Across all study

groups, administrative records demonstrated that the frequency of medical, mental or behavioral

health, and substance use visits, and of inpatient stays of any kind, declined after admission to

the HUD-VASH program. Nonleased exiters received more healthcare services than leased-up

exiters in the 90 days before exit and in the 180 days after exit, although Veterans’ use of

inpatient and emergency care either remained flat or declined for both groups of exiters after

exit.

Common Barriers To Obtaining Housing

Veteran Respondents.  | Qualitative interview respondents indicated critical barriers to accessing HUD-VASH housing. Some Veterans indicated that case managers were impersonal,

overworked, and held irregular meetings that were insufficient to forge a supportive relationship.

Several respondents indicated that they experienced discrimination from property owners, who in

some instances charged higher amounts for security deposits or failed to return phone calls.

Nonleased exiters tended to find the HUD-VASH housing process to be more difficult than did

stayers and leased-up exiters. Common challenges articulated by Veterans during qualitative

interviews included:

•  Housing located in undesirable, high-crime neighborhoods.

•  Limited accessible housing.

•  Limited funds for move-in.

•  Conflicts with property owners, who were slow with paperwork or had issues

coordinating rent and using HUD-VASH vouchers.

•  Unsuitable housing (for example, plumbing and electrical issues and bug infestations).

•  Unwillingness of landlords to rent to Veterans with criminal backgrounds.

•  Limited transportation resources for Veterans to visit housing units of interest.

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•  Lengthy apartment inspection process.

•  Medical and mental health conditions that hindered apartment searches.

Program Staff.  | Program staff responses about barriers to obtaining housing overlapped with Veterans’ responses in the areas of affording move-in costs; Veteran background characteristics

such as poor credit, past evictions, or criminal background; and medical and mental health

conditions. Program staff also added that Veteran readiness in transitioning from homelessness

to new housing units was a barrier to obtaining housing.

Effect of Community Factors on the Success of HUD-VASH

Qualitative interviews with local housing authority and case management staff revealed a variety

of resources unique to the study sites that contributed to the local success of the program. For

example, VA case management in Los Angeles includes a nurse who assists Veterans with

ongoing medical issues, sometimes directly within Veterans’ homes. Life skills groups in Palo

Alto teach Veterans the tools to get and stay housed. The Philadelphia VA team indicated that

housing, peer support, and substance use disorder specialists, as well as resources to assist

Veterans interested in furthering education or finding employment and transitioning out of HUD-

VASH, were vital to their team. The Houston Housing Authority has a waiver enabling the

housing authority to pay up to 110 percent of the Fair Market Rent for HUD-VASH participants

in high-opportunity areas, enabling Veterans to move to areas with higher performing schools

and more community resources.

HUD and VA Collaboration

The process for moving a Veteran into HUD-VASH housing is depicted in summary exhibit 5.

Although some components of the HUD-VASH program are standardized across the country,

flexibility exists in how the local housing authorities and VA case management teams

collaborate to fulfill requirements. In communities with multiple housing authorities the steps

may differ in number or execution across agencies. Program staff identified elements of HUD

and VA collaboration that facilitate the program, including co-location of housing authority and

VA case management, HUD-VASH boot camps, and streamlining the application process. For

example, VA case managers are collocated with the Harris County Housing Authority in

Houston; the teams share a vision and collaborate to determine how best to serve Veterans. The

Los Angeles city and county housing authorities created a single, uniform HUD-VASH

application that makes paperwork easier for VA staff. VA staff complete the voucher application

for the Housing Authority of the County of Monterey, which shortens turnaround time.

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Executive Summary

Summary Exhibit 5. Overview of HUD-VASH Processes

HUD-VASH = U.S. Department of Housing and Urban Development (HUD)-U.S. Department of Veterans Affairs (VA) Supportive Housing. SSVF = Supportive Services for Veteran Families.

LIMITATIONS OF THE STUDY

Despite the amount of data collected in this study, several limitations exist:

•  Due to data limitations, the research team was unable to assess other characteristics of

Veterans’ history that would increase understanding of housing stability such as the

chronicity of homelessness, incarceration, or family composition.

•  The difficulty of recalling an event in the past, as well as feeling the need to provide a

favorable answer (social desirability bias), may have influenced Veterans’ responses.

•  The results of the study do not indicate whether Veterans who exited case management

continued to receive HUD housing assistance. 3

Using multiple sites for primary data collection also has some limitations:

•  Although the research team conducted a number of quality assurance activities, the study

methodology may have been carried out inconsistently across sites.

•  Each site has different geographies and housing markets, making some of the findings

more context specific rather than generalizable.

3 In-house analysis conducted in December 2016 by HUD indicates that, among Veterans who exited HUD-VASH

case management, about two-thirds probably also had exited housing assistance much earlier or around the same time.

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RECOMMENDATIONS FOR PROGRAM IMPROVEMENTS

The HUD-VASH program demonstrated high rates of retention and low rates of returns to VA

homeless programs. The program fulfills its purpose in serving the needs of Veterans with

medical conditions, mental health conditions, or a history of substance use. Based on innovations

that the research team observed in practice, the study suggests that to maintain Veterans’ long-

term housing stability, HUD and VA should:

•  Maintain continuity of care through a team approach.

•  Increase assistance during the housing search.

•  Provide assistance during the transition to independent housing.

•  Explore additional opportunities for project-basing HUD-VASH vouchers to streamline

the provision of more intensive support and services.

•  Evaluate Veterans’ needs and housing satisfaction more regularly using more accurate

metrics.

To mitigate the difficulty in affording move-in costs, HUD-VASH should coordinate with

Supportive Services for Veteran Families (SSVF) programs and other community organizations

to assist with the financial aspect of the housing process. SSVF could also be useful in

transitioning Veterans from receiving a HUD-VASH subsidy to paying their full market-rate rent

through the use of small subsidies. Additionally, other programs need to be identified to assist

Veterans with utility bills.

As the HUD-VASH study was being completed, many of these recommendations were being

employed. For instance, VA implemented a team-based approach to case management, and in

each of the past 3 years, HUD successfully held competitions for HUD-VASH project-based

vouchers.

The study recommends that future efforts to improve the program include a focus on assessing

Veterans more regularly throughout program admission and the housing process, while in

housing, and on exiting the HUD-VASH program. The goal would be to ensure that Veterans

receive the level of assistance they need to maintain housing stability. Interventions with varying

levels of intensity should be considered. Veterans who do not need the full complement of HUD-

VASH services may benefit from lower intensity intervention, including shallow subsidies for

Veterans transitioning out of the program. Veterans transitioning from a literally homeless

situation may require more intensive services for a longer period of time. More indepth

assessment of reasons for exiting HUD-VASH would provide a deeper understanding of what

constitutes success and Veterans’ views on what is needed to attain success.

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CHAPTER 1:

INTRODUCTION AND OVERVIEW OF STUDY

Preventing and ending homelessness among Veterans is a national priority supported by the

White House and the U.S. Interagency Council on Homelessness (USICH, 2010). Both the U.S.

Departments of Veterans Affairs (VA) and Housing and Urban Development (HUD) are

committed to using evidence-based approaches to address Veteran homelessness. An example of

the collaboration between these two agencies is the HUD-VA Supportive Housing (HUD-

VASH) program, which has been credited with reducing unsheltered homelessness among

Veterans (USICH, 2014).

HUD-VASH is a vital tool that ends homelessness among Veterans by providing permanent

supportive housing (PSH)—housing subsidies provided by HUD combined with supportive

services provided by VA—specifically for Veterans and with a focus on those experiencing

chronic homelessness. To understand how HUD-VASH contributes to the decline in Veteran

homelessness and to inform practice and policy responses, additional information is needed, such

as how effective the program is at assisting formerly homeless Veterans to access and maintain

housing, whether Veterans who leave the program sustain their housing stability, and reasons

why Veterans leave the program.

Previous research on PSH has examined access to housing, the process of attaining a housing

unit, and housing retention. Research related to residents’ exits from PSH has primarily focused

on types of program exits and predicting circumstances of exit and length of stay. Building on

this work, this study offers a comprehensive examination of HUD-VASH program processes,

services, and program exits—defined as exits from HUD-VASH case management—and is the

first study to examine exits that occur both before and after accessing HUD-VASH subsidized

housing. Extensive quantitative analysis of VA administrative data is contextualized by survey

and interview data from Veterans, housing authority staff, and VA case managers.

BACKGROUND

Approximately 48,000 Veterans were homeless on one night in January 2015; about 64 percent

were staying at an emergency shelter or transitional housing, and the remainders were living in

an unsheltered situation (HUD, 2015a). During federal fiscal year (FFY) 2014, approximately

132,000 Veterans accessed emergency homeless shelters or transitional housing (HUD, 2015b).

Although the size of the homeless Veteran population has gradually declined—35 percent

between 2010 and 2015—several studies have found that Veterans’ risk of homelessness is at

least double that of a comparable population of non-Veterans (Fargo et al., 2012; HUD, 2015a;

HUD and VA, 2011). To address the disproportionately high rates of homelessness among

Veterans, VA developed a strategy that includes ending chronic homelessness among Veterans

through HUD-VASH.

The following sections describe the concept of PSH, how it has been operationalized at VA

medical centers (VAMCs), and what is known about exits from PSH, including HUD-VASH.

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Permanent Supportive Housing

PSH, which combines subsidized housing with wraparound supportive services, is the preferred

intervention for addressing chronic homelessness (HUD, 2013). This intervention often is

indicated for individuals who are experiencing a chronic condition, particularly serious mental

illness and substance use disorders (SUDs), that may be associated with an increased risk of

housing instability (Caton, Wilkins, and Anderson, 2007) and asserts that they should live in

“normal” housing regardless of their level of functioning (Blanch, Carling, and Ridgway, 1988).

The general tenets of PSH dictate that housing is permanent and based on the individual’s

preference and that adequate supportive services are available to assist those individuals in

maintaining housing stability (Carling, 1990).

PSH is an evidence-based practice that improves outcomes such as housing stability among

persons with serious mental illness and decreases unnecessary use of acute care and institutional

services (Culhane, Metraux, and Hadley, 2002; Rog, 2004). Retention rates in PSH are as high as

85 percent during the first year, and studies have found that up to one-half of PSH residents

remain in program housing for 3 to 5 years (Caton, Wilkins, and Anderson, 2007).

HUD-VASH

HUD-VASH, jointly funded and implemented by HUD and VA, comprises a permanent housing

subsidy provided through HUD’s Housing Choice Voucher (HCV) program and case

management provided by VA clinicians. To be eligible for HUD-VASH, Veterans must be

eligible for VA health care and be considered homeless, as defined by the McKinney Homeless

Assistance Act and amended by the Homeless Emergency Assistance and Rapid Transition to

Housing (HEARTH) Act of 2009. 4 Specifically, HUD-VASH is intended to serve chronically homeless Veterans (i.e., Veterans who have experienced long-term or repeated homelessness),

with the goal of helping them access and maintain stable housing.

Through its national HCV program, HUD provides rental assistance for units in the private rental

market through housing vouchers that are administered by local public housing authorities.

Participants pay a portion of their monthly income toward the rent, with the remaining portion

subsidized by the voucher. VA serves Veterans participating in HUD-VASH by providing case

management and other supportive services to assist Veterans with the housing search and move-

in processes and connecting them with medical, mental health, and substance use services either

at local VA facilities or from community-based providers. The goal of case management is to

connect Veterans with services they need to access and maintain housing stability. Chapter 4

includes more detailed information on HUD-VASH processes; chapters 5 and 6 provide further

information on housing and case management.

4 To be eligible for VA health care, Veterans must have served in active duty and had an other-than-dishonorable discharge. Although eligibility is not restricted to chronically homeless Veterans, HUD-VASH is prioritized for those with the greatest needs. HEARTH defines an individual or family as chronically homeless if they reside in a place not meant for human habitation, a safe haven, or an emergency shelter; have been homeless for at least 1 year or on 4 separate occasions in the last 3 years; and have an adult head of household with a substance abuse disorder, mental illness, developmental disability, post-traumatic stress disorder (PTSD), cognitive impairments resulting from brain injury, or chronic physical illness or disability (HUD, 2016b).

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Chapter 1: Introduction and Overview of Study

HUD and VA originally established HUD-VASH in 1992 with approximately 1,700 vouchers.

The size of the program increased significantly in 2008 with an allotment of 10,000 vouchers; as

of FFY 2015, nearly 79,000 HUD-VASH vouchers are in use across the country (HUD, 2016a).

Local public housing authorities receive HUD-VASH vouchers based on a set of community

characteristics: the number of Veterans who are homeless on one day in January based on local

point-in-time (PIT) counts; the frequency of contacts that the VAMC has with Veterans

experiencing homelessness; and how well the local housing authorities and VAMCs are

performing in terms of housing Veterans. Based on those data, the agencies select communities

with the greatest need; HUD identifies one or more corresponding housing authorities to

administer the vouchers, and VA identifies VAMCs to provide supportive services, with mutual

agreements between the agencies in place regarding the number of vouchers to be used in each

community (HUD, 2016a). Although the HUD-VASH program includes national requirements

regarding eligibility and minimum services provision for Veterans, each local program operates

differently.

During FFY 2013, VA shifted its policy regarding the implementation and administration of

HUD-VASH to be consistent with a Housing First approach. A traditional model of PSH places

requirements—such as accepting treatment for mental health or substance use issues or agreeing

to a representative payee to manage their income—on individuals before they can access

permanent housing. Housing First is distinguished from this model because it provides

individuals access to housing with no further requirements, based on the rationale that once an

individual has attained housing stability, she or he is more likely to engage in services

(Tsemberis, 2010). This study was conducted during HUD-VASH’s transition to Housing First;

therefore, each program studied was in a different stage of adopting Housing First principles.

Although the Housing First approach does not require individuals to participate in services,

HUD-VASH regulations require that the program serve Veterans who need support to obtain and

maintain housing; Veterans typically have medical, mental health, or substance use disorders and

an extensive history of homelessness. Regulations also require that participating Veterans

communicate with VA case managers or VA case management teams at least monthly.

PREVIOUS RESEARCH

PSH generally—and HUD-VASH specifically—is intended to be permanent housing. Given that

aim, previous research has attempted to address why individuals and households participating in

PSH exit those programs. Those studies have looked at households’ access to housing, the

process of attaining a housing unit, housing retention, and types of program exit.

Housing Process

Two studies considered the relationship between the housing process—from receiving a referral

to a PSH program to attaining permanent housing—and households’ housing-related outcomes.

The first study used data from the initial phase of the HUD-VASH program (1991–1999) and

found that Veterans’ entry into the program (that is, receiving a referral to be considered for the

program) was more likely if the Veteran had a history of drug or alcohol use and had participated

in a VA treatment program; however, those Veterans who reported recent substance use were

less likely to receive a referral. This study also sought to identify conditions and characteristics

associated with attaining a voucher and accessing permanent housing. Only one demographic

characteristic, female gender, was consistently associated with successful progress through the

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Chapter 1: Introduction and Overview of Study

program. Veterans affiliated with more mature programs had greater success obtaining vouchers,

and Veterans accompanied by VA case managers during the housing search were more likely to

attain housing (Kasprow et al., 2000).

A second study randomly assigned individuals with serious mental illness who were

experiencing homelessness to one of four groups: HCV plus traditional case management, HCV

plus more intensive case management services, traditional case management only, or intensive

case management only. This study assessed whether access to a housing voucher or supportive

services, demographics, and clinical characteristics were associated with individuals’ ability to

attain housing. Those individuals who were assigned an HCV—regardless of level of case

management intensity—were approximately 20 percent more likely to achieve some type of

consistent housing and almost five times more likely to obtain independent permanent housing

than those who did not receive a voucher (Hurlburt, Hough, and Wood, 1996).

Housing Retention

Approximately 85 percent of individuals living in PSH retain their housing for at least 1 year

(Caton, Wilkins, and Anderson, 2007). An early study of HUD-VASH found that the average

length of stay in the program was 15 months, that approximately one-half of Veterans remained

in HUD-VASH housing for at least 1 year, and approximately two-thirds of Veterans who left

the program moved into independent housing (Mares, Kasprow, and Rosenheck). A later study

found that 93 percent of a sample of Veterans remained in stable HUD-VASH housing 12

months following move-in (Montgomery et al., 2013). Several studies have identified

characteristics of households and programs that contribute to long-term housing retention.

Kasprow and colleagues (2000) found that Veterans were more likely to remain housed for 1

year if VA case managers helped them obtain Supplemental Security Income (SSI) benefits.

Another study using HUD-VASH data found that Veterans with more medical problems

experienced longer lengths of stay in housing (Mares, Kasprow, and Rosenheck, 2004). Female

gender and shorter histories of homelessness have been associated with longer-term housing

stability (Hurlburt, Hough, and Wood, 1996; Pearson, Montgomery, and Locke, 2009), whereas

a report of drug and alcohol problems increased an individual’s probability of unstable housing

by a factor of more than two (Goldfinger et al., 1999; Hurlburt, Hough, and Wood, 1996).

Researchers also have observed that individuals identifying as Black were more likely to exit

PSH within 12 months of entry (Pearson, Montgomery, and Locke, 2009; Wong et al., 2008) and

that a positive relationship exists between education and housing retention (Pearson,

Montgomery, and Locke, 2009).

At the nexus of person- and program-level characteristics, one study determined that a higher

proportion of individuals who stay in PSH use outpatient behavioral health services compared

with those who leave PSH. Alternatively, individuals who leave PSH use a higher proportion of

inpatient services during their time in PSH compared with those who stay in PSH (Wong et al.,

2008).

Program-level characteristics associated with long-term housing retention have been found to

account for more of the variation in the housing outcomes than do client characteristics

(Harkness, Newman, and Salkever, 2004; Mares, Kasprow, and Rosenheck, 2004). A specific

program characteristic that enhances housing retention is access to rental subsidies (Mares,

Kasprow, and Rosenheck, 2004), including HCVs (Hurlburt, Hough, and Wood, 1996).

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Chapter 1: Introduction and Overview of Study

Individuals in cluster-site housing stay for shorter periods of time than individuals in scattered-

site housing (Wong et al., 2008), and poor building quality is also associated with shorter stays

(Harkness, Newman, and Salkever, 2004).

Types of Exit

Several studies related to PSH and housing stability have explored exit dispositions among

individuals who leave the programs. Wong and colleagues (2006) studied differences—

demographic and diagnostic factors, history of homeless shelter use, characteristics of service

use, and program features—between individuals who stayed in PSH and three categories of exits:

(1) positive versus nonpositive exits; (2) voluntary versus involuntary exits, with voluntary exits

being further categorized into opportunity seekers and situational exiters; and (3) exits to

independent housing versus nonindependent housing. They identified one-third of their study

sample as positive exiters who exited the program to live in an independent setting without

services and two-thirds as nonpositive exiters who returned to homelessness or entered a

residential or institutional setting. Compared with positive exiters, nonpositive exiters reported a

higher level of services use, particularly acute services (for example, emergency department,

inpatient psychiatric treatment), during and following their tenure in PSH.

Individuals who made the choice to leave PSH were considered voluntary exiters and constituted

approximately two-thirds of the sample, whereas individuals who were asked to leave PSH as a

result of rule violations or inability to sustain independent housing constituted approximately

one-third of the sample. Among voluntary exiters, the group of opportunity seekers often

“graduated” from the program after exhibiting the ability to live independently. On the other

hand, situational exiters elected to leave the program to address “personal, housing, and support

situations” (p. xiv) or because of changes in functioning or housing preference. Common reasons

for exiting PSH among involuntary leavers were that they were asked to leave by the program,

were actively abusing substances, became ill, or were hospitalized; in contrast, voluntary exiters

moved to more desirable housing (Wong et al., 2006). The third category of leavers that Wong

and colleagues (2006) identified was based on the exiters’ post-PSH living situation;

approximately one-third were independent-housing exiters, one-third were nonindependent

housing exiters, and the remaining one-third exited to unknown locations. As expected,

involuntary exiters were more likely to leave for nonindependent housing, whereas voluntary

exiters were more likely to leave for independent housing.

Another study included death, the need for more intensive care, incarceration, and eviction

related to violence as involuntary reasons for exit. Voluntary reasons included refusing to obtain

identification needed to secure benefits and being a wanderer (Pearson, Montgomery, and Locke,

2009). A study using HUD-VASH data similarly characterized Veterans’ exit type as either

mutually agreed on (both Veteran and VA case manager decided that VA case management was

no longer necessary) or premature (Veterans left under other circumstances or were asked to

leave). During the study period, one-half of the Veterans who exited the program did so under

mutual agreement; 20 percent exited prematurely because of rule violations, most frequently

related to substance use; and the remaining Veterans initiated their own exit. Although Veterans

who waited longer for housing were more likely to exit prematurely and to have poor housing

and employment outcomes, there was a positive association between VA case management visits

and mutually agreed-on exits as well as housing and employment outcomes (Mares, Kasprow,

and Rosenheck, 2004).

HUD-VASH Exit Study

5

Final Report

Chapter 1: Introduction and Overview of Study

OVERVIEW OF STUDY

This study intends to provide a better understanding of how and why Veterans exit the HUD-

VASH program. This study identified facilitators and barriers to program engagement, housing

processes, and VA case management; described participants’ use of VA services before, during,

and after program participation; explored the timing and reasons for program exits; and assessed

collaborative efforts between HUD and VA in the administration of four local HUD-VASH

programs.

The study addressed the following research questions at the Veteran level:

•  What are common barriers that prevent Veterans from using HUD-VASH vouchers to

obtain housing or that make remaining in permanent housing difficult?

•  What are the reasons that Veterans exit the HUD-VASH program?

•  What different types of exits are there, and do reasons for exit differ across exit types?

•  What Veteran characteristics or program antecedents (for example, housing stability,

frequency of supportive services, mental health status, substance use) predict whether

Veterans exit the program, the type of exit, and length of stay in the program?

•  What are Veterans’ patterns of VA medical, mental or behavioral health, and homeless

services use before, during, and after participation in the HUD-VASH program,?

•  The study also considered program-level questions regarding implementation and

collaboration:

•  What community factors impact the success of local housing authorities and VAMCs in

administering the program?

•  How do HUD and VA work together to implement HUD-VASH at the community level?

To address those research questions, the VA National Center on Homelessness Among Veterans

(NCHAV) coordinated a multisite research study conducted through four HUD-VASH

programs: Houston, Texas; Los Angeles, California; Palo Alto, California; and Philadelphia,

Pennsylvania. Data were collected on Veterans who were currently in the HUD-VASH program

and had been for 2 years or more, Veterans who exited the program after obtaining permanent

housing using a HUD-VASH voucher, and Veterans who exited the program after receiving a

voucher but before attaining permanent housing.

Existing VA medical record and homeless system data for HUD-VASH participants at each site

allowed the research team to assess Veterans’ background characteristics and services use during

their participation in HUD-VASH and explore the relationship between clinical characteristics

and program exits. Research staff also conducted closed- and open-ended interviews with a

subsample of HUD-VASH participants. During those interviews, Veterans provided information

about their personal characteristics, perceptions of the HUD-VASH housing process from

admission to the program to moving into housing, satisfaction with their housing (if housed), and

their relationship with their VA case managers.

In addition, research staff from the NCHAV visited local HUD-VASH housing authorities and

VA case management teams at each of the study sites to develop comprehensive descriptions of

those sites and to contextualize Veteran-level findings. Program-level information also highlights

HUD-VASH Exit Study

6

Final Report

Chapter 1: Introduction and Overview of Study

coordination and collaboration between HUD and VA as well as best practices across the sites,

common facilitators and barriers to engaging and retaining Veterans in the program, and frequent

reasons why Veterans exit the program.

THIS REPORT

This report presents findings about Veterans and local HUD-VASH programs. Following an

overview of the methods employed during this study, this report describes HUD-VASH

participants who met the study criteria at each of the study sites, including Veterans’

demographic and clinical characteristics. The report then summarizes and compares features of

the HUD-VASH study sites, including an overview of the process from program engagement to

housing and retaining a Veteran in the program. Next, the report describes Veterans’ experiences

in the HUD-VASH program; experiences with VA case management; VA services use before,

during, and after program enrollment; and why Veterans exited the program. Finally, the report

outlines facilitators and barriers to accessing and sustaining HUD-VASH housing and concludes

with a summary of study findings and policy implications.

HUD-VASH Exit Study

7

Final Report

CHAPTER 2:

METHODS

The NCHAV led this multisite study conducted at four HUD-VASH programs. Research staff

used administrative data to describe HUD-VASH participants and identify study respondents to

provide subjective, contextual data to support the analyses of administrative data. At each study

site, research staff selected a subsample of participants to be recruited for individual, structured

interviews; a portion of those participants also responded to open-ended qualitative interviews.

Finally, research staff from NCHAV visited each of the study sites to collect program-level

information from local housing authority staff and VA case managers.

This study was approved by the Institutional Review Board (IRB) at the Corporal Michael J.

Crescenz Veterans Affairs Medical Center (VAMC) in Philadelphia. In addition, each of the

study sites received IRB approvals from their respective VAMCs and affiliated academic

institutions, where applicable.

STUDY SITE SELECTION

During FFY 2012, the research team and NCHAV leadership selected a sample of HUD-VASH

programs throughout the country. Selected sites were large enough to recruit a sufficient study

sample based on the sites’ voucher utilization for FFY 2008–2011. In addition, the sites

represented wide geographic and programmatic variation. The four study sites were:

•  Houston, Texas

•  Los Angeles, California

•  Palo Alto, California

•  Philadelphia, Pennsylvania

Philadelphia served as the coordinating site; in that role, research staff affiliated with NCHAV

oversaw the project and ensured, to the extent possible, that each study site conducted study

procedures consistently. Two additional sites were originally included in the study: Tampa,

Florida, and Bedford, Massachusetts. The Tampa site left the study before subject recruitment.

Although the Bedford site received approval from the local IRB for this study and commenced

recruitment, only 32 Veterans were recruited during the study period. Because this study was

intended to assess findings within and across sites, the Bedford sample was insufficient for

inclusion in this report.

VETERAN SAMPLE SELECTION

The study population comprised Veterans who were admitted to the HUD-VASH program,

obtained a HUD-VASH voucher, and met the following criteria to be included in one of three

study groups:

•  Stayers—Obtained a lease with a HUD-VASH voucher and remained in the housing unit

with the voucher for 600 days or longer and had not exited the program at the time of

selection into the study

HUD-VASH Exit Study

8

Final Report

Chapter 2: Methods

•  Leased-up exiters—Exited HUD-VASH after leasing a housing unit, regardless of reason

for exit

•  Nonleased exiters—Exited HUD-VASH after obtaining a voucher but before leasing a

housing unit, regardless of reason for exit

For the purposes of this study, an exit from HUD-VASH means that a Veteran exited HUD-

VASH case management and is no longer receiving supportive services from the program (i.e.,

by leaving one of the two components of the program, the Veteran is considered to have exited).

Exit status is indicated by VA case managers in VA administrative data systems; however, there

is no indication of whether Veterans who exited case management continued to use their HUD-

VASH voucher to subsidize their housing expenses. Therefore, this study did not explore the

relationship between an exit from HUD-VASH case management and an exit from voucher-

subsidized housing. 5

Exhibit 2.1 depicts the pathways of each of the study groups into and out of the program.

Exhibit 2.1 Study Group Pathways Into and Out of HUD-VASH

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Throughout this report, results are presented for HUD-VASH participants at each of the study

sites—with some exceptions noted—as well as a subsample of HUD-VASH participants who

responded to surveys, referred to as “study respondents” and a subsample of study respondents

who participated in semi-structured interviews, referred to as “qualitative respondents.”

HUD-VASH Participants

A total of 7,383 Veterans (63.8 percent of all HUD-VASH participants at the four study sites)

met the study criteria. The research team identified HUD-VASH participants at each study site

using existing administrative data. Veterans included in analyses met the criteria for one of the

5 In-house analysis recently conducted by HUD indicates that among 64,000 Veterans who exited HUD-VASH case management nationally between 2008 and 2016, voucher status is unknown for about one quarter; among the 47,000

Veterans for whom voucher status is known, a small proportion (10 percent) ended participation in HUD housing assistance more than 45 days before exiting case management and more than half ended housing assistance within 45 days before or after exiting case management; of the one-third of exiters who continued housing assistance, at least half continued housing assistance for a year or more after exiting case management.

HUD-VASH Exit Study

9

Final Report

Chapter 2: Methods

study groups: stayers, leased-up exiters, or nonleased exiters. For Veterans with multiple entries

into the program, research staff retained only the most recent entry. Approximately one-third of

HUD-VASH participants did not meet the criteria for one of the three study groups, including

Veterans who were new to the program and had not yet received a voucher or had not yet moved

into a unit, housed Veterans who had not yet lived in a rented unit for more than 600 days, and

Veterans who exited HUD-VASH before receiving a voucher.

Veterans in Los Angeles constituted more than one-half (51.0 percent) of the study sample,

followed by 23.9 percent in Houston, 17.4 percent in Palo Alto, and 7.6 percent in Philadelphia.

Leased-up exiters made up the largest study group (41.8 percent), followed by stayers (37.8

percent) and nonleased exiters (20.4 percent). Exhibit 2.2 provides the sample sizes for HUD-

VASH participants included in analyses by study site and group.

Exhibit 2.2 HUD-VASH Participant Count

Stayers

Leased-Up

Nonleased

Exiters

Exiters

Total

N=2,788

N=3,088

N=1,507

N=7,383

N

%

N

%

N

%

N

%

Houston

495

17.8

1,013

32.8

260

17.3

1,770

23.9

Los Angeles

1,643

58.9

1,251

40.5

873

57.9

3,767

51.0

Palo Alto

314

11.3

680

22.0

293

19.4

1,287

17.4

Philadelphia

336

12.1

144

4.7

81

5.4

561

7.6

Houston

Los Angeles

Palo Alto

Philadelphia

Total

N=1,768

N=3,767

N=1,287

N=561

N=7,383

N

%

N

%

N

%

N

%

N

%

Stayers

495

28.0

1,643

43.6

314

24.4

336

59.9

2,788

37.8

Leased-up exiters  1,013

57.3

1,251

33.2

680

52.8

144

25.7

3,088

41.8

Nonleased exiters  260

14.7

873

23.2

293

22.8

81

14.4

1,507

20.4

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Homeless Operations Management and Evaluation System

The program admission years for HUD-VASH participants are listed in exhibit 2.3. The majority

of Veterans meeting study criteria entered the program during or after 2011.

Exhibit 2.4 indicates the average length of time that HUD-VASH participants remained in the

program. Because stayers did not have an exit date, their length of stay was calculated between

voucher issuance or move-in and the end of the study’s observation period (December 2, 2014).

On average, stayers were housed through HUD-VASH for more than 3 years (1,148 days);

leased-up exiters remained in housing for more than 1 1/2 years (658 days) before exiting; and

nonleased exiters left the program after nearly 5 months (148 days).

Exhibit 2.5 provides data on the number of HUD-VASH participants who remained housed

through the program for at least 1 or 2 years. The majority of participants who moved into

housing stayed for at least 2 years. Among leased-up exiters, three-quarters stayed for at least 1

year.

HUD-VASH Exit Study

10

Final Report

Chapter 2: Methods

Exhibit 2.3 Year of Program Admission, HUD-VASH Participants

Stayers

Leased-Up

Nonleased

N=2,783

Exiters

Exiters

N=3,088

N=1,503

N

%

N

%

N

%

2008 or before

49

1.8

85

2.8

1

0.1

2009

350

12.6

500

16.2

20

1.3

2010

489

17.6

668

21.6

43

2.9

2011

1,018

36.6

914

29.6

243

16.2

2012

832

29.9

585

18.9

338

22.5

2013

45

1.6

312

10.1

502

33.4

2014

0

0.0

24

0.8

356

23.7

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Homeless Operations Management and Evaluation System

Exhibit 2.4 Days in HUD-VASH, by Quartile, HUD-VASH Participants

N

25%

50%

75%

Mean

Stayers

Voucher issuance to end of observation period

2,781

917

1,153

1,462

1,230

Move-in to end of observation period

2,781

844

1,076

1,391

1,148

Leased-up exiters

Voucher issuance to exit

3,068  433

651

968

731

Move-in to exit

3,073

365

573

889

658

Nonleased exiters

Voucher issuance to exit

920

89

129

177

148

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Homeless Operations Management and Evaluation System

Exhibit 2.5 Years in HUD-VASH Housing, HUD-VASH Participants

All Study Groups

Leased-Up

Exiters Only

N=5,876

N=3,088

N

%

N

%

1 year or longer

5,089

86.6

2,309

74.8

2 years or longer

3,551

60.4

1,116

36.1

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Homeless Operations Management and Evaluation System

Study Respondents

The process for recruiting and enrolling subjects differed to some degree by study site; those

variations are summarized in exhibit 2.6. Recruitment lists were developed using administrative

data provided by the coordinating site and input from local HUD-VASH staff. Sites with access

to a larger sample pool randomized their recruitment lists and attempted to recruit all Veterans

on the lists.

HUD-VASH Exit Study

11

Final Report

Chapter 2: Methods

Exhibit 2.6 Study Site Recruitment and Enrollment

Houston

Los Angeles

Palo Alto

Philadelphia

Stayers–VA HUD-VASH  Stayers–NCHAV

Stayers–VA HUD-

Stayers–NCHAV

supervisor generated list  provided randomized

VASH supervisor

provided randomized

of current HUD-VASH

stayer list twice as large  identified Veterans

stayer list twice as large

participants; research

as the desired sample

currently participating  as the desired sample

staff randomized list and  size (anticipating 50%  in HUD-VASH using

size (anticipating 50%

created recruitment list  response rate); when

local HUD-VASH

response rate); when

twice as large as the

site attempted to recruit  database; research staff  the site attempted to

desired sample size

all Veterans but still had  randomized list and

recruit all Veterans but

(anticipating 50%

not reached target,

created recruitment list  did not reach target,

Recruitment list  response rate).

NCHAV provided

twice as large as the

NCHAV provided

Exiters–VA HUD-VASH  second randomized

desired sample size

second list with

housing coordinator

stayer list of 100

(anticipating 50%

remaining 85 Veterans.

generated list of Veterans  Veterans.

response rate).

Exiters–NCHAV

who exited the program  Exiters–NCHAV

Exiters–VA HUD-VASH provided list of all

during the 6 months

provided list of all

supervisor identified

Veterans who exited

before the study start

Veterans who exited

Veterans who exited

HUD-VASH; VA case

date.

HUD-VASH.

HUD-VASH using local  manager identified

HUD-VASH database.  exiters and regularly

provided a recent exiter

list to research staff.

Enrollment

period

03/12/14–07/31/14

11/25/13–06/16/14

07/16/13–07/29/14

04/17/13–07/17/14

Mode of

In-person interviewsa

In-person interviews

In-person and

In-person interviews

interviews

and three quantitative  telephone interviews

interviews via telephone

$20 cash, bus pass

$20 cash voucher

$20 canteen voucher

$20 cash, 2 bus tokens

redeemable at

Incentives

VAMC/$20 electronic

funds transfer for

Veterans interviewed by

telephone

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

a. Research staff in Houston conducted qualitative interviews with all exiters and stayers until they reached thematic saturation. In addition, they administered a Working Alliance Inventory-Short Revised (WAI-SR), a Multidimensional Scale of Perceived Social Support (Zimet et al., 1988), a Relationship Questionnaire (Griffin and Bartholomew, 1994), and a Health Literacy measure (Chew, Bradley, and Boyko, 2004; Chew et al., 2008) at the end of the interviews.

Once eligible Veterans were identified, research staff at each site first contacted the Veterans by

mailing a study flyer and recruitment letter, asking the Veterans to contact them with questions

or to indicate interest in participating in the study. If research staff did not receive a response

within 2 weeks of mailing recruitment materials, they called each Veteran, asked if the Veteran

had received the recruitment letter, reviewed the contents of the letter if the Veteran had not

received it, and asked the Veteran whether he or she wanted to opt out of the study. Local VA

case managers also informed exiting Veterans of the opportunity to participate in the study by

verbally summarizing the information contained in the study flyer and providing the Veterans

with a copy of the study flyer. Veterans received an incentive for their participation.

Power analyses and expected participation rates from another study of exits from PSH (Wong,

Hadley, and Culhane, 2006) indicated that the subsample of Veterans who would respond to in-

person interviews should include 533 respondents: 70 percent (N=373) stayers and 30 percent

(N=160) exiters. The power analysis is described in appendix C.

HUD-VASH Exit Study

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Final Report

Chapter 2: Methods

The final sample that responded to interviews comprised 508 Veterans; the majority (72.8

percent) of the respondent sample was stayers, and the remaining were leased-up exiters (15.7

percent) and nonleased exiters (11.4 percent). Exhibit 2.7 summarizes the respondent sample size

by study site and group. Additional information about the subsample of study respondents is

included in appendix D.

Each of the study sites also conducted qualitative interviews with a portion of study respondents.

The target was to include one-third of all exiters (either leased-up or nonleased) in the

subsample, for a total of 14 qualitative interviews with exiters, as well as an equal number of

stayers for comparative purposes. Exhibit 2.8 provides the size of the qualitative sample by study

group and study site.

Exhibit 2.7 Study Respondent Count

Stayers

Leased-Up

Nonleased

Total

Exiters

Exiters

N=370

N=80

N=58

N=508

N

%

N

%

N

%

N

%

Houston

92

24.9

8

10.0

5

8.6

105

20.7

Los Angeles

95

25.7

25

31.3

16

27.6

136

26.8

Palo Alto

86

23.2

24

30.0

22

37.9

132

26.0

Philadelphia

97

26.2

23

28.8

15

25.9

135

26.6

Houston

Los Angeles

Palo Alto

Philadelphia

Total

N=105

N=136

N=132

N=135

N=508

N

%

N

%

N

%

N

%

N

%

Stayers

92

87.6

95

69.9

86

65.2

97

71.9

370

72.8

Leased-up exiters  8

7.6

25

18.4

24

18.2

23

17.0

80

15.7

Nonleased exiters  5

4.8

16

11.8

22

16.7

15

11.1

58

11.4

Source: Veteran Survey

Exhibit 2.8 Qualitative Respondent Count

Stayers

Leased-Up

Nonleased

Exiters

Exiters

Total

N=56

N=28

N=26

N=110

N

%

N

%

N

%

N

%

Houston

14

25.0

8

28.6

5

19.2

27

24.5

Los Angeles

14

25.0

7

25.0

7

26.9

28

25.5

Palo Alto

14

25.0

5

17.9

8

30.8

27

24.5

Philadelphia

14

25.0

8

28.6

6

23.1

28

25.5

Houston

Los Angeles

Palo Alto

Philadelphia

Total

N=27

N=28

N=27

N=28

N=110

N

%

N

%

N

%

N

%

N

%

Stayers

14

51.9

14

50.0

14

51.9

14

50.0

56

50.9

Leased-up exiters  8

29.6

7

25.0

5

18.5

8

28.6

28

25.5

Nonleased exiters  5

18.5

7

25.0

8

29.6

6

21.4

26

23.6

Source: Veteran Interview

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Chapter 2: Methods

DATA COLLECTION

Three types of data were included in the study: administrative data, Veteran data (collected

through surveys and interviews), and program-level data. Only the NCHAV research team

collected administrative and program-level data, whereas each study site participated in Veteran

survey and interview data collection, with procedures reviewed and approved by local IRBs.

Veterans

This study examined administrative data and primary Veteran data. Research staff affiliated with

the coordinating site obtained administrative data from existing VA databases; staff at each site

collected primary Veteran data during closed-ended surveys and open-ended qualitative

interviews.

Administrative Data

The research team accessed the following administrative databases to obtain information about

Veterans’ demographics, medical diagnoses, and military history, as well as their stays in the

HUD-VASH program:

•  VA Medical Record—demographics; medical, mental or behavioral health, and substance

use conditions; VA services use.

•  VA Homeless Operations Management and Evaluation System (HOMES)—HUD-VASH

records, including program dates and exit information.

The research team accessed administrative data for the period beginning 12 months before a

Veteran’s admission to HUD-VASH and 12 months following exit from HUD-VASH, if

applicable. Exhibit 2.9 provides a summary of administrative data accessed for this study. A list

of variables, including their source and definitions, is included in appendix C.

Exhibit 2.9 Administrative Data Sources and Variables

Database

Category

Variables

VA Medical

Demographics

Sex, age, race, ethnicity, marital status, and VA enrollment priority

Record

group

VA Medical

Military service

Period of service and combat experience

Record

VA Medical

Diagnoses and VA

Medical health and mental or behavioral health diagnoses;

Record

services use

frequency of VA primary care, mental or behavioral health, and

substance use outpatient visits; frequency of emergency

department visits; and frequency of inpatient medical health,

mental or behavioral health, and substance use inpatient visits and

lengths of stay

VA Medical

VA case management

VA case management services received before, during, and

Record

following HUD-VASH enrollment

VA HOMES

HUD-VASH program

Program enrollment date, voucher receipt date, lease date, exit

dates

date, time to placement in permanent housing, and length of stay

VA HOMES

HUD-VASH program exit  Reason for exit

VA HOMES = VA Homeless Operations Management and Evaluation System. HUD-VASH = U.S. Department of

Housing and Urban Development-U.S. Department of Veterans Affairs (VA) Supportive Housing.

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Chapter 2: Methods

HOMES data related to demographics, military service, incarceration history, and homelessness

history, as well as living situation at program exit, were not reported here due to missing data. 6

Finally, given that this study was initiated before the institution of Housing First and the

program’s accelerated focus on chronic homelessness, comparing groups related to those

program measures was not possible. However, analyses did take into account whether Veterans

entered HUD-VASH before or after the transition to a Housing First approach.

Survey Data

Interviewers at each study site used an interview protocol—specifically tailored to each of the

three study groups—to conduct in-person, one-on-one surveys with a subsample of HUD-VASH

participants either onsite at VAMC facilities or by telephone. The objective of those surveys was

to collect subjective data from study respondents to contextualize the analyses based on

administrative data. Surveys included questions related to the following areas:

•  Housing and homelessness history—Interviewers used the Residential Time-Line Follow-

Back Calendar7 method to identify where Veterans were living when they enrolled in

HUD-VASH and during their participation in the program (Tsemberis et al., 2007).

•  HUD-VASH housing process—Interviewers asked a series of questions to collect more

detailed information about the ease with which Veterans enrolled in the program,

obtained a housing voucher, and leased an apartment.

•  Housing satisfaction—Using a scale measuring apartment and neighborhood satisfaction,

interviewers assessed Veterans’ satisfaction with the housing they obtained through

HUD-VASH (Tsemberis et al., 2003).

•  Income, work, and education—Several questions assessed Veterans’ sources of income

during their tenure in HUD-VASH, as well as whether they were involved in any

educational or vocational programs.

•  VA case manager relationship—This section estimated the number of monthly VA case

management contacts Veterans had while in HUD-VASH, as well as the extent to which

they worked well with their VA case managers, based on questions adapted from the

Working Alliance Inventory, Short Form (Hovarth, 1987, 1989).

•  Medical and mental health conditions—This section assessed Veterans’ medical and

mental health status and ability to perform activities of daily living during their tenure in

HUD-VASH; several of these questions were based on items included in the RAND

Health Medical Outcomes Study (Hays, 1994).

•  Substance use status—Two questions, influenced by the Addiction Severity Index

(Treatment Research Institute, 1998), asked Veterans to indicate the severity of substance

use issues during their tenure in HUD-VASH, as well as whether they accessed inpatient

or outpatient treatment during that time.

6 Of the HUD-VASH participants, 40.5 percent had missing demographic, military service, and incarceration history data, and 44.4 percent had missing data regarding their homelessness history. Among exiters, 26.8 percent had missing data related to housing status, housing stability, and living arrangement at exit.

7 This is a validated method of collecting residential histories from homeless people that involves organizing the chronology around events of personal significance and using open-ended dialogue with the respondent.

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Chapter 2: Methods

In addition, interviewers asked study respondents about their program exit, including whether the

exit was voluntary or not, the reasons that contributed to the Veteran’s leaving the program, and

whether HUD-VASH staff assisted the Veteran in finding a place to live following program exit.

Exiters also provided information about their current housing situation, postexit contact with VA

staff, and their income, work, and education following program exit. Copies of the surveys and a

list of variables are included in appendix C.

Interview Data

For a subsample of study respondents, interviewers conducted semistructured qualitative

interviews based on interview guides developed by NCHAV research staff. Those questions

prompted Veterans to walk through their experiences in HUD-VASH, from how they learned

about the program to their housing search, as well as their relationship with their VA case

manager and any positive or challenging experiences they had in the program. Research staff

audio recorded these interviews, which were then transcribed verbatim and de-identified by an

independent third party. Members of the research team checked the transcripts for accuracy

against the audio recordings. Copies of the interview guides are included in appendix C.

Programs

The NCHAV research team visited each study site between April and June 2014 and interviewed

staff affiliated with the HUD-VASH program at local housing authorities, as well as HUD-VASH

VA case management staff. Those interviews followed an interview guide and were recorded and

transcribed. Copies of the interview guides are included in appendix C. Descriptions of the sites are

current as of the date of the site visit and are included in appendices E through H.

DATA ANALYSIS

NCHAV research staff analyzed the quantitative data and contracted with the Mixed Methods

Research Lab (MMRL) at the University of Pennsylvania to code and assist in analyzing the

qualitative data.

Quantitative Data Analysis

During the data collection period, research staff from each of the study sites survey data to the

NCHAV research team, which reviewed a sample of 10 completed surveys from each of the sites

and compared them with the site-specific dataset to ensure appropriate data entry. At the

completion of the data collection period, NCHAV research staff merged the files into one dataset

and cleaned the data, checking for missing data and logical inconsistencies. Not all HUD-VASH

participants were included in every analysis because of missing dates or other variables.

NCHAV researchers ran frequencies and tests of significance (ANOVA, chi-square, t-tests) by

study group and study site; levels of significance are indicated in the exhibits. Using administrative

data for HUD-VASH participants, research staff ran a series of multivariate analyses: multiple

regression analysis modeling duration of housing process (exhibit 5.2); logistic regression

modeling exits from HUD-VASH (exhibit 8.7); latent class analysis identifying profiles of leased-

up and nonleased exiters (exhibits 8.8–8.11); and Cox proportional hazards survival analysis for

time to return to homelessness within 360 days (exhibits 8.12, 8.13). Where applicable, reference

groups used in the statistical models—typically either the most conceptually appropriate or the

largest subgroup—are referenced either in the table or in footnotes.

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Chapter 2: Methods

Detailed methods for each of the multivariate analyses presented in this report are included in

appendix C.

Qualitative Data Analysis

Research staff at the MMRL entered de-identified transcripts into NVivo 10 (QSR International,

2012), a program that facilitates systematic qualitative analysis, and employed a thematic

analysis approach to support the organization of data into thematic categories (Guest, MacQueen,

and Namey, 2012). Following line-by-line readings of a sample of interviews, staff developed a

coding dictionary. To ensure coding accuracy and facilitate intercoder reliability, staff explicitly

defined each code in the dictionary and provided examples of the appropriate use of the code.

Staff also developed codes a priori from the interview guide.

Using the Constant Comparative Method, research staff compared newly collected data with the

initial coding schema to ensure the comprehensiveness of the coding dictionary (Glaser and

Strauss, 1967; Viera and Garrett, 2005). Two research assistants, each with extensive training in

qualitative analysis, coded each transcript and independently double coded 20 percent (N=22) of

the sample. During the initial coding phase, discrepancies in coding were resolved by consensus

and review with senior members of the research team. Upon coding completion, intercoder

reliability was evaluated using the Kappa statistic and review of percent agreement by code

(Guest, MacQueen, and Namey, 2012; Viera and Garrett, 2005). The median Kappa was 0.8,

with a range of 0.6–1.0, indicating substantial to nearly perfect agreement; that finding was

supported by percent agreement analysis, which yielded 95 percent (range 82–100 percent)

agreement of the codes examined for this report (Guest, MacQueen, and Namey, 2012; Viera and

Garrett, 2005).

Research staff organized emergent codes into the following themes:

•  Participant background, including personal and homeless history.

•  HUD-VASH processes, including program facilitators and barriers.

•  Exiting experiences for leased-up and nonleased exiters.

•  Veteran-generated recommendations.

Research staff then compared the relative frequencies of themes and looked for code co-

occurrence, including differences across study groups. Qualitative findings included in this

report do not represent mutually exclusive categories, as many participants reported multiple

types of experiences within each thematic area, and other participants reported none. Qualitative

quotes included throughout this report were edited to eliminate repetition, remove filler words

and stock phrases, and clarify references made by the speaker. A copy of the qualitative data-

coding dictionary is included in appendix C.

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CHAPTER 3:

CHARACTERISTICS OF HUD-VASH PARTICIPANTS

This chapter describes demographics, military history, and medical and mental or behavioral

health conditions of each of the study groups—stayers, leased-up exiters, and nonleased

exiters—for the sample of HUD-VASH participants. A list of variables is included in appendix

C. Supporting data tables are included in appendix I.

DEMOGRAPHICS

The vast majority of HUD-VASH participants across the study sites were male, regardless of

study group (88.9 percent of stayers, 89.1 percent of leased-up exiters, and 90.5 percent of

nonleased exiters; N=7,341). However, the age distribution varied by study group. Nonleased

exiters were generally younger than both stayers and leased-up exiters, but this group had the

largest proportion of Veterans older than 65 years (see exhibit 3.1).

As shown in exhibit 3.2, the majority of stayers and leased-up exiters identified as Black,

whereas nonleased exiters more often identified as White. The vast majority of HUD-VASH

participants identified as non-Hispanic.

Exhibit 3.1 Age, HUD-VASH Participants

Stayers

Leased-Up Exiters

Nonleased Exiters

N=2,776

N=3,074

N=1,491

N

%

N

%

N

%

<35

233

8.4

357

11.6

229

15.4

35–44

269

9.7

366

11.9

190

12.7

45–54

1,006

36.2

1,045

34.0

417

28.0

55–64

1,025

36.9

1,087

35.4

501

33.6

≥65

243

8.8

219

7.1

154

10.3

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Medical Record

Exhibit 3.2 Race and Ethnicity, HUD-VASH Participants

Stayers

Leased-Up Exiters

Nonleased Exiters

N=2,693

N=2,999

N=1,423

N

%

N

%

N

%

Race

Black or African-American

1,627

60.4

1,721

57.4

634

44.6

White

925

34.3

1,105

36.8

683

48.0

Other

141

5.2

173

5.8

106

7.4

Ethnicity

N=2,714

N=3,024

N=1,450

Hispanic/Latino

189

7.0

234

7.7

148

10.2

Non-Hispanic/Non-Latino

2,500

92.1

2,758

91.2

1,278

88.1

Multiple

25

0.9

32

1.1

24

1.7

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Medical Record

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Chapter 3: Characteristics of HUD-VASH Participants

About one-third of HUD-VASH participants were never married and more than one-third were

divorced; leased-up exiters more frequently reported being divorced than did the other groups,

and nonleased exiters were more frequently married (see exhibit 3.3).

Veterans’ eligibility for healthcare through the Veterans Health Administration (VHA) is based

on VA’s enrollment priority groups, which indicate the extent to which a Veteran is receiving

compensation as a result of a disability incurred during military service, as well as whether a

Veteran is very low income. VA enrollment priority groups are collapsed into five categories: (1)

Veterans with a service-connected disability 50 percent or more disabling; (2) Veterans with a

service-connected disability less than 50 percent disabling; (3) Veterans with no service-

connected disability but Medicaid eligible, which includes Veterans who are not disabled but are

low income; (4) Veterans with no service-connected disability and not Medicaid eligible, which

includes Veterans who are neither disabled nor low income; and (5) Veterans meeting other

criteria for eligibility (for example, exposure to certain hazards).

Higher service-connected disability ratings likely reflect a greater level of disability, as well as

higher income received by the Veteran from the VA. About one-half of HUD-VASH participants

had no service-connected disability but were very low income. Most of the remaining Veterans

had a service-connected disability, with leased-up and nonleased exiters more likely than stayers

to have a service-connected disability of 50 percent or more (see exhibit 3.4).

Exhibit 3.3 Marital Status, HUD-VASH Participants

Stayers

Leased-Up

Nonleased

N=2,765

Exiters

Exiters

N=3,071

N=1,486

N

%

N

%

N

%

Married

286

10.3

360

11.7

207

13.9

Widowed

80

2.9

90

2.9

38

2.6

Separated

252

9.1

310

10.1

141

9.5

Divorced

1,048

37.9

1,372

44.7

554

37.3

Never married

1,099

39.7

939

30.6

546

36.7

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Medical Record

Exhibit 3.4 VA Enrollment Priority Group, HUD-VASH Participants

Stayers

Leased-Up

Nonleased

N=2,774

Exiters

Exiters

N=3,064

N=1,477

N

%

N

%

N

%

≥ 50% service-connected disability

476

17.2

824

26.9

398

26.9

< 50% service-connected disability

528

19.0

552

18.0

262

17.7

No service-connected disability; Medicaid eligible

1,653

59.6

1,510

49.3

736

49.8

No service-connected disability; not Medicaid eligible

3

0.1

4

0.1

5

0.3

Other

114

4.1

174

5.7

76

5.1

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Medical Record

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Chapter 3: Characteristics of HUD-VASH Participants

MILITARY HISTORY

The majority of HUD-VASH participants served during either the Vietnam or post-Vietnam era

(75.3 percent of stayers, 70.8 percent of leased-up exiters, and 62.0 percent of nonleased exiters).

Both leased-up and nonleased exiters were more likely than stayers to have served in the Persian

Gulf War; of those Veterans, nonleased exiters were the most likely to have served during that

conflict. Nonleased exiters were also more likely to have been deployed during Operations

Enduring Freedom (OEF), Iraqi Freedom (OIF), or New Dawn (OND). Only a small percentage

of HUD-VASH participants had an indication in their VA medical record of exposure to combat

(see exhibit 3.5).

Exhibit 3.5 Period of Service and Combat Exposure, HUD-VASH Participants

Stayers

Leased-Up

Nonleased

N=2,776

Exiters

Exiters

N=3,074

N=1,490

N

%

N

%

N

%

Period of service

World War II

7

0.3

9

0.3

4

0.3

Korean War

44

1.6

24

0.8

14

0.9

Vietnam era

1,097

39.5

1,197

38.9

480

32.2

Post-Vietnam era

993

35.8

980

31.9

444

29.8

Persian Gulf War (including OEF/OIF/OND)

574

20.7

796

25.9

508

34.1

Other

61

2.2

68

2.2

40

2.7

Combat exposure

OEF/OIF deployment

123

4.4

200

6.5

177

11.9

Combat exposure

89

3.2

146

4.7

64

4.3

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Medical Record

MEDICAL CONDITIONS AND MENTAL OR BEHAVIORAL HEALTH CONDITIONS

About one-fourth of HUD-VASH participants had any of the 25 medical conditions assessed for

this study; rates of the four most prevalent conditions were consistent across study groups. Both

types of exiters were more likely to have mental or behavioral health conditions: leased-up

exiters had the highest rate of any mental or behavioral health condition, followed by nonleased

exiters. Leased-up exiters were the most likely to have a diagnosis of depression or drug abuse,

whereas nonleased exiters had higher rates of post-traumatic stress disorder (PTSD), schizophrenia

and other psychoses, alcohol abuse, and suicide or self-inflicted injury (see exhibit 3.6).

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Chapter 3: Characteristics of HUD-VASH Participants

Exhibit 3.6 Medical Conditions and Mental or Behavioral Health Conditions, HUD-VASH

Participants

Stayers

Leased-Up

Nonleased

Exiters

Exiters

N=2,776

N=3,074

N=1,491

N

%

N

%

N

%

Medical conditions

Any medical condition

703

25.3

853

27.7

388

26.0

Most prevalent medical conditions

Hypertension

378

13.6

452

14.7

203

13.6

Diabetes, uncomplicated

151

5.4

181

5.9

64

4.3

Chronic pulmonary disease

111

4.0

142

4.6

72

4.8

Obesity

106

3.8

144

4.7

50

3.4

Traumatic brain injury

4

0.1

12

0.4

5

0.3

Mental or behavioral health conditions

Any mental or behavioral health condition

931

33.5

1,243

40.4

564

37.8

Post-traumatic stress disorder

165

5.9

251

8.2

158

10.6

Depression

315

11.3

420

13.7

191

12.8

Psychoses

327

11.8

456

14.8

247

16.6

Schizophrenia

212

7.6

332

10.8

176

11.8

Alcohol abuse

435

15.7

594

19.3

299

20.1

Drug abuse

592

21.3

818

26.6

355

23.8

Suicide and intentional self-inflicted injury

100

3.6

169

5.5

92

6.2

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing. Participants may have multiple conditions.

Source: VA Medical Record

DESCRIPTIVE BACKGROUND CHARACTERISTICS

During qualitative interviews, study respondents reported experiences related to their physical

and mental health, addiction, incarceration, family, and other concerns, including a history of

physical and sexual trauma, and how those factors related to their housing history. The most

common background characteristics that emerged from analysis of Veterans’ personal histories

are identified in exhibit 3.7.

Exhibit 3.7 Background Characteristics, Qualitative Respondents

Criminal history

Medical concerns

Substance use

Family concerns

Mental health concerns

Source: Veteran Interview

Veterans from all study groups described background characteristics that affected their housing

history. Stayers described their circumstances before entering HUD-VASH.

I was in [a shelter] here and it was for… I had a problem with crack cocaine. And I finally,

for the last, well, I am clean for around about these 4 or 5 years. And, you know, it is

sensibility, having my mind back. PTSD works on you in such a way that, I mean, it comes

and it haunts you. And—the irony on myself—maybe I am just saying it too much, I used to

be into law enforcement. And, I knew that some things that I used to do were wrong. But, I

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mean, I kept stepping over that line. And, then it got grandiose to a point that I really did

not care. That is what PTSD will do to you, a part of the effects of it… I had children, and I

kind of at one time turned my back on them, and that was really, that was really unheard

of. So, I decided I better check myself into a program, which I did. And, like I said, with

this help right here, with the VASH program, they set me back onto the point of being more

responsible, and bringing myself back to where I used to be. So, I mean, it is a Godsend to

me. (Stayer—Los Angeles)

I was comfortable in the car, but not when it got cold or somebody would see my pills and

they would steal them out of my car thinking they were really hard drugs. But they were

psych meds and stuff like that. I am a diabetic too. (Stayer—Los Angeles)

I take about seven medications that, thank God, the VA helps me with that… [The VA] was

close by. It was very convenient for me. But over the years that I was there—I think I was

there like maybe 6 years—the last few years I started going downhill and to the point

where I lost my place. I was in the streets. I wanted to end my life. This police officer told

me about the VA… He said, you know what? You should go to the VA and seek help.

(Stayer—Palo Alto)

Compared with stayers, both types of exiters more frequently referenced personal background

factors that influenced their housing experiences. Leased-up exiters more often shared mental

health concerns, whereas nonleased exiters more frequently referenced medical concerns,

substance use, and family issues. Some examples of the complex background characteristics that

preceded Veterans’ entries into HUD-VASH follow.

I can’t do no work. They already know I was there and I was sick, throwing up and

everything because when he asked me to work I was throwing up, I couldn’t stand up,

nothing; they had to get me out of there. So he knows that I’m sick, you know what I mean,

because I have diabetes so sometime I mess up. I don’t take my medicine, none of that. But

at the same time that’s, get away from her—it’s an accident waiting to happen. Maybe go

to jail this time and might not get out. (Leased-up exiter—Philadelphia)

And my son—because I was pretty much bouncing around from place to place and my son

was at my friend’s house and was not able to see me all the time, he was like getting in

trouble in school and so I had to get—you know, he got some help at the school that he

was going. And he finally stabilized. (Nonleased exiter—Philadelphia)

When [my son] died and the whole world shifted at that moment. I say this, and I do not

mean to be funny with other people, I call him my baby. He was 28 years old. He was my

baby. He is my youngest child. He died and when he died, everything went like a ball. It

started steamrolling. Once we got him settled over there at the—they shipped him back

here. After we got him all in the grave and everything, then I could start focusing back on

myself. My lease was coming up to leave. I did not want to make a longer lease. I just

decided to leave and I left. It’s not that I didn’t want to live there, I just left. I just started figuring out everything. I stayed with my other son, my oldest son, but for—I left there and

I came back. I finally got an apartment. (Leased-up exiter—Philadelphia)

SUMMARY

About 90 percent of Veterans who participated in the HUD-VASH programs at each of the study

sites were male, regardless of study group. Stayers tended to be older than Veterans in the other

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study groups and were most likely to be Black, non-Hispanic, and never married. Stayers most

often served in the military during the Vietnam era. Although the prevalence of medical

conditions was similar across study groups, stayers were least likely to have a mental or

behavioral health condition.

Similar to stayers, leased-up exiters were most often Black, non-Hispanic, and served during the

Vietnam era. However, leased-up exiters were most likely to be divorced and had the highest

prevalence of any mental or behavioral health condition.

Finally, nonleased exiters were younger than Veterans in the other two study groups and most

frequently identified as White and non-Hispanic. Nonleased exiters were as likely to be married

as divorced and most frequently served during the Persian Gulf War or OEF/OIF/OND.

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CHAPTER 4:

FEATURES OF STUDY SITES

Four sites participated in the study: Houston, Texas; Los Angeles, California; Palo Alto,

California; and Philadelphia, Pennsylvania. This chapter details the homelessness and housing

context for each of those sites and briefly describes local HUD-VASH practices and Veterans’

experiences in the program. For analytical overviews of each site’s implementation of HUD-

VASH, see the case studies in Appendixes E through H. Supporting data tables may be found in

appendix I.

POPULATION DATA

The total population of the study sites ranged from 1.3 million in Philadelphia to 7.7 million in

Los Angeles. Veterans constituted slightly more than 5 percent of the population in Houston,

Palo Alto, and Philadelphia, and only 3.8 percent of people in Los Angeles were Veterans.

Veterans experienced poverty at about one-half the rate of the general population at each of the

study sites, ranging from 7.4 percent in Palo Alto to 11.7 percent in Philadelphia (see exhibit

4.1).

Exhibit 4.1 Adult Population, 2013

Houston

Los Angeles

Palo Alto

Philadelphia

Overall

3,148,444

7,690,569

4,652,993

1,259,073

Veterans

162,451

295,347

236,174

68,553

% Veterans

5.2

3.8

5.1

5.4

Overall poverty rate

15.2

16.4

12.1

24.0

Veteran poverty rate  8.3

9.6

7.4

11.7

Note: Population statistics are based on 1-year estimates published by the U.S. Census Bureau, American Community Survey (2013).

Source: U.S. Census Bureau

HOMELESSNESS AND HOUSING CONTEXT

The size of the general and Veteran homeless populations measured on one day in January

remained fairly constant at the study sites between 2009 and 2014. Exhibit 4.2 illustrates the size

of the general homeless population, and exhibit 4.3 illustrates the size of the Veteran homeless

population at each of the study sites from 2009 to 2014. 8

8 The size of the general and Veteran homeless populations reported here are based on the local VAMC catchment area; each catchment area includes at least a portion of multiple Continuums of Care (CoC) matched to the catchment area using zip codes (Mulpuri, Harris, and Ruege, 2014). Therefore, they will not match the CoC-level estimates for the major CoCs affiliated with the study sites.

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Chapter 4: Features of Study Sites

Exhibit 4.2 Homeless Population, 2009–2014 | count

47,247

46,984

45,042

42,038

36,574

35,090

18,494

18,360

18,614

17,558

18,996

18,955

10,881

9,732

12,038

10,429

9,153

8,067

8,729

8,417

8,783

8,092

7,975

8,803

2009

2010

2011

2012

2013

2014

Houston

Los Angeles

Palo Alto

Philadelphia

Source: Point-in-Time Count

Exhibit 4.3 Veteran Homeless Population, 2009–2014 | count

7,052

6,899

7,375

5,867

3,949

3,627

2,106

2,039

1,702

1,550

1,782

1,855

1,171

1,125

1,574

1,522

1,259

839

509

481

472

512

534

525

2009

2010

2011

2012

2013

2014

Houston

Los Angeles

Palo Alto

Philadelphia

Source: Point-in-Time Count

Los Angeles had the largest homeless population—35,090—with Veterans accounting for 10.3

percent of homeless individuals. Palo Alto had the second largest homeless population—

18,955—with Veterans accounting for 9.8 percent of homeless individuals. Philadelphia had the

third largest homeless population—8,803—but a smaller proportion (6.0 percent) were Veterans.

Houston had the smallest homeless population—8,067—and Veterans again accounted for

approximately one in 10 homeless individuals (10.4 percent).

In 2014, more than two-thirds of Veterans experiencing homelessness in Los Angeles and Palo

Alto were unsheltered. In Houston, about one-half of Veterans were unsheltered, and in

Philadelphia—the study site with the least temperate climate—fewer than one in 10 were

unsheltered (see exhibit 4.4).

Based on data from the 2013 American Community Survey (U.S. Census Bureau, 2013), the

median rent at each of the study sites varied widely. Houston had the lowest median rent ($872),

followed by Philadelphia ($912), Los Angeles ($1,205), and Palo Alto ($1,397). More than one-

half of the residents of Los Angeles were renters, compared with slightly less than one-half at the

other study sites (see exhibit 4.5).

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Chapter 4: Features of Study Sites

Exhibit 4.4 Proportion Sheltered/Unsheltered Veteran Homeless, 2014 | count and percent

387

31 (5.9%)

(53.9%)

2,517

1,290

(69.5%)

(69.6%)

494

453

(94.1%)

(46.1%)

1,111 (30.6%)

565

(30.4%)

Houston

Los Angeles

Palo Alto

Philadelphia

Sheltered

Unsheltered

Source: Point-in-Time Count

Exhibit 4.5 Rental Market, 2013

Houston

Los Angeles

Palo Alto

Philadelphia

Median rent

$872

$1,205

$1,397

$912

Rent-occupied housing  45.7%

54.5%

45.0%

49.7%

Source: U.S. Census Bureau

HUD-VASH VOUCHER ALLOCATION

As previously described, HUD-VASH vouchers are allocated based on need. Exhibit 4.6 displays

the cumulative number of vouchers allocated through the VAMCs at each of the study sites for

FFY 2008–2014, illustrating the growth of the program (HUD, 2016a).

Exhibit 4.6 HUD-VASH Voucher Allocation, 2008–2014 | count

5,069

4,139

3,320

2,370

1,945

1,695

1,392

1,295

1,115

1,478

840

790

915

1,195

665

930

385

530

680

280

105

70

245

345

420

555

620

743

2008

2009

2010

2011

2012

2013

2014

Houston

Los Angeles

Palo Alto

Philadelphia

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: HUD (2016a)

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Chapter 4: Features of Study Sites

HUD-VASH PROCESSES

Although some aspects of HUD-VASH are operationalized uniformly across the country, each

program has some latitude in how the local housing authorities and VA case management teams

work together, requirements for VA case management, and other processes. In general, local

HUD-VASH programs must incorporate the steps that follow, adapted for the collaborating

HUD and VA agencies, into their program processes (see exhibit 4.7).

Exhibit 4.7 Overview of HUD-VASH Processes

HUD-VASH = U.S. Department of Housing and Urban Development (HUD)-U.S. Department of Veterans Affairs (VA) Supportive Housing. SSVF = Supportive Services for Veteran Families.

After moving into a housing unit, the Veteran is responsible for reexaminations if she or he

experiences any income changes. The local housing authority also conducts regular (typically

annual) recertifications to ensure that the Veteran continues to meet eligibility criteria; this also

includes an inspection to ensure that the selected unit continues to meet HQS.

VA case management typically begins at program enrollment and continues for at least 1 year after

move-in. Depending on local procedures, a Veteran may “graduate” from VA case management

and continue to use the HUD-VASH voucher or transition to a regular HCV, if available.

STUDY SITE PROCESSES

The following sections outline how the HUD-VASH processes at each study site differ. An

overview of each site is provided, followed by a figure that outlines the individual program

processes as described by local housing authorities and VA case management teams, highlighting

the diversity and complexity of HUD-VASH across these sites. Particularly in communities with

more than one housing authority, process steps may be similar yet differ in number or execution

across agencies. Study site processes are based on site interviews conducted during the spring and

summer of 2014, following the adoption of Housing First; the sites were at varying stages of

implementation. More detailed site descriptions are included in appendices E through H.

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Chapter 4: Features of Study Sites

Houston

The Houston HUD-VASH program operates in Harris, Galveston, and Jefferson counties. The

coordinating VA site is the Michael E. DeBakey VAMC in Houston, TX. The HUD-VASH

program has 1,695 vouchers, including both tenant- and project-based vouchers. The majority of

vouchers are held by the Houston

Housing Authority (HHA, 1,042)

and Harris County Housing

Authority (HCHA, 546). HHA

serves Veterans within the City of

Houston, as well as up to five

miles outside the city limits.

HCHA serves Veterans anywhere

within the county. Exhibit 4.8

outlines the general steps in

Houston’s HUD-VASH processes,

based on information provided by

VA case management teams and

housing authorities serving

Houston and Harris County.

Exhibit 4.8 Houston HUD-VASH Processes

HUD-VASH = U.S. Department of Housing and Urban Development (HUD)-U.S. Department of Veterans Affairs (VA) Supportive Housing.

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Chapter 4: Features of Study Sites

Los Angeles

The Los Angeles HUD-VASH program’s service area includes Greater Los Angeles County, as

well as the counties of Ventura, Kern, Santa Barbara, and San Luis Obispo. The coordinating VA

site is the VA Greater Los Angeles Healthcare System in Los Angeles, California. The HUD-

VASH program has 5,069 vouchers. The

majority of vouchers are held by the

Housing Authority of the City of Los

Angeles (HACLA, 3,179) and the Housing

Authority of the County of Los Angeles

(HACoLA, 1,293). HACLA serves Veterans

within the City of Los Angeles. HACoLA

serves Veterans anywhere in the county.

Exhibit 4.9 outlines the general steps in the

Los Angeles HUD-VASH processes, based

on data provided by VA case management

teams and housing authorities serving the

City of Los Angeles and Los Angeles

County.

Exhibit 4.9 Los Angeles HUD-VASH processes

HUD-VASH = U.S. Department of Housing and Urban Development (HUD)-U.S. Department of Veterans Affairs (VA) Supportive Housing.

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Chapter 4: Features of Study Sites

Palo Alto

The Palo Alto HUD-VASH program

operates in the following counties:

Alameda, Monterey, San Joaquin, San

Mateo, Santa Clara, Santa Cruz, and

Stanislaus. The coordinating VA site is

the VA Palo Alto Health Care System

in Palo Alto, California. The HUD-

VASH program has 1,478 vouchers.

The majority of vouchers are held by

the Housing Authority of the County

of Santa Clara (HACSC, 740) and the

Housing Authority of the County of

Monterey (HACM, 199). HACSC

serves Santa Clara County, including

the urban area around San Jose.

HACM serves Monterey County, the

southernmost part of the study site area, including Salinas and many coastal and rural areas.

Exhibit 4.10 outlines the general steps in Palo Alto’s HUD-VASH processes, based on

information provided by VA case management teams that serve the entire region and the

HACSC and HACM housing authorities.

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Chapter 4: Features of Study Sites

Exhibit 4.10 Palo Alto HUD-VASH Processes

HA = Housing Authority. HACM = Housing Authority of the County of Monterey. HACSC = Housing Authority of the County of Santa Clara. HAP = Housing Assistance Payment. HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing. RFTA = Request for Tenancy Approval. SSVF =

Supportive Services for Veteran Families.

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Chapter 4: Features of Study Sites

Philadelphia

The Philadelphia HUD-VASH program operates in Philadelphia County and Bucks County,

Pennsylvania, and the City of Camden, New Jersey. The coordinating VA site is the Philadelphia

VAMC in Philadelphia, Pennsylvania. The HUD-VASH program has 743 vouchers. The

majority of vouchers are held

by the Philadelphia Housing

Authority (PHA, 583) and

Housing Authority of the City

of Camden (HACC, 135). PHA

serves Veterans within

Philadelphia. HACC serves

Veterans within the Camden,

New Jersey city limits. Bucks

County Housing Authority

serves Bucks County. Exhibit

4.11 outlines the general steps

in Philadelphia’s HUD-VASH

processes, based on

information provided by VA

case management teams and

housing authorities serving

Philadelphia and Camden.

Exhibit 4.11 Philadelphia HUD-VASH Processes

HA = Housing Authority. HACC = Housing Authority of the City of Camden. VA = U.S. Department of Veterans Affairs.

HAP = Housing Assistance Payment. HUD-VASH = U.S. Department of Housing and Urban Development-U.S.

Department of Veterans Affairs Supportive Housing. PHA = Philadelphia Housing Authority. RFTA = Request for Tenancy Approval. SSVF = Supportive Services for Veteran Families.

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Chapter 4: Features of Study Sites

Summary of Study Site Processes

Although each of the study sites followed a similar process for housing Veterans in HUD-

VASH—referral and admission; voucher application and briefing; housing search; inspection,

rent negotiation, and contracts; move-in—they did so in slightly different ways. For example, the

sites processed referrals differently: Los Angeles had two dedicated intake workers, whereas

Philadelphia determined Veterans’ participation through a committee-level case review.

Most of the sites provided either weekly housing readiness groups (Los Angeles) or “ride-

alongs” (Palo Alto and Philadelphia), in which VA case managers took groups of Veterans on

housing searches throughout the community. In Philadelphia, the housing authority maintained a

list of preinspected apartments that were available for Veterans with a HUD-VASH voucher.

After a Veteran selected a housing unit, VA case managers in Palo Alto and Philadelphia

attended the contract signing with the Veteran. One consistent theme across the four study sites

was that they each relied heavily on assistance through the Supportive Services for Veteran

Families (SSVF) program to obtain move-in essentials, including utility and security deposits, as

well as first and last months’ rent.

STUDY SITE OUTCOMES

The following sections describe outcomes for each of the study sites, based on both program-

and Veteran-level data. As part of regular program operations, VA case managers track the dates

when a Veteran completes each step of the HUD-VASH process, from assessment to move-in.

Houston has the fastest housing process: accessing permanent housing typically takes Veterans

nearly 4 months (116 days). The process takes about 5 months in Philadelphia (159 days), 6

months in Palo Alto (184 days), and 7 months (216 days) in Los Angeles. Exhibit 4.12 illustrates

the average numbers of days Veterans took to move through the program’s steps at each study

site between FFY 2009 and 2014. 9

Exhibit 4.12 HUD-VASH Days to Placement in Permanent Housing, 2009–2014 (N=7,383) |

mean

216

184

130

159

94

115

68

82

80

116

60

58

39

37

47

53

Assessment

Admission

PHA referral

Receipt of voucher

Move-in

Houston

Los Angeles

Palo Alto

Philadelphia

HA = housing authority. HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of

Veterans Affairs Supportive Housing.

Source: Veterans Health Administration Support Service Center

9 Process times, provided by the VA Northeast Program Evaluation Center, are based on 5-year averages for Veterans housed in HUD-VASH between 2009 and 2014.

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Chapter 4: Features of Study Sites

VA performance measures percent vouchers resulting in housing, percent Veterans housed

within 90 days, and percent chronic homeless among those Veterans served—at each of the

study sites during FFY 2014 are shown in exhibit 4.13. 10 Most HUD-VASH vouchers at each of the sites resulted in housing. The proportion of Veterans who were housed within 90 days varied

by site, with more than one-half being housed within that timeframe in Houston and

Philadelphia. In addition, most Veterans entering HUD-VASH were considered chronically

homeless.

Interviewers asked study respondents about the ease of the HUD-VASH enrollment process,

using a five-point scale ranging from very difficult (1) to very easy (5). Study respondents in

Palo Alto reported the highest level of ease in enrolling in the program, whereas study

respondents in Philadelphia reported the highest level of ease with submitting the application and

providing documentation to the housing authority (see exhibit 4.14).

Exhibit 4.13 VA Performance Measures, 2014 | percent

93.1

90.3

92.7

91.5

84.2

80.0

83.0

63.5

78.1

40.2

40.1

51.9

Vouchers resulting in housing

Housed within 90 days

Chronically homeless served

Houston

Los Angeles

Palo Alto

Philadelphia

VA = U.S. Department of Veterans Affairs.

Source: Veterans Health Administration Support Service Center

Exhibit 4.14 Ease of HUD-VASH Enrollment Process, Study Respondents (N=508) | mean

4.18

4.24

4.32

4.00

4.13

4.09

4.02

3.93

3.74

3.76

3.78

3.8

Enrolling in the HUD-VASH program**

Submitting applications to HA**

Providing documentation of identity and

income to HA***

Houston

Los Angeles

Palo Alto

Philadelphia

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Note: Response values ranged from 1 (very difficult) to 5 (very easy). Statistical significance is indicated by**p ≤ 0.05 and

***p ≤ 0.01.

Source: Veteran Survey

10 Performance data are from the VA Homeless Programs Scorecard, collected between October 1, 2013 and August 31, 2014.

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Chapter 4: Features of Study Sites

Interviewers asked study respondents about the ease of the HUD-VASH housing process, using

the same five-point scale ranging from very difficult (1) to very easy (5). Veterans in Houston

and Philadelphia indicated that finding listings of available apartments and locating an

acceptable apartment were easier compared with Veterans in Los Angeles and Palo Alto. Given

the difficult housing markets at the California sites, this finding is unsurprising. The ease of

getting the apartment inspected by the housing authority was fairly consistent across all sites.

Similarly, the ease of being selected as a tenant by a landlord was also fairly consistent across all

sites, with the exception of Philadelphia, where Veterans indicated a higher level of ease. This

may be related to Philadelphia’s offering preinspected units, demonstrating good relationships

with property owners. At all study sites, Veterans described finding an acceptable apartment

option and obtaining the money needed for move-in costs as the most difficult steps in the

housing process (see exhibit 4.15).

Exhibit 4.15 Ease of HUD-VASH Housing Process, Study Respondents (N=508) | mean

3.86

4.61

3.75 3.70 4.09

3.42

3.75

3.96

4.19 4.05

4.03

4.02

3.62

3.95

3.10

3.93

4.03

3.25

3.56 3.42

Finding listings of

Finding an acceptable

Getting an apartment Being selected as a tenant Obtaining money for rent,

available apartments

apartment option***

inspected by HA

by a landlord***

security deposit, moving

costs**

Houston

Los Angeles

Palo Alto

Philadelphia

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Note: Response values ranged from 1 (very difficult) to 5 (very easy). Statistical significance is indicated by **p ≤ 0.05

and ***p ≤ 0.01.

Source: Veteran Survey

SUMMARY

The study sites were diverse in a number of ways. They represented western, southwestern, and

northeastern parts of the country. The size of the communities ranged from 1.3 to 7.7 million

people and the proportion of Veterans in each community ranged from 3.8 percent to 5.4 percent.

Although the poverty rates among the Veteran population were much lower than among the

general population, the numbers of homeless Veterans at one point in time ranged from 525 to

3,627 and in 2014 the rates at which they were unsheltered ranged from 5.9 percent to 69.6

percent. Given tight rental markets and high median rents—up to $1,397 in one community

during the study period—accessing housing presented a challenge.

The context in which the HUD-VASH programs operated and the distinct relationships between

HUD and VA within each community contributed to variations in the housing processes across

sites. Some of those differences were reflected in the amount of time between a Veteran’s

assessment and admission into HUD-VASH and moving into a housing unit: among the sites

studied, that process ranged from a 5-year average of 116 to 216 days. However, during FFY

2014, three sites placed the majority of Veterans using a HUD-VASH voucher into housing in

fewer than 90 days.

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Chapter 4: Features of Study Sites

During interviews, Veterans provided information about their experiences with their local HUD-

VASH program. They expressed varying levels of difficulty and ease in the course of the

housing process. For some sites, Veterans found enrolling in the program moderately difficult,

whereas in others finding an acceptable housing unit was particularly challenging. Despite those

differences, the variability across sites was fairly minimal, which indicates that data are likely to

be fairly representative of the HUD-VASH program as a whole.

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CHAPTER 5:

PROGRAM ENGAGEMENT AND HOUSING PROCESS

This chapter presents findings related to the housing process, from program assessment through

move-in. Findings from interviews with Veterans describe their experiences throughout this

process, as well as program facilitators and barriers. A list of variables is included in appendix C.

Supporting data tables are included in appendix I.

TIME TO PLACEMENT IN PERMANENT HOUSING

Exhibit 5.1 illustrates the average number of days that HUD-VASH participants at the four study

sites moved through each step of the HUD-VASH enrollment and housing process, beginning

with Veterans’ initial assessment by the program. After being assessed, the next step for those

admitted to the program is admission, followed by referral to the housing authority, receipt of the

voucher, selection of housing, inspection of the housing, execution of the Housing Assistance

Payment (HAP) contract (in which the housing authority promises to pay rent to the landlord),

and, finally, move-in.

Veterans moved from assessment to admission in about 1 1/2 months and received their vouchers

within 3 months of admission to the program. The largest time differences were between stayers

and leased-up exiters; leased-up exiters received their vouchers more than 1 week sooner than

stayers and accessed permanent housing about 3 weeks sooner, perhaps because stayers

generally entered HUD-VASH before the transition to a Housing First approach.

Exhibit 5.1 Days to Placement in Permanent Housing, HUD-VASH Participants (N=7,383) |

mean

200

181

192

164

182

174

165

149

111

77

101

99

46

73

48

68

0

45

Assessment

Admission

HA referral**

Receipt of

Housing

Inspection

HAP

Move-in

voucher***

selection***

Contract***

Stayers

Leased-Up Exiters

Non-Leased Exiters

HA = housing authority. HAP = Housing Assistance Payment. HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Note: Statistical significance is indicated by **p ≤ 0.05 and ***p ≤ 0.01.

Source: VA Homeless Operations Management and Evaluation System

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Chapter 5: Program Engagement and Housing Process

To identify factors related to the speed at which a Veteran proceeded through the HUD-VASH

housing process, the research team conducted a series of regression analyses that modeled the

effect of selected Veteran and program characteristics on the duration of the following process

stages: (1) program admission to housing authority referral, (2) housing authority referral to the

Veteran’s receipt of the HUD-VASH voucher, (3) receipt of the voucher to the Veteran moving

into housing, (4) program admission to receipt of voucher, and (5) program admission to move-

in. A summary of the model results are presented in exhibit 5.2; the first column lists the

variables that were entered into the model, and the subsequent columns summarize the findings

for each of the five models, with the outcome of interest indicated at the top of each column. A

detailed description of the methods is included in appendix C, and supporting data tables are

included in appendix I.

Exhibit 5.2 Summary of Multiple Regression Analyses, HUD-VASH Participants

Admission  HA Referral  Receipt of

Admission

to HA

to Receipt of  Voucher to  to Receipt of  Admission

to Move-in

Referral

Voucher

Move-In

Voucher

N=6,055

N=6,102

N=5,308

N=5,724

N=4,882

Study site

Houston

-

-

-

-

-

Los Angeles

Reference

Palo Alto

NS

-

-

-

-

Philadelphia

+

-

-

-

-

Study group

Stayer

Reference

Leased-up exiter

+

NS

NS

NS

NS

Nonleased exiter

+

+

Not included  +

Not included

Age

+

-

-

NS

NS

Male

NS

NS

NS

NS

NS

Race

Black

Reference

White

NS

NS

-

NS

NS

Other

NS

NS

NS

NS

NS

Service-connected disability

NS

+

+

NS

NS

Housing First

NS

-

-

-

-

Monthly average VA case management

contacts

-

-

-

-

-

Adjusted R2

0.166

0.255

0.090

0.211

0.158

HA = housing authority. HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of

Veterans Affairs Supportive Housing. NS = not statistically significant.

Note: Statistical significance is indicated by bold font (p ≤ 0.05).

Sources: VA Homeless Operations Management and Evaluation System; VA Medical Record

In exhibit 5.2, a “+” sign in a cell indicates that the variable in the first column increased the

amount of time it took for Veterans to move through each stage of the housing process. For

example, the first model indicates that leased-up exiters took longer to to move from program

admission to referral to the housing authority. Similarly, a “-” sign indicates that the variable in

the first column decreased the amount of time it took to move through each step of the housing

process. For example, each additional VA case management contact was associated with

decrease in time between admission and referral to the housing authority.

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Chapter 5: Program Engagement and Housing Process

Across each of the five process stages assessed, more frequent VA case management was related

to more rapid housing. Although the results of the regressions show that, controlling for site and

other characteristics, Veterans who ultimately exited the program needed more days than stayers

needed to proceed through the housing process, the effect sizes were minimal. Generally, older

age increased the pace at which a Veteran moved through the housing processagain, with very

small effect sizes. However, Veterans admitted to HUD-VASH after the transition to a Housing

First approach required 7.2 to 13.6 fewer days to move through the housing process once they

received a HUD-VASH voucher.

LIVING SITUATION PRIOR TO HUD-VASH AND SOURCE OF REFERRAL

Study respondents reported during surveys that they entered the HUD-VASH program from a

variety of living situations. Veterans who ultimately accessed housing most frequently stayed in

a supported environment before receiving their vouchers: nearly one-half of stayers and leased-

up exiters were living in either transitional housing or a substance abuse treatment facility or

detox center. Nonleased exiters most frequently received their voucher while living with a family

member or friend; nearly one-third received their vouchers while staying at a place not meant for

human habitation or at an emergency shelter (see exhibit 5.3).

Exhibit 5.3 Living Situation at Voucher Receipt, Study Respondents (N=489) | percent

28.2

28.0

23.8

23.5

24.4

20.5

19.9

18.0

14.0

16.0

10.5

12.0

11.4 11.5

7.8 6.4 8.0

6.4

2.6

3.0

4.0

Emergency

Place not meant

Permanent

Transitional

Substance abuse Family member's

Other

shelter

for human

housing

housing for

treatment facility or friend’s room,

habitation

homeless person or detox center

apartment or

house

Stayers

Leased-Up Exiters

Non-Leased Exiters

Note: N includes 361 stayers, 78 leased-up exiters, and 50 nonleased exiters.

Source: Veteran Survey

Respondents also indicated where they were living at the time they selected their housing unit.

The distribution of types of living situation was fairly consistent between voucher receipt and

apartment selection for stayers and leased-up exiters. One-third of nonleased exiters selected an

apartment but did not ultimately move in; among those Veterans, 35.3 percent were living in

places not meant for human habitation (see exhibit 5.4).

During qualitative interviews, respondents reflected on their experiences with homelessness,

including their housing situation immediately before entering the HUD-VASH program. Many

Veterans described a complex variety of unstable housing arrangements. One Veteran described

the living situation as, “different people’s couches, floors, sleeping bags, cars” (Leased-up

exiter—Los Angeles), and another related “going from pillow to post and it was very frustrating”

(Leased-up exiter—Houston). The housing situations that Veterans described most frequently

during qualitative interviews are listed in exhibit 5.5.

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Chapter 5: Program Engagement and Housing Process

Exhibit 5.4 Living Situation at Apartment Selection, Study Respondents (N=454) | percent

35.3

23.927.3

22.220.8

21.9 22.1 23.5

17.6

10.0

10.611.7

8.1 9.1

7.8

5.9

5.9

5.9

3.3

5.9

1.3

Emergency

Place not meant

Permanent

Transitional

Substance abuse Family member's

Other

shelter

for human

housing

housing for

treatment facility or friend’s room,

habitation

homeless person or detox center

apartment or

house

Stayers

Leased-Up Exiters

Non-Leased Exiters

Note: N includes 360 stayers, 77 leased-up exiters, and 17 nonleased exiters.

Source: Veteran Survey

Exhibit 5.5 Living Situations, Qualitative Respondents

Car, recreational vehicle, or trailer

Rented room

Family member’s room, apartment, or house

Street or other place not meant for human habitation

Friend’s room, apartment, or house

VA hospital, shelter, or program

Non-VA shelter or program

Source: Veteran Interview

Stayers and leased-up exiters most commonly described staying in non-VA shelters, transitional

housing programs, or treatment facilities before entering HUD-VASH.

I came through a shelter and HUD-VASH was mentioned and everything. And I was all for

it because I wanted to get out of there and I wanted to be on my own. And I wanted to have

a home. (Stayer—Philadelphia)

I first learned about the HUD-VASH program when I was a resident at a homeless

Veterans’ rehabilitation program about maybe 3 months into the program. They talked to

me about a new program starting up. It was a pilot program and it was to help Veterans

who had homelessness issues to get help, specifically for Veterans that had families. I had

a wife and three kids and they asked me to apply. I basically came to the program so I can

see a future. I knew that I had a problem with drugs and alcohol. It was a start for me to

like look at what we can do in the program and that there is a path there I can see where,

hopefully, combined with the program and completing the program, going and getting

supportive housing, that I will be able to connect with my family. (Stayer—Palo Alto)

Veterans in each study group, particularly nonleased exiters, discussed staying with family

members or friends. Often Veterans would remain for a time with one person and then move in

with another when they felt that they had outstayed their welcome, which they reported was a

stressful experience.

I was staying at, well, different places. Like my son was at my friend’s house. You know,

she allowed him to stay there. But because she was there with her husband and I have to

like, you know, go there—I would sleep there at night and then leave during the day, pick

up my son, you know, drop him to her. But then I could not really be there. So it was like

maybe I had three or four friends [where] I would sleep. (Nonleased exiter—Philadelphia]

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Chapter 5: Program Engagement and Housing Process

I stayed in [my son’s] house until about June. Then from June to maybe July, I stayed at

that girl’s house. Then I moved back to his house. I came back and I was sleeping on the

floor again. I have to stay out all the time. People do not realize, but it wears you. I am

serious—it wears you. (Leased-up exiter—Philadelphia)

Compared with the other study groups, nonleased exiters far more frequently described staying in

cars or on the street or other places not meant for human habitation. One respondent described

living in a storage unit, and other Veterans spoke about living in tents or public places. Those

individuals moved around frequently and often felt unsafe and uncomfortable, although some of

them said that they believed their military training helped them adapt to those situations.

Depressed, pissed off that there was no other help. I couldn’t live in my car. I didn’t have a

car at that time. I was living in a tent with a motorcycle. (Nonleased exiter—Palo Alto)

Having been in the service, I didn’t have no problem sleeping on the street. You know how

to camp out. You have two or three other people there with you that you trust, and no

problem. I knew that it’s a dollar a day to go take my showers and everything at the Y. I do

all of that. I knew where to go get a free meal if I had to. I might not like it, but if I ran out

of money, I could always go get a free meal and that kind of thing. (Nonleased exiter—Los

Angeles]

Interviewers also asked qualitative respondents how they first learned about the HUD-VASH

program; the most common referral sources are listed in exhibit 5.6.

Exhibit 5.6 Exposure to Program/Referral Source, Qualitative Respondents

Doctors or other medical personnel

VA hospital, shelter, or program

Family or friend

Veterans

Non-VA shelter or program

Source: Veteran Interview

VA was the initial point of entry to HUD-VASH for many Veterans of every study group, through

drug and alcohol rehabilitation, mental health, and domiciliary or other programs that shelter

Veterans experiencing homelessness, as well as Veterans service organizations and VA outreach.

I first learned about it when I was in prison. And, the unit I was on, once a month they had

a VA group that would meet. And we would have, every now and then, speakers from the

VA hospital here, and different networks would come down there and give us information

and give us books and help us file disabilities and all that. And when they gave us the

books, it was a section in there about HUD-VASH program, and when I got out, I looked

into it. (Stayer—Houston)

I learned about the program through the information book that the VA provides every year.

I looked through there and there was something about homeless Veterans. They had a

phone number and I called and they directed me to here. I spoke to a counselor.

(Nonleased exiter—Philadelphia)

Veterans in each study group learned about HUD-VASH through case managers and other

staff at rehabilitation programs, shelters, or other assistance programs that were outside

the VA.

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I was in the treatment facility. A case manager, when I did the intake, they had me down as

a regular. I was getting ready to graduate the program, and I was thinking about housing

and we had a one-on-one, and he said, well you know, being that you’re a Veteran, Obama

signed a bill for Veterans. I hadn’t thought any more about it until he brought it to my

attention. And he happened to know one of the guys who was running the VA program and

got me in. (Stayer—Los Angeles)

All study groups, but particularly leased and nonleased exiters, cited other Veterans as initially

informing them about HUD-VASH, often at a VA hospital or at shelters.

I was with a group of Veterans, talking about help, looking for places and how they had a

process for Veterans where you could get a house really quickly if you did not have your

own house. I interrupted and asked him how you do it. He said they have this VASH

program where you can get—I knew of a program, but it was not for Veterans, if you go

down to housing. I heard that takes 5 years. It is a 5-year wait on your voucher. Then he

said they have VASH, where you can get your voucher in 2 or 3 months, for Veterans in

this program. You have to sign up. I said all right. They gave me the number and I went

and called. (Leased-up exiter—Los Angeles)

HUD-VASH ENROLLMENT PROCESS

Ease of HUD-VASH Enrollment Process

Interviewers asked study respondents about the ease of HUD-VASH enrollment—using a five-

point scale ranging from very difficult (1) to very easy (5)—and two steps along the housing

process: submitting the voucher application to the housing authority and providing sufficient

documentation. Stayers reported more ease with the enrollment process, whereas nonleased

exiters reported the most difficulty. Leased-up exiters responded similarly to stayers (see exhibit

5.7).

Exhibit 5.7 Ease of HUD-VASH Enrollment Process, Study Respondents (N=508) | mean

4.02

3.98

4.01

3.90

4.14

4.18

3.81

3.41

3.60

Enrolling in the HUD-VASH program

Submitting applications to HA***

Providing documentation of identity and

income to HA***

Stayers

Leased-Up Exiters

Non-Leased Exiters

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Note: Response values ranged from 1 (very difficult) to 5 (very easy). Statistical significance is indicated by ***p ≤ 0.01.

Source: Veteran Survey

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When asked about the enrollment process, qualitative respondents described meetings with their

VA case manager or other HUD-VASH staff; undergoing background, income, and drug

screenings; participating in tuberculosis testing, vaccinations, or receiving other preventative

services; filling out paperwork; and providing required documentation. Required documentation

included government identification, Department of Defense Form 214 (DD-214, military

discharge status), proof of income, and identifying information about their families, if applicable.

Veterans often enrolled during a group orientation or through an individual meeting with a HUD-

VASH staff member. Exhibit 5.8 lists the main themes Veterans discussed regarding the

enrollment process.

Exhibit 5.8 Enrollment Process Experiences, Qualitative Respondents

Difficult

Homeless status

Timeline was longer than expected

Easy

Income requirement

Timeline was shorter or as long as expected

Facilitation by staff

Support from staff

Source: Veteran Interview

Although Veterans did not generally describe program eligibility as a barrier to enrolling in the

program, some did express concerns regarding requirements related to their homeless status and

income. Many participants referenced the term chronic homelessness and their understanding that

eligibility for the HUD-VASH program depended on meeting certain criteria; however, they

reported confusion and dissatisfaction with the concept.

When I first spoke to them, I was very, very disappointed because I am like, well, how are

you going to tell me that I do not qualify because I have not been homeless long enough?

Like, I have a child that is not stable anywhere. So I was really drawn back—very, very

disappointed that the criteria that you have—that is what I thought. I mean, I do not know

what is that criteria, but the way I felt was that you have to be homeless for a certain

period of time to qualify to get into this program. I do not know how that works.

(Nonleased exiter—Philadelphia)

You have to know what to put down on the application in order to be selected. You can’t

just put down and say I was homeless one time—they want people who have been homeless

multiple times; they think they are more needy than somebody that has been homeless

once. And the person that has been homeless only one time probably has more resources to

fall back on in order to find housing instead of a—if you go through the rehab it is usually

because of drinking or drugs or both or prescription drugs or all three or whatever that

made you homeless. You know they want a cause on why you became homeless and then

family would come first and then you had to have been homeless more than at least five

times. They want somebody that has been through it more than a couple of times. (Stayer—

Palo Alto)

I applied for it because I was homeless and sleeping in my car and living in a homeless

shelter. I was turned down because I was sleeping on the couch at a friend’s house.

(Nonleased exiter—Palo Alto)

They say I’m not chronically homeless yet. I have to start all over. Chronically homeless to

the VA is that I got to be a year or more in the streets. Living in the streets, that’s chronic

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homeless. I said, how can I not be chronic? I can’t even walk. I’m in a wheelchair. I’m a

homeless disabled Veteran that can’t walk. I’m in a wheelchair. I’m sleeping in the back

shed of my mother’s house. I don’t have no running water, no electricity. I have no eating

quarters and they told me that I’m not chronic homeless because I haven’t been homeless

long enough because I just had me a place about 5 months. So, now I’m 5 months going

into chronic homeless[ness]. So, I got to do another 8 months for them to even see about

letting me on the list. It’s crazy. (Leased-up exiter—Palo Alto)

If you don’t have any source of income they don’t even want to talk to you; you need to

have some kind of income. (Stayer—Houston)

The majority of qualitative respondents in every study group described the enrollment process as

easy and taking about as long as or less time than they expected. Veterans often attributed the ease

of enrollment to the provision of information about the program, checklists, or other materials.

Respondents who found the process easier to navigate noted general support from VA case

managers or housing authority staff, as well as access to required application documents and group

orientations to complete the application. For some respondents, the timeframe for enrollment was

shorter because they were involved in other VA programs that facilitated their entry into HUD-

VASH, their VA case manager was able to fast-track their application, or they were identified as

having a higher need for housing than other Veterans.

The application did not take but really 3 weeks—went down, met with the people, and they

gave me a drug test, TB shot, then I came back the next week and I had to bring source of

income, IDs, and DD-214s. I had to bring that back, and once I brought that, they sent me

to Building 121. I went in there for orientation, and then a few days later they sent us to

housing to pick up our vouchers. It was real quick. (Stayer—Houston)

The process is pretty smooth, because we had workers here at the VA that were

knowledgeable of the application. They had been through the process hundreds of times, so

it made it a lot easier to get through the application process. (Leased-up exiter—Los

Angeles)

I went over to the housing authority and I filled out the paperwork. And then my counselor,

she kind of intervened and she kind of rushed it and told people that I was going to be out

in the streets. And after that, I think it was just a little more time, you know, that it took for

me to get in. So it was pretty fast, I can just say that. (Stayer—Houston)

I feel it went fairly quickly because of my level of homelessness. From what I understand

about the program, that is pretty much how it works—your level of homelessness sets up

where you’re at on a waiting list basically. I think because of my level of homelessness at

the time, living at the Veterans Transition Center, I was at high risk and so they offered me

a first voucher. (Leased-up exiter—Palo Alto)

Some respondents described difficulties with the enrollment process, including lack of assistance

from staff, trouble gathering necessary documentation or negotiating their goals and program

qualifications, complex processes, initial rejections, lost paperwork, travel to VA or housing

authority offices, and waiting. They identified specific steps in the enrollment process that were

problematic: reapplication following an initial rejection, long waiting lists for limited vouchers,

lack of follow-up, VA case managers who moved too slowly, or not having an assigned VA case

manager.

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While you are going through the documentation process and completing all the forms for

the program, you bring a copy of your compensation letter, which shows how much you

receive per month because of your service-connected disabilities. Once you take them, it

has a dollar amount. Mine was $900. Based on what I received, they do some kind of

percentage calculation and it breaks down the percentage that you will pay, based on the

type of home you stay in, whether it is an apartment or renting a condo. It shows how

much you will pay per type of home, and how much you are responsible for. Because of my

responsibilities to my kids, I did not have enough to cover it. (Nonleased exiter—Houston)

It was kind of disarming because I spent a lot of time to gather up all this information and

I just got everything that they told me was required and that took some time. When I

brought it in I had everything I needed, everything. It was processed. I want to say it was

processed almost in 1 day. When I left the office, I had a date to report to the house

mentor, which was maybe 3 or 4 days away. When I asked about the voucher, I got a call

from my case manager who said that my information had been lost. I was really distraught

about that. For one thing, I wonder where could my information be? As far as I knew, it

could be anywhere. But at the same time, I did not want to start pointing fingers, because I

did not know what it was. I felt like everyone who I came in contact with was genuinely

trying to do their jobs. I felt kind of let down because I felt like I fell through the cracks.

That does happen, and I just hated that it happened to me. (Nonleased exiter—Houston)

You know, you can slip through the cracks, or, maybe, I mean, I do know you guys have so

much workload, because I kind of look around. I think somebody just says, “Oh,” you

know. I have to ask myself, how many people get caught up like that? Here I am waiting by

the phone and the phone never rings and someone says, “Hey, I called this guy and left

him a message.” What are you talking about, you know? I am sitting here almost 9 months

looking at my phone every day. (Stayer—Los Angeles)

It took her forever to get that paperwork done. If they look at the computer from the time

that she picked me up as a client until the time that she did the paperwork to get the ball

rolling for anything, they will see a huge gap there. And I had nothing to do; I had time on

my hands. (Leased-up exiter—Houston)

I eventually got it. Took some time because they dropped the ball. They did not assign me a

case manager, so it wound up taking me close to a year and a half to get into VASH.

(Leased-up exiter—Los Angeles)

This is how it was explained to me how HUD-VASH works. They get so many vouchers

where they are to be distributed to homeless Veterans, Veterans that are in the recovering

process. And once those vouchers run out there is a wait period and no one seems to know

how long that wait period will be. (Stayer—Philadelphia)

Also of note, nonleased exiters more frequently described staff facilitating their enrollment or

providing other support:

[My VA case manager] was checking on me to make sure that I was all right and I was

seeking assistance from the VA, I guess. When I left [the city], they didn’t take it away. She

gave me, I guess, a second shot because I was on the 7th floor and when I was checking

out she inquired about where I would be staying and then I told her and I didn’t go—she

called because I told her she could. That was my agreement with her, that I would go

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somewhere so that she knew that I was all right and that I was trying to stay out of trouble,

and I gave her the information and she called and I wasn’t there. So then they took the

voucher. (Nonleased exiter—Philadelphia)

Program Orientation

Respondents across each study group expressed overall positive feelings about the HUD-VASH

orientation, which took place at the local housing authority or was facilitated by housing authority

staff at the VA. Respondents also recalled orientations hosted by VA staff either in groups or in

one-on-one meetings at VA locations. They noted that orientations were opportunities for HUD-

VASH staff to provide Veterans with programmatic guidelines, a description of the process to

receive a voucher, and tips for finding qualified housing. Many Veterans reported being generally

pleased with the orientation, usually agreeing that it was “helpful” and that the information was

adequately explained, either at the orientation or in continued interactions with HUD-VASH staff.

They had a lot of good information and a lot of knowledgeable information and resources.

The people there at the housing authority, the ones that presented the orientation, they

were very helpful. They answered a lot of questions. They gave out a lot of information. I

was very pleased with it. (Nonleased-exiter—Palo Alto)

[They had classes] to fill out the paperwork, for them to tell you what the dos and do nots

are, everything—what areas to pick, when to go shopping for a place; make sure you have

schools, markets, or whatever you need—to make sure you look for that. They were

showing us how to budget your money and how to pay your bills and all that. Everything

you can think of, they came out and they took care of the homework. (Stayer—Los Angeles)

Several respondents indicated that they did not attend an orientation. Other respondents, especially

exiters, noted dissatisfaction with the information provided, explaining that some facilitators were

not fully versed in how HUD-VASH works, the information was common knowledge or not

particularly useful, or they had personal difficulties that hindered their ability to receive the

information in the orientation setting. The most common negative orientation experiences that

Veterans described are shown in exhibit 5.9.

Exhibit 5.9 Negative Program Orientation Experiences, Qualitative Respondents

Did not attend orientation

Overall negative experience

Dissatisfaction with information provided

Personal difficulties

Information wasn’t useful

Source: Veteran Interview

With the way they did it, they went a little too fast in showing people. He was going

through the thing, rushing it. He did not really take the time to explain things. It was put

your name here, put this here and put that there. I really did not learn anything. I just did

as he told us. (Leased-up exiter—Los Angeles)

[The orientation is] not on a case-by-case basis. They’re generalizing the application

process in order to shorten it down for them, but then when the individual goes through the

housing authority, that individual is like, “Okay, why are you lying on this paperwork?

Why isn’t this filled out properly?” and it was like, we got helped. But you won’t see our

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caseworkers there vouching for me like, “Okay, I’m sorry. I filled this out.” No, they’re all

the way over here. They don’t answer their phones when you’re calling from that office.

So, it is pointless. (Nonleased exiter—Los Angeles)

The fact that, how to go about asking the proper questions being in the program, because

when you are new to something, you do not really know what questions to ask. I think that

should be in VASH. I think there should be like a checklist or like a formatted list.

Questions that you should ask the property owner and get responses and feedback for.

What do you do in this situation, what is your rent, and so on and so forth. I think if they

just created like a mini-questionnaire [or] a checklist. (Nonleased exiter—Los Angeles)

It was murky. It did not really go too smoothly because I did not understand. It is hard for

me to take in things. That is just on my part. The case manager explained everything that

day as well as it is the same right now. (Stayer—Houston)

Program Rules and Regulations

Exhibit 5.10 lists the most common rules that Veterans understood they needed to follow to

remain in HUD-VASH. Because qualitative respondents entered the program between 2008 and

2014, experiences with program rules and regulations may reflect policies both before and after

Housing First implementation.

Exhibit 5.10 Program Rules and Regulations, Qualitative Respondents

Class or group therapy attendance

Sobriety

Concern over requirements

VA case management compliance

No problem with rules

VA = U.S. Department of Veterans Affairs.

Source: Veteran Interview

Veterans discussed sobriety as a requirement to enroll and remain in HUD-VASH, and several

respondents also noted that they were required to take a urinalysis.

No drinking, no partying, no dope, no this, and no that, you know, and that at any time the

social worker could come through and check out your living quarter[s]/ living situation.

(Stayer—Los Angeles)

They check [your urine]. It is random, though. They might not check you for a year. They

might not check you for 2 years, you know, but it is at random. They do not tell you when

they are going to do it. But they do have the right to check to make sure you are staying

sober. (Stayer—Houston)

However, Veterans felt that if they were to relapse, they could receive assistance through the

program without automatically losing their housing.

If you relapsed and started using again and—I didn’t think you would be automatically

disqualified. The hope is that the program would help me get back into what I needed to

take care of if I relapsed. Lucky for me, I have been over 6 years clean now, so I didn’t

have that issue. (Stayer—Palo Alto)

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Respondents described requirements to comply with VA case management to remain in HUD-

VASH, such as attending classes (for example, budgeting) or group therapy sessions to support

abstinence.

Then we had group. I think it was twice a week or even once a week, every week, and we

had to attend meetings. The rules were very strict. You had to be participating in a

program in order to get a voucher. (Stayer—Philadelphia)

The rules and regulations hindered me at the time when I first entered because I was

working contract work. That meant I had to take a car and sometimes I had to go out to

see, or I had to go to other locations to work. It was difficult meeting up with my case

manager, which was a requirement to stay in the program, because of my work schedule.

(Nonleased exiter—Houston)

Learning about the program was one thing, but it seemed a little bit intrusive on anybody’s

life. It was like mandatory once every 2 week visits or you couldn’t leave town for over a

month or over whatever. I’m like, my parents live in North Carolina. I am going to be gone

for over 2 weeks. And if we got to sign off on that permission to do this. (Nonleased

exiter—Philadelphia)

What I was just saying about that, somebody keeping their eye on you like a child making

you feel like—I mean this ain’t really mine. Somebody like always checking up on you and

stuff like that. (Leased-up exiter—Philadelphia)

HUD-VASH HOUSING PROCESS

Ease of HUD-VASH Housing Process

Stayers and leased-up exiter respondents rated the ease of the housing process, including

accessing lists of available apartments, selecting an apartment and securing resources, and

moving into housing. Stayers and leased-up exiters described the difficulty of this process with

little variation. However, finding an acceptable apartment and obtaining assistance with rent,

security deposits, and moving costs were more challenging than other steps (see exhibit 5.11).

Exhibit 5.11 Ease of HUD-VASH Housing Process, Study Respondents (N=508) | mean

3.89

3.65

3.36

4.05

4.17

3.48

3.96

4.20

3.62

3.74

Finding listings of

Finding an acceptable

Getting an apartment Being selected as a tenant Obtaining money for

available apartments

apartment option

inspected by HA

by a landlord

rent, security deposit,

moving costs

Stayers

Leased-Up Exiters

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Note: Response values ranged from 1 (very difficult) to 5 (very easy).

Source: Veteran Survey

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Although nonleased exiters left HUD-VASH before they moved into permanent housing, almost

two-thirds (61.8 percent) found a listing of available apartment options, fewer than one-half

(43.1 percent) found an acceptable apartment option, and nearly one-quarter (22.4 percent)

obtained resources for move-in. Far fewer nonleased exiters indicated that a landlord selected

them as a tenant (15.5 percent) or that the apartment was inspected (8.6 percent) before exiting

the program.

Housing Selection

Exhibit 5.12 displays the number of apartments that study respondents visited during their

housing search. The majority visited one or more apartments, demonstrating some level of

choice in selecting a unit. More than one-fourth of stayers and leased-up exiters visited only one

unit, but two-fifths visited four or more, which may indicate a high degree of choice in housing.

However, although the majority of leased-up respondents viewed one or more units, a substantial

portion (14.1 percent of stayers and 17.9 percent of leased-up exiters) stated that they did not

have a choice in selecting their apartment. Additionally, both stayers and leased-up exiters

indicated that approximately seven out of 10 apartments were acceptable (70.9 percent for

stayers and 68.4 percent for leased-up exiters), possibly accounting for the large number of units

they visited.

Exhibit 5.12 Number of Apartments Visited During Housing Search, Study Respondents

(N=502) | percent

41.6

49.1

39.2

34.0

28.1 26.6

14.1 17.7

15.1 15.2

1.1

1.3

9.4

3.8

3.8

None

One

Two

Three

Four or more

Stayers

Leased-Up Exiters

Non-Leased Exiters

Note: N includes 370 stayers, 79 leased-up exiters, and 53 nonleased exiters.

Source: Veteran Survey

About one-third of nonleased exiters indicated that they did not visit any units, probably because

they exited the program before starting the housing search. However, almost one-half of

nonleased exiters visited four or more units, 10 percent more than the other study groups.

Nonleased exiters also indicated that only 42.2 percent of the apartments they visited were

acceptable, almost 40 percent less than the proportion of acceptable apartments visited by the

other study groups. These data suggest that nonleased Veterans either exited before beginning

the housing search or viewed many units but had difficulty finding one that was acceptable.

Both stayers and leased-up exiters cited location or neighborhood as the main reason for their

choice of apartment (63.4 percent of stayers and 65.4 percent of leased-up exiters). The majority

of Veterans indicated that they were “very comfortable” during their first few nights in their new

apartment (58.4 percent of stayers and 65.0 percent of leased-up exiters), and few said that they

were “not comfortable” (10.3 percent of stayers and 12.5 percent of leased-up exiters).

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Services Received During Housing Process

Although the majority of respondents reported receiving assistance getting an appointment with

the housing authority, less than one-half had help providing the required documentation for the

HUD-VASH application. Stayers and leased-up exiters more frequently indicated that they

received (1) assistance completing and submitting the HUD-VASH application and (2) support

finding housing options compared with nonleased exiters (see exhibit 5.13).

During the move-in process, leased-up exiters reported that they received more support than

stayers obtaining items essential to move-in and moving belongings into their new apartments

(see exhibit 5.14).

Exhibit 5.13 Services Received During Housing Process, Study Respondents (N~508) |

percent

81.4

82.5

83.9

71.3

73.8

66.1

46.2

45.0

44.8

46.1

43.8

26.3

Assistance getting and receiving Assistance providing proof of

Assistance completing and

Assistance finding apartment

appointment with PHA

identity or income

submitting PHA application

options

Stayers

Leased-Up Exiters

Non-Leased Exiters

Note: N includes 370 stayers, 80 leased-up exiters, and 58 nonleased exiters.

Source: Veteran Survey

Exhibit 5.14 Services Received During Move-in, Study Respondents (N=458) | percent

40.0

29.0

15.7

21.3

8.4

5.1

Assistance getting essential move-in items Assistance moving belongings into the

Assistance setting up utilities

apartment

Stayers

Leased-Up Exiters

Note: N includes 369 stayers and 89 leased-up exiters.

Source: Veteran Survey

FACILITATORS AND BARRIERS

Veterans described a variety of experiences related to the HUD-VASH housing process, such as

feeling supported and guided through the process, as well as encountering barriers that were not

mitigated by the program, including the amount of time required to find a unit and the pressure to

act quickly because housing stock was limited. Many Veterans spoke about the effect of their

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credit and incarceration histories on their house-hunting experiences, as well as having limited

funds for move-in costs. Other Veterans described housing that was located too close to “high

crime” neighborhoods or drug dealers. Many respondents related how prospective property

owners “stood them up” or how they felt judged on their appearance. Some, such as Veterans

who used wheelchairs, spoke about a limited inventory of accessible housing. Exhibit 5.15 lists

the most common facilitators and barriers to housing described by Veterans.

Exhibit 5.15 HUD-VASH Housing Process Facilitators and Barriers, Qualitative Respondents

Facilitators

Barriers

Ability to meet requirements

Conflict with property owners/managers

Flexible property owners

Criminal background

Housing list or resources for housing search

Financial issues

Move-in assistance

Inspection issues

Quick move-in process

Limited housing options

Supportive VA case manager

Limited time for housing search

Medical condition or mental or behavioral health conditions

Transportation

Undesirable neighborhoods

Unsuitable housing

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: Veteran Interview

Facilitators

Ability To Meet Requirements

Veterans described requirements imposed by both the program (for example, property inspections)

and property owners (for example, background checks). The majority of stayers and leased-up

exiters indicated that they had no problems with requirements; fewer nonleased exiters stated that

the requirements were not a problem.

Basically, the place that I lived, they were used to dealing with vouchers and they had

already had a rapport with [the housing authority]. So they called up and set up the

inspection and everything. (Stayer—Philadelphia)

The housing authority came out and did their inspection, and it seemed to have been pretty

expeditious. It was pretty thorough, and I do not remember any problem at all. (Stayer—

Houston)

Flexible Property Owners

Respondents, particularly stayers, described accommodating roperty owners, those who gave them

“a chance” despite background characteristics, such as criminal histories, and waived screening

processes or application fees.

[The property owner] was really nice. We skipped all of the screening processes. We

talked for a while. I guess she liked my answers and the way I presented myself. We

agreed, just like that, without any paperwork. (Leased-up exiter—Los Angeles)

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[My landlord] is also a Veteran. And he knows about HUD-VASH. So he was very

cooperative. He waited the length of time before he was paid for the move-in deposit. And,

like I said, it was trying for me because I was wondering if I was going to get kicked out or

not, but it [came] through. He was happy. And to this day, he is more than happy.

(Stayer—Palo Alto)

I was lucky in the respect that the landlord used to be where we were at. There are a lot of

pro-Veteran landlords. But corporate housing—places that are owned by corporations—

they don’t allow their managers to do that. (Leased-up exiter—Palo Alto)

Housing List/Resources For Housing Search

Respondents in each study group found housing lists and similar resources helpful in their housing

search, particularly those that identified properties that accepted tenants with criminal

backgrounds.

The biggest help was getting a list that was compiled by the VASH program of various

housing that was available. And it somewhat broke it down to the extent of whether they

accepted felonies, whether they required this deposit or whatever deposit, or whatever of

the few dos and do nots. (Stayer—Houston)

It was about the second or third ride-along; it didn’t take very long, because [of] the guys

that was driving and having the list of where the apartments were, they were great.

(Stayer—Palo Alto)

Move-in Assistance

Although a significant proportion of study respondents reported insufficient move-in assistance, a

number of qualitative respondents—most frequently leased-up exiters—described receiving

assistance in obtaining money for move-in costs or in moving into their new housing. Veterans

indicated that they received financial assistance from VA programs, as well as outside

organizations such as the Salvation Army. HUD-VASH staff often assisted Veterans in identifying

resources and helping them move.

Any kind of purchasing, I went to one of the places where they actually donate furniture,

and where people give to for this. It was nice stuff. It wasn’t anything that you wouldn’t

want to get if you already wanted furniture at your apartment, but me, myself, I’m kind of

crippled in the hands, and I don’t want to be lugging any heavy stuff around. I was happy.

I made it comfortable once I got into [it]. I made it into what I wanted it to be, so it was all

right. (Leased-up exiter—Palo Alto)

You have to pay your own deposit, but there are organizations out there that will help pay

your deposits for your rent. If you need electricity, they got a lot of organizations out here

that you can go to, and they will pay your [bill] for 6 months. (Stayer—Houston)

Quick Move-In Process

Both stayers and leased-up exiters noted that they were able to move into their housing much more

quickly than they expected.

When they first came and inspected the apartment when it was empty, they inspected it and

got the paperwork going. It was done. It was over with. They told us when we could move

in there. It was timely. They said the 1st of April we could move in. It was like that. All that

was done within a 2-week period. (Leased-up exiter—Houston)

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The process went quickly. I got there and lived there. She handled all the paperwork. She

filled it all out. I guess she knew people down there at Section 8. She has been doing it. She

did all the paperwork. The next thing you know, she said I could move in a week. She gave

me the keys. (Leased-up exiter—Los Angeles)

Supportive VA Case Manager

Veterans in every study group described VA case managers who supported or advocated for them

during the housing process. VA case managers provided Veterans with addresses of prospective

housing units and transportation for the housing search, assisted with paperwork, and mediated

interactions between Veterans and the housing authority and prospective property owners.

[VA case managers] even took you around to certain spots so you can look at the places

that you wanted to move into and then once you found the one you wanted to move into,

then you went to—I did, I went down to the Veterans Multi-Service Center because I had

no income and the first month’s deposit. And then you had to go through a little process

with them and then you got your move-in day. (Stayer—Philadelphia)

As far as the housing search, that was beautiful that they set up and supplied a van and

everything else and would take you out. All you had to do is say, “Hey, look, now I’m not

from [City 1], I’m from [City 2]. I know all of [City 2], but I don’t know [City 1].” So, I

did not know where to go or what to do. And, I told them. I said, “You know, this is where

I’m going to have my problem.” I said, “I can sit up here and I got a GPS in my car. Still,

I don’t know how to do all this.” And, they assisted us, and that was the best thing.

(Stayer—Los Angeles)

[My VA case manager] connected me with [a property management company]. And they

had so many apartments, and she went every step of the way with me to see the apartments,

everything. (Leased-up exiter—Philadelphia]

Barriers

Conflict with property owners | Several respondents in each study group commented on conflicts

with property owners during their housing search, noting that they were rude, sometimes deceitful,

and unwilling to make repairs to apartments. Often struggles occurred in coordinating rent and

using the HUD-VASH voucher. A few respondents discussed property owners being slow to

process paperwork, and others referenced property owners not returning phone calls or inquiries

about housing.

I had an issue, a situation, dealing with [the property owners], I guess. Like I said, I

turned in the paperwork to him and her in a timely manner and they just sat on it. And I

would call, checking on a weekly basis, had they done their part as far as filling out the

paperwork that they needed to fill out. And the deed and everything that the program was

requesting from them. All the paperwork that they needed. And it just seemed like they

dragged their feet on it. And it did not help me. But I would call every week, saying, “Do

you have those documents ready so I can turn the packet in?” And they just dragged their

feet on it. (Nonleased exiter—Los Angeles)

The quality sucked, because it is a voucher. So, people feel that they do not give you what

they don’t want to give you, and they do not want to deal with the rigmarole of the

paperwork with the housing authority and receiving their check from whoever sends the

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check and blah, blah, blah. So, some places, if it is really, really nice, they will tell you that

they do not take the voucher, because they do not want your class of people in there. They

stereotype you. (Leased-up exiter—Philadelphia)

Criminal Background

Veterans explained that some property owners would not rent to them because of their criminal

histories.

It really is very hard. I mean, I can understand why they would not want to rent to a felon,

but a lot of these people that have felonies—not to find an excuse for myself—it was from

being in the wrong time and the wrong place. Totally my fault I guess. (Stayer—Houston)

[Housing] was fairly limited. I mean there are a large number of allowances, some that

require a timeframe from your last felony conviction and some that just will not take felony

convictions period. And the place where I am living at now, that I have been living at for

the last few years, I mean they extorted me somewhat. They required a $300 deposit, which

is $200 more than a normal deposit. And they did it, I am certain, because of my

background. (Stayer—Houston)

Financial Issues

A number of respondents asserted that high rents, particularly in the neighborhoods where they

desired to live, posed a challenge to their housing search. Other obstacles included having a poor

credit history or access to limited funds for security deposits or application fees. Leased-up exiters, in particular, described financial issues.

My voucher was only so much. And mostly all the places that I had looked at, I still had to

pay over what the voucher was. And a lot of the places, I was paying $500–$700 more.

And they were just a small kind of room. And I am a little claustrophobic. It was just trying

to find something big enough and close enough to HUD-VASH, to the VA center here.

(Stayer—Palo Alto)

The biggest difficulty I had was coming up with the deposit. I asked, but they didn’t have

anything available. They told me about a program that was available in the county, but I

didn’t qualify for it. (Leased-up exiter—Palo Alto)

I do not have money to find a right place because all the places are so expensive. I cannot

afford all of that. I cannot afford a single. I cannot afford the whole thing. Then you have

utilities on top of it and you have a phone. It is kind of all of those things. (Nonleased

exiter—Palo Alto)

And then the day before my voucher expired, they called and said I wasn’t getting the

apartment because of what was on my credit report. (Stayer—Houston)

Inspection Issues

Some respondents, most frequently exiters, commented on the inspection requirement and the

challenge of completing it in a timely manner, as well as the possibility of the apartment failing the

inspection.

Everything with my apartment was okay, but there were other things around the apartment

complex itself that they didn’t like so they flunked it. And I said, “Oh geez.” They said,

“Don’t worry about it, because they will come out a second time and look at it again.” So,

they did that and this place flunked again. They had to have work done. Then I got a letter

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that said we are not helping you with the rent at that place anymore. You need to come over

here and get a new voucher from us and start looking for a new apartment. (Stayer—Houston)

Getting the apartment inspected was probably the longest part. It took about 2 weeks to get

the apartment inspected to make sure everything was up to code, the heaters were working

and there were no leaks. It took about 2 weeks to get that inspection done. I was kind of

worried, because it was a good apartment. To me, it looked good. (Leased-up exiter—Los

Angeles)

They wouldn’t come down to inspect it, so they had to rent it to somebody else because

they had 5 days. It wasn’t the fifth day, it was the sixth day, the day after 5 days and

housing didn’t respond in time. I said you guys have already cost me one place to live. I

said it took me about 28 days to find that place, but now I am not getting any responses.

(Stayer—Palo Alto)

Limited Housing Options

Each study group, particularly nonleased exiters, reported difficulties in obtaining housing because

of the limited options available, housing lists being out of date, and restrictions on localities where the voucher could be used. One Veteran reported difficulty finding an apartment that was

wheelchair accessible.

The list that the housing authorities would supply, by the time—if there was anything good

on that list—it was gone by the time you got the information. So, that is why it was good to

get out—I had to get out—and do the leg work myself and try to find something that was

available as it just became available. (Stayer—Los Angeles)

I continued to look. I tried to look for VA Section 8 after all the places were, “Oh no, we

don’t [take] Section 8. Oh no, we don’t do city voucher.” And I was just okay because I’m

staying in hotels, there’s no big refrigerator, there’s no microwave, there’s no stove. So,

I’m eating out. I’m gaining weight. All my saved-up funds, they’re going elsewhere. So, by

the time I chose to move on my apartment—even though I have like 2 weeks left on my

voucher, I had enough money the day I chose to jump on that apartment—I had enough

money to pay for the rest of December, which was 2 weeks plus 1 month security deposit.

(Nonleased exiter—Los Angeles)

The difficulty is zip codes. You’re limited to where you can go. You know sometimes a

mere number on the zip code can shatter your plans, because I had a place, but the zip

code—they told me I couldn’t stay there. They said I could. Everything was a go, but the

zip code said no. (Nonleased exiter—Houston)

I have a wheelchair. I was turned down from a lot of places, because they did not have

access to get in with a wheelchair, or they did not want somebody that had a wheelchair,

because they did not have access for it. (Nonleased exiter—Palo Alto)

Limited Time For Housing Search

Veterans in each study group discussed the time pressure associated with the housing search,

explaining that they could lose their voucher if they could not identify an apartment within the

allotted time.

I was in a little hurry, but it’s time consuming when you want something particular going

through VASH. You don’t have too much time because your voucher has a time limit on it.

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I was getting close to that time limit. I’m going, “Ahh!” Then, I knew that there was more

paperwork that you had to do to get an extension. (Stayer—Los Angeles)

We are going to get it filled out—they would tell me that and tell me that. Until I ended up

getting an extension because they used up so much of the time. And it did not leave me any

other time or option to look for anything else. Because [of] the time constraint and time

was running out. And I was like, “Wow. Now I got to take it because you got me behind the

eight ball. I do not have time to be searching for anything else.” (Nonleased exiter—Los

Angeles)

I mean, imagine it—you got this time limit. That’s what drives you crazy every day. You’re

worrying about it, and it throws you off. It throws some people off. I think it makes people

manic too much. (Leased-up exiter—Palo Alto)

Medical Conditions or Mental or Behavioral Health Conditions

Respondents, particularly nonleased exiters, discussed their health (for example, needing surgery)

or history of mental health conditions or substance use as a challenge in their house-hunting

experience.

Because I have PTSD and bipolar, and my therapist gave me a letter stating how

important it was for me to keep my dog with me because my dog was a therapy dog. He

was not certified yet. I had not had the opportunity to have him certified as a service dog.

That right there was an issue. (Nonleased exiter—Palo Alto)

I mean, thank God the treatment is right here, but it’s like very difficult going on a housing

search when you have those issues going on and trying to focus and not deal with the

triggers that’s going on. (Stayer—Palo Alto)

Transportation

Veterans described transportation, or lack thereof, as a barrier to the housing search. It limited the

areas in which they could look for housing and also prolonged the housing search because bus

routes often did not offer direct routes between available units.

I had to get up funding for transportation and stuff like that. I was mostly interested in

going over to the east side anyway. I had to think that if I wanted to maybe catch access to

a bus going towards that way, that would eventually take me over towards [the shopping

area] for the purpose of maybe going for groceries or something like that, and on the way

stopping to investigate an apartment or something. It just never panned out. (Nonleased

exiter—Houston)

It was hard to make a decision, because the housing that was available in the location was

sort of far away from where I was working. Sad to say, that is a long commute. (Nonleased

exiter—Palo Alto)

I would just say [the biggest challenge was an] inability to really get around like I needed

to. Even though I do have a bus pass, it is time consuming. Public transportation is time

consuming. So, having to get off this bus, that bus, this bus, it lessens the amount of places

that you could get to in a day’s time. (Leased-up exiter—Palo Alto)

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Undesirable Neighborhoods

Respondents, especially exiters, described challenges related to avoiding high-crime and drug-

infested neighborhoods. That issue was particularly important to Veterans who had a history of

substance use and were trying to avoid relapse.

When I walked in the office, they did not seem very friendly about helping me from the

beginning. They said they did not have anything available. I left the office and I walked to

the end of the street of the apartment complex. I turned around and went back in there. I

wanted to see what it was like. I started walking around the complex. I saw one guy in an

alley smoking crack. I saw some man who came up to me and asked if I had a couple of

dollars. There was no security in the place. All kinds of stuff was going on. People had

some kind of makeshift clothesline from one end of a door to another building, stretching

their clothes, three or four lines, stretching their clothes across the lines. There was loud

music. You could smell the stench of urine around the buildings and all that kind of stuff.

(Leased-up exiter—Houston)

I’m an ex-drug addict. I’d like to stay away from drugs, and everything that they were

accepting were right there in the drug area. So, it was hard to find a place that wasn’t in

those areas. (Nonleased exiter—Palo Alto)

I tried to get myself on track and then I explained to them where I wanted to live at in a

nice, comfortable area. No drugs or alcohol. No loudness. Comfortable, peace, quiet, and

something that I can appreciate. Being on drugs and alcohol and then moving into a

neighborhood or vicinity or environment that has that around, it only increases the nature

of you running back to your old, familiar behaviors. I wanted to get away from all of that.

(Stayer—Philadelphia)

Unsuitable Housing

Several respondents described the units they visited as unsuitable for habitation, reporting

problems with plumbing, electrical outlets, broken appliances, and bug infestation. Although

Veterans were less likely to speak about undesirable neighborhoods during interviews, stayers

were more apt to describe unsuitable housing than were both exiter groups.

When I first used the HUD-VASH, the list that HUD-VASH gave me for housing, the

majority of the houses that I went to on the HUD-VASH were like holes in the wall, dumps.

Then I called my friend, who is a realtor, and she went on a database and we found a place

that was suitable. (Stayer—Houston)

I found them unacceptable. Water issues, I mean, plumbing issues, paint chipping, and

even the area had a lot to do with it. But, mainly, it was the physical structure of the

apartment that, to me, it was not acceptable. I did not need an inspector to come out and

see that this was unacceptable, because I have been a home and office remodeler for 17

years. (Leased-up exiter—Los Angeles)

HOUSING SATISFACTION

Both stayers and leased-up exiters described general satisfaction with the housing they leased

while in HUD-VASH, using a five-point scale ranging from very dissatisfied (1) to completely

satisfied (5). Veterans had some concerns, however, including neighborhood and building safety

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and security. Leased-up exiters reported less satisfaction overall with HUD-VASH housing

compared with stayers (see exhibit 5.16).

Exhibit 5.16 Housing Satisfaction While in HUD-VASH and After Exit, Study Respondents

(N=508) | mean

3.63

3.47

Opportunities to socialize

3.79

***exit

3.09

3.60

3.39

Stayers -

Neighborhood safety

3.91

HUD-VASH Housing

***exit

3.30

4.31

4.01

Access to public transportation

3.76

Leased-Up Exiters -

**HUD-VASH

3.96

HUD-VASH Housing

4.10

3.86

Access to shopping

3.83

*HUD-VASH

3.49

Leased-Up Exiters -

3.61

Housing after exit

3.59

Building safety and security

3.88

**exit

3.31

3.84

Non-Leased Exiters -

3.89

Affordability

Housing after exit

3.91

3.67

3.78

3.81

Apartment condition

3.73

***exit

2.98

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Notes: Response values ranged from 1 (very dissatisfied) to 5 (completely satisfied). Statistical significance is indicated by *p ≤ 0.10, **p ≤ 0.05 and ***p ≤ 0.01.

Source: Veteran Survey

Interviewers also asked leased-up exiters to rate their satisfaction with their current housing. In

contrast to low levels of satisfaction with safety while in HUD-VASH, satisfaction with

neighborhood safety increased more than 10 percent and satisfaction with building safety and

security increased more than 5 percent following their exit from the program. Veterans’

satisfaction with opportunities to socialize also rose by more than 6 percent for leased-up exiters.

Satisfaction with apartment condition and access to shopping and public transportation decreased

following their exit from HUD-VASH, however. Compared with the other study groups,

nonleased exiters had lower levels of satisfaction in every area except access to public

transportation, and they reported the least satisfaction with the apartment condition.

Respondents spoke in detail about the quality of their housing. Although some respondents

reported positive experiences with moving in, living independently, accessing new amenities,

and having responsive property owners, others reported unresponsive property owners or poorly

maintained housing units. The main themes related to housing satisfaction are listed in exhibit

5.17.

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Exhibit 5.17 HUD-VASH Housing Satisfaction Experiences, Qualitative Respondents

Amenities

Location

General satisfaction

Problem with housing, property owner or neighborhood

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: Veteran Interview

Amenities

Respondents commented on the amenities (for example, weight room, community center,

computer room, elevators, security cameras) available with units and how they played a role in

their housing decision and satisfaction. Several respondents placed a greater value on the

availability of those amenities than on other factors, such as price.

When I first drove out there, it looked like it was brand new. Every other place had been

there for like 8 years. And, one of the attractions there—they have a weight room, and they

have got a computer room, with free access to the Internet, and they got a community

center where they throw little parties and stuff like that. Of course, it was like $100–$150

cheaper at the other places, but I would rather pay that for the amenities. (Stayer—

Houston)

It’s a very secure building with cameras. It’s reasonably secure. Nothing is foolproof, but

it’s relatively quiet. The tenants are decent people for the most part. To that end, it has a

washer, dryer, whatever you need to survive in this situation, so that’s good. (Stayer—Los

Angeles)

General Satisfaction

Some respondents were content with living independently and having their own housing, which

they often described as “acceptable” and “nice.” Stayers were slightly more likely to discuss

general housing satisfaction than were leased-up exiters.

That was the best feeling in the world, when I first got my place. It was my bed, my food.

That was good. (Leased-up exiter—Houston)

I think that my best experience was having my own place with privacy, you know, gaining

a certain dignity and self-respect to maintain. You know, I actually enjoy keeping my

apartment clean. (Stayer—Philadelphia)

I walked in and I fell in love with it. I just liked everything about the apartment. I did not

even really need to do a tour. (Stayer—Los Angeles)

My main concern was my safety, being a female and being alone, and you know [my VA

case manager] suggested this place. I went out there, and I knew the area, because I used

to work in that area, so I was kind of familiar with the area, but I was just like—I liked it

from day one. I’m like, I think this is really good. (Stayer—Philadelphia)

Location

Respondents discussed being pleased with the location of their unit. Some Veterans mentioned

looking for housing close to their current place of employment or family, and a significant number

discussed proximity to public transportation and business centers as a key factor in choosing their

housing location. Several respondents commented on the importance of neighborhood

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characteristics. Stayers were much more likely than leased-up exiters to express satisfaction with

their housing location.

It’s all good. It’s all family-orientated so it’s not really like a—you don’t have people moving

in and out monthly; it’s like people actually live there and they kind of keep that place like a

home. Like the whole building—everybody knows everybody. (Stayer—Los Angeles)

I was pretty much set on that one because it was very convenient. You know, I could take

the bus in or I could take the train in town. I am going to AA and I made most of the

meetings downtown so that was what I was interested in. (Stayer—Palo Alto)

I also chose that location because of my background and it is in a place where nobody

knows me. I know nobody except for the one person that’s from the recovery house that I

am. And that is how it has been over the last 3 years. (Stayer—Philadelphia)

Problem With Housing, Property Owner, Or Neighborhood

Some Veterans reported problems with substandard housing or neighborhoods in which they felt

unsafe or had security concerns. A few respondents noted that some property owners did not

maintain the buildings or charged them extra rent, although they were not permitted by the housing

authority to do so. Leased-up exiters discussed those problems slightly more frequently than did

stayers.

You go onto the website on apartments and you rate them. Oh, yeah, I went on there and

told them, “Do not move over there. He is an asshole. It is a waste of time.” Once you get

there, they going to talk to you real nice to get you in, and once you in, they do not care.

All they want is they money, they do not, I mean, they do not keep the property up. The city

had to come out and make them do landscaping. They had to make them fix the pools,

because one of the pools was condemned. They do not care. They just want money.

(Stayer—Houston)

I just felt that my privacy a lot of times was violated because the guys they kind of lobbied

around the pool, and I lived by the pool. I felt uncomfortable with my blinds open because

they were always in a position that they could look straight through. One time, I went to

walk toward the window and close it, and they waved at me. I thought, “I will just close the

blinds,” you know. I could not keep my bedroom—I caught them looking through the

bedroom. It was just an uncomfortable feeling. I was alone with a son—one child—I just

did not, I never felt comfortable there. (Leased-up exiter—Houston)

A guy got killed about 50 feet from where I was staying. I was on the corner; I lived in the

alley. [He was] killed across the street. That was just one. There were several—young

gang bangers, kids—doing that gangster stuff. (Leased-up exiter—Los Angeles)

We do not have secure doors and you have hoochies crawling up and down the hallways at

night, and drug dealers, and guys that had been to prison. It was not cool. And meanwhile,

the landlord is oblivious to all that. He is just busy collecting his rent. (Leased-up exiter—

Los Angeles)

PROGRAM SATISFACTION

The overwhelming majority of study respondents felt that HUD-VASH was a good fit for their

needs (95.9 percent of stayers, 90.0 percent of leased-up exiters, and 87.9 percent of nonleased

exiters). Those Veterans who did not believe it was a good fit either felt that they did not need as

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Chapter 5: Program Engagement and Housing Process

much support as the program offered and that it had too many rules or they needed more support

than the program offered.

SUMMARY

Accessing the voucher took approximately 3 months and was slightly faster for nonleased exiters

than for Veterans in the other study groups. Along each stage of the housing process—from

assessment to moving into permanent housing—stayers required more time than did leased-up

exiters. That may be because the vast majority of stayers entered the program before its shift in

FFY 2013 to a Housing First approach, which emphasizes rapid placement in permanent

housing. Further exploration indicated that both admission to the program after HUD-VASH’s

transition to Housing First and the frequency of VA case management contacts significantly

decreased the number of days required for a Veteran to receive a voucher and access permanent

housing.

Stayers and leased-up exiters most frequently reported receiving their HUD-VASH vouchers

while living in a location that provided supportive services, such as transitional housing or

substance abuse treatment facilities, followed by living with friends and family. By contrast,

nonleased exiters more frequently reported being literally homeless (that is, in an emergency

shelter or a place not meant for human habitation), followed by living with friends or family.

Stayers’ and leased-up exiters’ living arrangements seem to have remained stable during the

period between voucher receipt and apartment selection.

Compared with stayers and leased-up exiters, nonleased exiters generally found the HUD-VASH

housing process to be more difficult. A substantial portion of nonleased exiters, however,

completed two of the processes described as most difficult by stayers and leased-up exiters:

finding an acceptable apartment option and obtaining money for move-in costs, although they

never accessed housing. Nonleased exiters were less likely than the other groups to report

receiving assistance in submitting the HUD-VASH application or finding apartment options.

Additionally, although at least 40 percent of all study respondents visited four or more

apartments during their housing search—indicating a high degree of choice in housing—more

than one-half reported not receiving assistance with that process.

A minority of Veterans who leased housing reported receiving move-in assistance. Veterans

were only moderately satisfied with the level of safety at their units; after leaving the program,

leased-up exiters reported higher levels of satisfaction regarding safety issues. On the other hand,

nonleased exiters, who never entered HUD-VASH housing, were less satisfied with their housing

than were Veterans who leased housing with HUD-VASH vouchers. Some Veterans expressed

concerns regarding program requirements, such as meeting with their VA case manager,

attending a group, or maintaining sobriety. Although Veterans reported a variety of facilitators

and barriers to the housing process, a significant majority of Veterans in all study groups

reported that HUD-VASH was a good fit for their needs.

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CHAPTER 6:

VA CASE MANAGEMENT

This chapter presents information about VA case management. VA case management is intended

to support participants’ access to housing and housing stability; VA case managers may assist

Veterans with the housing search and move-in processes and connect Veterans with supportive

services such as health care, mental health treatment, and substance use counseling. This chapter

includes details from administrative records entered by VA case managers that indicate when

Veterans received VA case management throughout their participation in HUD-VASH, as well

as descriptive findings related to facilitators and barriers to VA case management described by

Veterans during qualitative interviews. Supporting data tables are included in appendix I.

FREQUENCY OF VA CASE MANAGEMENT CONTACTS

VA Case Management Requirements

During site visits, VA case management teams described current VA case management

requirements for HUD-VASH participants; those requirements differed across programs, but

each site required at least monthly contact with Veterans (see exhibit 6.1).

Exhibit 6.1 VA Case Management Requirements

Houston

Los Angeles

Palo Alto

Philadelphia

During housing

Monthly face-to-face

Weekly phone call and  Weekly face-to-face  Weekly orientation

process

meeting, monthly

monthly face-to-face

meeting

meeting, weekly

contact with VA housing  meeting

phone call, and

specialist

monthly face-to-face

meeting

Year 1

Monthly home visit

Monthly face-to-face

Monthly home visit

Monthly home visit

meeting

Year 2

Monthly home visit

Quarterly face-to-face

Monthly home visit

Monthly phone call

meeting

Year 3

Monthly home visit

Two annual face-to-face  Monthly home visit

Monthly phone call

meetings

Notes

Once a Veteran is

In lieu of monthly VA

accepted into HUD-

case manager contact,

VASH, the VA case

Veterans may attend a

manager becomes the

group meeting.

first point of contact at

the VA for all case

management services.

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs (VA)

Supportive Housing.

Source: Staff Interview

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Chapter 6: VA Case Management

Administrative Records

VA case managers enter information about HUD-VASH contacts in Veterans’ VA medical

records. Exhibit 6.2 depicts the average number of contacts per month that HUD-VASH

participants received throughout different stages of the housing process. 11 At most stages of the housing process, the frequency of contact with VA case managers was similar for the three study

groups.

Following move-in, both stayers and leased-up exiters saw a decline in contact with VA case

managers; however, 1 year following move-in, leased-up exiters’ frequency of contact with their

VA case managers was 1.5 times that of stayers (see exhibit 6.3).

Exhibit 6.2 Frequency of VA Case Management During Housing Process, HUD-VASH

Participants (N=7,383) | mean

8.96

9.54

9.69

3.54

4.22

4.08

2.52

2.45

1.06

0.95

1.08

30 days prior to admission**

Monthly average between

Monthly average between HA

Monthly average between

admission and HA referral

referral and receipt of voucher receipt of voucher and move-in

Stayers

Leased-Up Exiters

Non-Leased Exiters

HA = housing authority. HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of

Veterans Affairs (VA) Supportive Housing.

Note: Statistical significance is indicated by **p ≤ 0.05.

Source: VA Medical Record

Exhibit 6.3 Frequency of VA Case Management Following Move-in, HUD-VASH Participants

(N=7,383) | mean

1.93 2.01

1.59 1.54

1.49 1.52

1.45 1.43

1.41 1.32

0.88 1.22

30 days post-move-in 31-60 days post-

61-90 days post-

91-180 days post- 181 – 360 days post- 361-720 days post-

move-in

move-in

move-in monthly

move-in monthly

move-in monthly

average

average*

average***

Stayers

Leased-Up Exiters

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs (VA)

Supportive Housing.

Note: Statistical significance is indicated by *p ≤ 0.10 and ***p ≤ 0.01.

Source: VA Medical Record

11 Veterans were excluded if no time elapsed between two sequential points in the housing process (for example, if program admission and housing authority referral occurred on the same date). Note that contacts are measured by the number of notations made in the Veteran’s medical record and can range from a message left on a Veteran’s voicemail to a home visit.

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Veterans’ Perspectives

The majority of stayers and leased-up exiters indicated during interviews that they met with their

VA case managers monthly. Nonleased exiters were more likely to report that they met with their

VA case managers more often: one-third met with their VA case manager one to two times per

month or more than twice per month (see exhibit 6.4). The more frequent visits reported by

nonleased exiters likely reflects the higher level of VA case management that occurs when

Veterans first enter the HUD-VASH program; however, it also demonstrates that nonleased

exiters recall meeting with VA case managers quite often—more than one-third reported meeting

more than twice per month—yet those Veterans still did not access housing.

Exhibit 6.4 Self-Reported Number of Monthly Meetings With VA Case Manager, Study

Respondents (N=498) | percent

59.2 56.3

25.5

32.7

34.5

6.1

19.3

5.5

11.0

5.0

15.0

13.8

1.8

4.4 10.0

Do not meet with case Less than once per month

Once per month

One to two times per

More than twice per

manager

month

month

Stayers

Leased-Up Exiters

Non-Leased Exiters

VA = U.S. Department of Veterans Affairs.

Note: N includes 363 stayers, 80 leased-up exiters, and 55 nonleased exiters.

Source: Veteran Survey

VA CASE MANAGEMENT SATISFACTION

Among study respondents, stayers reported overall higher levels of satisfaction with their

relationships with their VA case managers compared with both exiter groups. Nonleased exiters

indicated higher levels of satisfaction than did leased-up exiters, with the exception of their VA

case managers’ ability to help them. Leased-up exiters seemed less satisfied with VA case

management overall (see figure 6.5).

Exhibit 6.5 VA Case Management Satisfaction, Study Respondents (N=508) | mean

4.3

4.39

4.01

4.46

3.86

3.74

3.89

3.95

3.56

3.92

4.19

4.15

My case manager was able to My case manager and I agreed My case manager and I had the My case manager and I trusted help me***

on goals***

same ideas about what my

each other**

problems were

Stayers

Leased-Up Exiters

Non-Leased Exiters

VA = U.S. Department of Veterans Affairs.

Note: Response values ranged from 1 (never) to 5 (always). Statistical significance is indicated by **p ≤ 0.05 and ***p ≤

0.01.

Source: Veteran Survey

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FACILITATORS AND BARRIERS

During qualitative interviews, many Veterans described positive and supportive relationships

with their VA case managers, highlighting the importance of continuity and access. They

explained that their VA case managers were able to keep them on task and inspire them to move

forward. Veterans also spoke about the support provided by VA peer support specialists,

underscoring the value of connecting with someone with shared experience. Other Veterans,

however, described poor experiences with their VA case managers, explaining that they were

often overworked, slow to respond to issues, and unsupportive. Some Veterans explained that

personal issues, such as substance abuse, were barriers to effective use of both VA case

managers and peer support specialists. The most common facilitators and barriers to VA case

management described by Veterans are listed in exhibit 6.6.

Exhibit 6.6 VA Case Management Facilitators and Barriers, Qualitative Respondents

Facilitators

Barriers

Accessibility

High turnover

Access to resources

Impersonal or nonempathetic interactions

Advocacy

Irregular meetings

Highly supportive and helpful

Nonresponsiveness

Individualized service

Unmet expectations

Peer support specialists

Veteran readiness

Veteran accountability

VA = U.S. Department of Veterans Affairs.

Source: Veteran Interview

Facilitators

Accessibility

Respondents described VA case managers’ accessibility (for example, returning phone calls)

leading to a positive relationship; stayers and leased-up exiters described VA case managers as

accessible more frequently than did nonleased exiters.

What I really like about them is they don’t waste any time getting things done. If I call

them today, they will call me back no later than tomorrow, and I’ve never gotten an “I

don’t know,” or “I can’t answer.” It’s like every problem that I’ve had, they’ve been on it.

They don’t mess around, in other words. (Stayer—Philadelphia)

I think it worked out pretty fine being that way that you would not have to wait around

when you need to see a case manager. Or if you had any problems and the case manager

that you wanted to see was not in, well, you was able to see others who could help you take

care of your business. (Stayer—Houston)

Open door. I can call and say, “Hey, I got some issues. I would like to come back and be

case managed” and be okay. (Stayer—Palo Alto)

Access to Resources

Access to resources was the most referenced facilitator of VA case management. Respondents

explained that VA case managers provided a variety of resources, including referrals to programs

that assist with or provide housing, security deposits, moving costs, clothing, food, and furniture,

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as well as information about educational programs, job search support, and therapeutic group

meetings.

My caseworker would help me with it, even financially sometimes. Not right from that

person, but information on where to get help. If I need food, there is a list you dig up.

Clothing is another thing. She gave me a list of different churches and stuff. At first, I did not

utilize anything like that. Like I said, my whole mindset was different. And they started to

come in handy. I had to change. So the relationship with her was basically she was trying to

domesticate me. And that helped domesticate me, information-wise. (Stayer—Houston)

They are very good at finding other resources like food banks, energy assistance

programs, even employment if that is what one is looking for. They are also very assisting

in helping one to get information, say, from the military, medical records. Right now I am

trying to get my discharge upgraded and my case manager sent the paperwork to my

apartment and I got to get it filled out and returned. (Stayer—Philadelphia)

They help and assist if you call them and let them know you are looking for a job and what

type of job you looking for. They will refer you to some people to help you find jobs. They

go out in the community to find people that will help Veterans into getting jobs. They will

hire Veterans, like basically they are going to help; they find people that will help hire

Veterans with disabilities or whatever. (Stayer—Houston)

Advocacy

Respondents described situations in which VA case managers helped them deal with the HUD-

VASH enrollment process or rent payments, spoke on their behalf, or expedited processes. VA

case managers also helped Veterans mediate conflicts with property owners, apartment

management, and the housing authority. Stayers and leased-up exiters discussed advocacy more

frequently than did nonleased exiters.

If I need anything or if I run into a problem—like I had a problem at my apartment

complex where I was coming off of my deck and I fell and my ankle was like this, and they

were giving me flack about fixing it. I was like, “Are you kidding me? I can sue you!” With

[my VA case manager] backing me up, calling [the housing authority], making sure the

inspector came down and everything—my deck is beautiful. I had no problem with them,

they were very respectful. The building is fantastic. So they are good backup. (Stayer—

Philadelphia)

I actually got interviewed by [my VA case manager] over the phone and it was very—she

was very informative. I told her that I had applied for the HUD-VASH a year prior to my

conversation with her and she did some research and along with one of the fellows that

works at the HUD-VASH program, they were able to recover my paperwork and basically

get me back into the same slot that I should have been all along. (Leased-up exiter—Palo

Alto)

Highly Supportive And Helpful

Veterans described their VA case managers as genuinely caring about their well-being. A few

respondents talked about establishing a level of trust, respect, and even friendship with their VA

case managers. Some described VA case managers as going beyond what was necessary to help

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them, including visiting Veterans during hospital stays. Stayers most frequently described VA case

managers as highly supportive and helpful, followed by leased-up exiters and nonleased exiters.

Just their willingness to help me take care of any problems I may have. They always seem

like they are concerned and ready to care about me helping myself, helping me help

myself. They always are willing to listen to anything I have to say, or any problems I am

having, or even the good things that are happening to me, and they have always got a good

ear for listening. I do not know. I have enjoyed them, you know? What can I say? I mean, I

am, like I said, I am so enamored with this program, I just cannot stand it. (Stayer—

Houston)

She was my guidance, I guess. They genuinely cared to see that you make it through the

issues that you are going through. I think they do more than their job in a way. (Nonleased

exiter—Philadelphia)

Individualized Service

Respondents from each study group commented that their VA case managers oriented them to the

HUD-VASH program, which they found very helpful.

It was an experience. It was almost like buying a new house, so to speak. [My VA case

manager] was very helpful. She walked me through everything, explained everything to

me. And it was—I could not believe how easy it was and why I could not have learned this

a long time ago. I could have been off the street a long time ago. (Stayer—Palo Alto)

I kind of got along with her right away. She understood everything. She dealt mostly with

people with schizophrenia. She knew the process—to not throw too much at you and go

slow, not pushing you. Right away, she knew that my situation was not as bad as others.

She knew she could be more lenient. As far as her being more understanding, I think she

was well on—she knew her stuff. She knew how to make a Veteran feel at ease. (Leased-up

exiter—Los Angeles)

The day I was getting ready to commit suicide, [the VA case manager and another VA staff

member] were on their way to my house. We was, my daughter and I had just walked into

the hospital. We were standing at the new emergency room window when I saw [my VA

case manager] pass. She said, “You called me.” I did not even remember calling her. She

said, “You called me and left me a strange message and we were on our way to your house

right now.” And me and my daughter was standing at the emergency room. She convinced

me to sign myself in. I was losing it and I did not even know. She saved my life. (Leased-up

exiter—Philadelphia)

Peer Support Specialists

Several stayers described the VA peer support specialists as a beneficial aspect of the program,

helping with appointments and securing resources.

She sent me another person to help—a peer counselor. That person was perfect, because I

hated her guts. She was so rough on me. Yeah, boy she was rough. And she was always

telling me—what is that phrase? “Pick up your books and…” She was all up in a tizzy.

And I did not like her. And I was going to tell her not to come back. And I realized boy, if it

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was not for her—stop feeling sorry for myself. I changed 180 degrees. I feel a lot better.

(Stayer—Houston)

She really connected with all of us. Like she would sit us in a room. And she also lives in

[City], so I think that really helped a lot, because if we would start a conversation that she

would follow-up, and she would say, “Oh, yeah, I know because X, Y, and Z. Oh, I know

about that. Trust me, trust me. I have been there.” So the fact that we were able to connect

with her, and she was able to relate to—I mean, she might not have been homeless, but at

one point in her life she was faced with some of these challenges that we were facing. And

because she was able to connect with us, she really put 100 percent effort into helping us

and finding different stuff to help us. (Nonleased exiter—Philadelphia)

Veteran Accountability

Veterans appreciated that their VA case managers regularly discussed goal setting, identification of

Veterans’ needs, and overall well-being. Most respondents—particularly stayers—found the

accountability provided by VA case managers to be very helpful.

She was very compassionate, very concerned as to my whereabouts and what I was doing

every step of the way. And even after all that fell apart, she still was checking. She still was

checking on me as far as my well-being. She really was. From beginning to end.

(Nonleased exiter—Los Angeles)

She is always checking up on me. She is asking me how I am doing. She texts me all the

time. She asks me what I need. I ask her and she gives me results. I ask a question and she

looks into it. She does. She does not wait 2 weeks to give me an answer. She will call me

that day or the next day. She is very helpful. Whatever I need, she is there for me. (Leased-

up exiter—Los Angeles)

Just trying to keep me focused on how I need to do things so that we can maintain stability

for the family. Sometimes you know when you are going through a crisis, especially, and

like with me because I was really on a downward spin after my son was killed. It was

really hard for me to try to just figure how to go on even putting one foot in front of

another. So, just to have that support. (Stayer—Houston)

Barriers

High Turnover

Respondents identified the high turnover rates of VA case managers as a barrier to developing

good relationships, establishing trust, and encouraging one-on-one attention. Veterans commented

that changes could be abrupt, with little or no warning and insufficient time to facilitate a smooth

transition. Stayers were most likely to take issue with VA staff turnover, followed by leased-up

exiters.

They were so short. Most of them stayed like a month and you didn’t get a chance to know

them that well. We changed case managers, and the others, they didn’t stay that long. I don’t

know if they’re in transition or they’re in training a day, a week, a month. Before you to get

to know them, well, they’re gone, someone else comes in. And it’s been like that because we

were trying to build a relationship with one person at a time. (Stayer—Philadelphia)

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I think it was an abrupt change without knowledge, first of all. I think a shift in case

management needs to be addressed, even if they don’t tell you one-on-one—just prepare

you for that to get help elsewhere and shift like that. Like shifting for a person with PTSD

is very difficult and so when I got with the new case manager, she was not as available as

my first case manager. And, again, not to say that she didn’t do a good job for me—it was

just an abrupt shift and also the caseload was much higher than when I first came into the

program. (Stayer—Palo Alto)

Impersonal or Nonempathetic Interactions

Some respondents described their VA case managers as nonempathetic or impersonal. Several

Veterans indicated that their negative relationships with their VA case managers made them feel

that they wanted to leave the program. Others noted that their VA case managers were not sensitive

to their concerns. Respondents with those experiences generally described the relationship as being

a “bad” one. Leased-up exiters described those types of interactions most often.

My experience with my second case manager, I really felt like a number. I knew at that

point there was an overload in case management and that my position was, “Just get you a

house and we’ll deal with this later.” But that wasn’t true for me. Again, being a female

with PTSD, some of the issues that came up for me were more frightening for me to look

for housing at that point. (Stayer—Palo Alto)

She never called me. She never even knew when [my voucher] expired. I figured if she did

even know about that, she didn’t care. So, I moved into the apartment and after I moved

into the apartment, she called me about 3 weeks to a month later and she’s like, “Oh, your

voucher is about to expire, I think, or is it not, or is it already expired?” Like she didn’t

know. I’m like, “I’m already in my own apartment.” She’s like, “Oh really?” I was like,

“Yeah.” She’s like, “Through VASH?” I said, “No, I wouldn’t have the money.” She

didn’t seem to care. She’s like, “Okay. Well, call me if you need anything. ‘Bye.” Click.

(Nonleased exiter—Los Angeles)

Irregular Meetings

Respondents discussed irregular meetings with their VA case managers as a barrier to maintaining

a good relationship. A similar proportion of respondents in each study group cited irregular

meetings as a barrier to VA case management.

I am sure I had somebody because everybody, according to what I understand, has a case

manager, but I did not see a case manager for over a year. (Stayer—Houston)

You know, actually, I think I did meet him for a minute at that enrollment. Yeah, he was

about to leave, they handed him my file, he shook hands with me and he went on his way. I

was able to meet him later on when I went to his office. I did meet him one time—I mean it

was just for a minute. He was already leaving. (Nonleased exiter—Houston)

I met the other guy twice. Once, a surprise visit at my house when you call him up and he

just knocks on the door, which I did not like. He did not call me or anything, he just

knocked. Matter of fact he knocked on the wrong door. He came to ours in the back. We

were number five. I guess he could not tell which was which, but that is how I met him,

come knock on my door. (Stayer—Los Angeles)

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Nonresponsiveness

Some respondents described their VA case managers as nonresponsive (for example, not returning

phone calls, slow to act). A few Veterans mentioned the importance of communication and having

a clear understanding of expectations at the beginning of the relationship, whereas others noted that

their VA case managers were never available and they did not feel well served while in the

program. Nonleased exiters described nonresponsiveness most frequently.

I called them. You get the reception lady. She will say that she will tell Such-and-Such that

you called. They will take your name and phone number. It may not be in the morning

when they call you back. It may be a day or so later. Sometimes I waited 3 days for them to

call me back. I understand that case managers have a certain caseload. They may have 50

people. You do not want to hear 50 people calling your line. I understand that. If she has

somebody that is taking messages for her in-office, or she can contact them directly, that is

fine. It is hard to get in touch with the HUD-VASH or the VA counselors for the HUD-

VASH. Some of these people gave me their direct numbers, and they still do not answer the

phone. (Leased-up exiter—Houston)

I’m not pleased with the response of the case manager. I know everyone is busy, but I’ve

been trying to call because I’m seeking to transfer my voucher now and move to a different

neighborhood. And unless you go to the meeting, that’s the only way you’re sure to see or

speak with your case manager. Lots of times you call and you leave a message on the

phone, they don’t return your calls. There’s no time you can pick up the phone and call

them directly or pick up and answer. I left three messages so far this week. And I’ll have to

go in probably to see her in person. I called her on her cell phone. She gave me her card—

I have it in my wallet right now. And I called her cell phone and I still—I even left a

message. She still hasn’t returned my call because they get that busy, or what have you, or

they said their priorities are different but that’s one thing that I don’t—you cannot speak to

them directly in case of an emergency. I guarantee you cannot pick up the phone and get

your case manager and talk to them directly. So access to your case managers, you know,

we’d much more appreciate. (Stayer—Philadelphia)

I just started to sink more into depression. I thought, “This is what you come home to.”

You know, you say, well, you go to Iraq, you come back. They say, now that you have been

at war, Veteran—they are going to look after you. They are going to take care of you. [My

VA case manager] was a no show several times. She just plainly came out and said she

forgot. And I thought, “Well what is it you think they are paying you for if you forgot me?”

(Leased-up exiter—Houston)

Unmet Expectations

Respondents described disappointment with their VA case managers’ inability to guide them

through the program, provide them with information or resources, and act as advocates on their

behalf. Some Veterans noted that their VA case managers did not understand the process

themselves and were unable to help them, and other Veterans thought their VA case managers

were simply doing the bare minimum of their duties. Exiters—especially nonleased—mentioned

this more frequently than stayers.

For example, he asked if I had enough food or anything. He asked if I needed help. One

day I called him because I did not have any food. He could not help me. Why would he

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Chapter 6: VA Case Management

even tell me that if he was not able to help me with certain questions I had? I had questions

about transportation programs and maybe about schooling. He had no answers for me. He

was surprised that I asked a question. He was the one who asked me if I needed help with

food and I asked. (Leased-up exiter—Los Angeles)

He did not support me one bit, told me what I had to do and that was it. He did not support

me one bit. He told me, “You know, I cannot help you with this, you are on your own.” If I

had been told at the beginning that you have to do all this stuff by yourself instead of, “We

will support you,” but they do not. That is why I asked the one to be removed from my

case. (Stayer—Palo Alto)

My case manager didn’t help me at all when I needed the help. Basically, I was on my

own. She was just a sounding board. She didn’t do much to help the progress of me

securing the voucher. And my case manager only spoke to the real estate agent one time

also. And she was just incompetent. I thought she was incompetent because it seemed like a

lot of times she just didn’t know what to do. (Nonleased exiter—Palo Alto)

I guess it’s that he doesn’t agree with my lifestyle choices as far as career-wise. So we’re

kind of stand offish with each other because of it. I mean, he was because when I told him

that I was in school, he was like, “What school are you in?” I was like, “The Art

Institute.” He was like, “The Art Institute?” He’s like, “You got time for that?” You know,

just the little comments that he was making. I was like, “I know that you don’t agree with

what I do, but this is what I do.” It seems like if this is what I’m going to do or if this is my

career choice, I’m not going to get the type of help that I need. (Stayer—Houston)

Veteran Readiness

A few respondents explained that their own lack of readiness to transition into the program—often

related to addiction, procrastination, or limited independence—affected their relationships with

their VA case managers. Although this reason was mentioned infrequently, leased-up exiters cited

this barrier more often than stayers or nonleased exiters.

I had a couple of peer support people that reached out to me that were going to help me try

and find a place right after I got the voucher, but I didn’t call them back, because I was

going through some other things right then. (Stayer—Houston)

As far as peer support, they would offer groups that I could come in at 10, but because of

my addiction, I procrastinated on that. My case manager would come out and talk to me. I

would be, honestly would with agreeing, but not fully honest. And as a result of me not

taking advantage of the support that was offered, I wound up losing it. (Leased-up exiter—

Palo Alto)

SUMMARY

VA case management requirements varied across the study sites but typically required at least

one monthly contact, consistent with the requirements of the HUD-VASH program.

Administrative data related to contact between Veterans and VA case managers indicated that

the most intense period of case management was between admission to the program and referral

to the housing authority, followed by the period between referral to the housing authority and

receipt of the voucher. Nonleased exiters generally had less frequent VA case management

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Chapter 6: VA Case Management

contacts during those periods, compared with Veterans in the other study groups, even after

taking into account the length of time between program admission and receipt of voucher. The

frequency of VA case management contact with Veterans who moved into a housing unit

gradually decreased.

Data collected during interviews with Veterans indicated that the majority of study respondents

reported that they had contact with their VA case managers at least monthly. Veterans in the

three study groups generally were satisfied with VA case management, with slightly higher

levels of satisfaction among stayers. Nonleased exiters generally agreed on goals and problem

areas with their VA case managers and felt that they had a trusting relationship, but VA case

managers were not able to assist them, at least in comparison with stayers and leased-up exiters.

Study respondents described a number of facilitators of the VA case management relationship,

including having a VA case manager who was accessible, supportive, resourceful, and able to

keep Veterans accountable. Barriers to that relationship were the high rate of turnover among

VA case management staff, as well as irregular interaction between Veterans and VA case

managers and Veterans’ level of readiness to actively participate in case management.

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CHAPTER 7:

VA HEALTH SERVICES USE

In addition to receiving VA case management, Veterans participating in HUD-VASH may

receive care provided by other clinicians at their local VA medical centers, including outpatient

and inpatient healthcare for medical, mental or behavioral health, and substance use issues.

Assessing HUD-VASH participants’ use of those health-related services provides some insight

into their engagement with primary care and the extent to which they may avoid more acute

services, such as inpatient admissions for mental or behavioral health and substance use issues. A

detailed description of the categories of health services is included in appendix C.

This chapter describes Veterans’ use of VA healthcare services immediately before their

enrollment in HUD-VASH, as well as at different stages of the housing process and after move-

in and exit from the program, if applicable. In addition, this chapter presents study respondents’

self-reported health status during their time in the program, as described during interviews.

Supporting data tables are included in appendix I.

VA HEALTH SERVICES USE DURING HOUSING PROCESS

Exhibit 7.1 displays the average monthly number of outpatient medical, mental or behavioral

health, and substance use visits, by study group, for HUD-VASH participants 90 days before

their admission to HUD-VASH, 90 days after admission, and 90 days after move-in, if

applicable. Data indicate that all study groups decreased the frequency of medical, mental or

behavioral health, and substance use visits after their admission to HUD-VASH; that decline

continued for stayers and leased-up exiters following move-in. Nonleased exiters had the fewest

number of outpatient visits and decreased their service use after program admission, which may

indicate a weaker connection with services among this group.

Exhibit 7.1 Monthly Outpatient Visits During Housing Process, HUD-VASH Participants

(N=7,383) | mean

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Note: Statistical significance is indicated by **p ≤ 0.05 and ***p ≤ 0.01.

Source: VA Medical Record

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Chapter 7: VA Health Services Use

Exhibit 7.2 displays the proportion of HUD-VASH participants who had a medical, mental or

behavioral health, or substance use inpatient stay or an emergency care contact during the same

time periods. The proportion of HUD-VASH participants with inpatient stays declined over time

for all study groups. Both leased-up and nonleased exiters, however, were more likely than

stayers to use inpatient and emergency care during each period. Although leased-up and

nonleased exiters had similar levels of inpatient care, a higher proportion of nonleased exiters

had a substance use inpatient stay or received emergency care 90 days after admission to HUD-

VASH.

Exhibit 7.2 Inpatient Stays and Emergency Care During Housing Process, HUD-VASH

Participants (N=7,294) | percent

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Notes: N includes 2,775 stayers, 3,068 leased-up exiters, and 1,451 nonleased exiters. Statistical significance is indicated by *p ≤ 0.10, **p ≤ 0.05 and ***p ≤ 0.01.

Source: VA Medical Record

VA HEALTH SERVICES USE BEFORE AND AFTER EXIT

Exhibit 7.3 illustrates the frequency of outpatient services use for leased-up and nonleased

exiters before and following their exit from HUD-VASH. The average monthly number of

medical visits increased slightly immediately after exit from the program for nonleased exiters

and then decreased over time. Among leased-up exiters, the number of visits decreased or

remained constant across all intervals. The frequency of mental or behavioral health visits

remained fairly constant for both groups. Substance use visits declined slightly for nonleased

exiters.

Exhibit 7.4 illustrates HUD-VASH participants’ use of inpatient and emergency care before and

following exit from the program. Compared with leased-up exiters, more nonleased exiters had

inpatient stays or emergency care contact 90 days before program exit. After exit, Veterans’ use

of inpatient and emergency care either remained flat or declined for both groups of exiters.

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Chapter 7: VA Health Services Use

Exhibit 7.3 Monthly Outpatient Visits Before and After Exit, HUD-VASH Participants

(N=5,876) | mean

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Note: Statistical significance is indicated by *p ≤ 0.10, **p ≤ 0.05 and ***p ≤ 0.01.

Source: VA Medical Record

Exhibit 7.4 Inpatient Stays and Emergency Care Before and After Exit, HUD-VASH

Participants (N=4,387) | percent

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Notes: N includes 2,963 leased-up exiters and 1,424 nonleased exiters. Statistical significance is indicated by *p ≤ 0.10,

**p ≤ 0.05, and ***p ≤ 0.01.

Source: VA Medical Record

SELF-REPORTED HEALTH IN HUD-VASH

During in-person interviews, stayers reported the best health while in the program. They were

more likely to report excellent, very good, or good health compared with the other study groups.

Conversely, nonleased exiters reported the worst health (see exhibit 7.5).

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Chapter 7: VA Health Services Use

Exhibit 7.5 Self-Reported Health Status, Study Respondents (N=508) | percent

54.1

51.3

48.3

38.8

30.8

34.5

13.8

7.0

8.1

2.5

7.5

3.4

Excellent

Very good or Good

Fair

Poor

Stayers

Leased-Up Exiters

Non-Leased Exiters

Note: N includes 370 stayers, 80 leased-up exiters, and 58 nonleased exiters.

Source: Veteran Survey

Despite indicating better health overall, stayers were more likely than other groups to report a

serious medical problem or to be hospitalized for a medical problem. Nonleased exiters indicated

that they had the poorest health and experienced serious medical problems more frequently than

did leased-up exiters; however, nonleased exiters were less likely to report being hospitalized for

a medical problem. Leased-up exiters were more likely to report experiencing and being

hospitalized for serious mental health problems than were the other study groups: three of five

leased-up exiters experienced a serious mental health problem while in HUD-VASH, a share

about 20 percent higher than for stayers and nonleased exiters. Note that the rates of self-reported

inpatient stays are much lower than Veterans’ VA medical records indicate; that may be partly

because of recall bias and partly because Veterans responded based on a different time period

than is measured in the administrative data see exhibit 7.6).

Exhibit 7.6 Self-Reported Medical and Mental Health Problems, Study Respondents (N=508)

| percent

57.6

60.0

51.3

53.4

38.6

38.9

41.4

31.3

24.1

10.0

15.0

10.3

Experienced serious medical

Hospitalized for medical

Experienced serious mental

Hospitalized for mental health

problems

problem

health problems

problem

Stayers

Leased-Up Exiters

Non-Leased Exiters

Source: Veteran Survey

More than two-thirds of stayers and a majority of nonleased exiters reported that they were not

troubled at al  by drugs or alcohol. Nonleased exiters, however, were more likely than stayers to

report being extremely troubled. Leased-up exiters reported being most troubled by substances while

in HUD-VASH, with more than one-fourth indicating being troubled at least moderately; they were

also more than twice as likely as the other groups to indicate being extremely troubled by drugs or

alcohol (see exhibit 7.7). Veterans reported receiving drug or alcohol treatment about equal y across

study groups (about one-fourth indicated they had received inpatient treatment, outpatient treatment,

or both), however, although nonleased exiters more frequently reported receiving inpatient treatment

(8.6 percent versus 4.1 percent of stayers and 0.0 percent of leased-up exiters).

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Chapter 7: VA Health Services Use

Exhibit 7.7 Self-Reported Being “Troubled” by Drugs/Alcohol, Study Respondents (N=507) |

percent

68.6 53.8 63.8

18.2 18.8 24.1

9.2 10.0 5.2

3.0

7.5

1.7

1.1 10.0 5.2

Not at all

Slightly

Moderately

Considerably

Extremely

Stayers

Leased-Up Exiters

Non-Leased Exiters

Note: N includes 369 stayers, 80 leased-up exiters, and 58 nonleased exiters.

Source: Veteran Survey

During qualitative interviews, Veterans discussed the intersection of medical, mental health, and

substance abuse issues. They most often described those conditions as barriers to retaining their

voucher or housing.

I was going through discovering about my ailments and dealing with losing my kids and

wife. I was still trying to work hard, but because my medical conditions kind of kept me

from reaching my full potential, I was not into handouts or whatnot. I was not really

looking forward to the program. I just got to a point where I had nowhere else to turn. My

personal problems caused me to be depressed and my temper was impulsive. (Nonleased

exiter—Houston)

I was breaking rules. It was saying that you could not allow people to come and live with

you. I had people living with me, friends. I know you are not supposed to do certain things in

the unit; I was doing them anyway because of my addiction. (Leased-up exiter—Palo Alto]

I get my bouts of depression. Sometimes I will not even go out or go downstairs to retrieve

my mail. I just do not want to do anything. I do not want to listen to anything. I just wake

up, and I will sit down and I will just—I am just there. (Stayer—Los Angeles)

I don’t support pharmaceutical medication as the VA prescribed due to the psychoactive

purpose of them, so the medicine that I choose, the more holistic kind, are not really shined

upon by society. So that’s occasionally an issue with landlords, but usually they don’t

mention that. (Nonleased exiter—Los Angeles)

Conversely, Veterans often described housing as an incentive to address their health and substance

abuse problems.

I took it hard. I wanted to pick up the bottle. I wanted to, I wanted to just—everything was

going beautiful until that one time. Then I—instead of picking up the bottle again, I went to

the VA. I told the doctors, “I need help. I might die tomorrow if I am out there in the

streets because I do not know what I am going to do.” I told them all right. They put me in

mental health. They kept me there for a few weeks. (Stayer—Palo Alto)

That was my main incentive when I felt like drinking or felt suicidal or felt anything; it was

like, “I do not want to lose this.” This was a very good thing. This is very valuable. It meant

a lot to me to have my own place. And it was an incentive—or no, more than an incentive—it

was like I had reached this goal of having my own place. (Stayer—Philadelphia)

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Chapter 7: VA Health Services Use

SUMMARY

Around the time of entry in the HUD-VASH program, stayers and leased-up exiters used

outpatient care at a higher rate than did nonleased exiters, possibly because those groups were

generally more connected to services than were nonleased Veterans. Leased-up and nonleased

exiters used inpatient and emergency care at similar rates and were much more likely to use

those services compared with stayers, indicating a greater need for more intensive and acute care

among exiters.

Comparing the monthly average of outpatient visits during the 90-day period immediately before

program entry to the 90-day period immediately preceding program exit indicates that Veterans

in both exiter groups had many more outpatient visits and more inpatient stays before program

entry than during the period of time leading up to their program exit. Around the time of their

exit, nonleased exiters had slightly more frequent visits for outpatient care than did leased-up

exiters; however, that fact is not surprising given that leased-up exiters were in permanent

housing during that time, which may have increased their access to care. Finally, the number of

Veterans in both exiter groups using medical or mental health services decreased over time after

their exit from HUD-VASH, suggesting that their needs were being met.

The majority of stayers reported good or better health during their stay in HUD-VASH;

nonleased exiters were almost twice as likely as the other groups to report poor health. Stayers,

however, were more likely to report having serious medical problems and receiving inpatient

medical care during their time in HUD-VASH. Leased-up exiters reported much more frequently

that they had a serious mental illness and had been hospitalized for those issues.

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CHAPTER 8:

EXITS FROM HUD-VASH

To better understand Veterans’ exits from HUD-VASH both before and after moving into a

housing unit, the research team collected data from administrative records, program staff, and

Veterans themselves. Administrative data provided information about Veterans’ length of stay in

the program, reasons that VA case managers cited for Veterans’ exits from the program, and

returns to homelessness after exiting the program. Program staff from both local housing

authorities and VA case management teams discussed common reasons why Veterans exit HUD-

VASH and Veterans described their exiting experiences. Supporting data tables are included in

appendix I.

For the purposes of this study, an exit from HUD-VASH means that a Veteran exited HUD-

VASH case management and is no longer receiving supportive services from the program (i.e.,

by leaving one of the two components of the program, the Veteran is considered to have exited).

Exit status is indicated by VA case managers in VA administrative data systems; however, there

is no indication of whether Veterans who exited case management continued to use their HUD-

VASH voucher to subsidize their housing expenses. Therefore, this study did not explore the

relationship between an exit from HUD-VASH case management and an exit from voucher-

subsidized housing. 12

FREQUENCY AND TIMING OF EXITS

Among the 7,383 HUD-VASH participants included in the study sample, 3,088 (41.8 percent)

were leased-up exiters who left the program after accessing a housing unit, and 1,507 (20.4

percent) were nonleased exiters who received a voucher but left the program before moving into

housing.

Leased-up exiters participated in HUD-VASH for about 2 years (731 days) from voucher

issuance to move-in and exit; on average, they remained in their housing units for more than 1

1/2 years (658 days). From voucher issuance to exit, nonleased exiters were in the program

approximately 5 months (148 days). Exhibit 8.1 displays the number of HUD-VASH participants

who exited the program in 30-day intervals from date of voucher receipt.

12 In-house analysis conducted in December 2016 by HUD indicates that among 64,000 Veterans who exited HUD-VASH case management nationally between 2008 and 2016, voucher status is unknown for about one quarter; among the 47,000 Veterans for whom voucher status is known, a small proportion (10 percent) ended participation in HUD housing assistance more than 45 days before exiting case management and more than half ended housing assistance within 45 days before or after exiting case management; of the one-third of exiters who continued housing assistance, at least half continued housing assistance for a year or more after exiting case management.

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Exhibit 8.1 Days Between Receipt of Voucher and Exit, HUD-VASH Participants (N=3,415) |

count

250

200

150

er of Exits

umb 100

N

50

0 0

90

180

270

360

450

540

630

720

810

900

990

1,080

Leased-Up Exiters

Non-Leased Exiters

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Homeless Operations Management and Evaluation System

Reasons for Exit

ADMINISTRATIVE DATA

When a Veteran exits HUD-VASH, VA case managers record in HOMES (the management

information system for VA homeless programs) one of the 12 reasons listed in exhibit 8.2 to

indicate why the Veteran ended his or her involvement in HUD-VASH case management.

According to VA case managers, the most common reason for exit among leased-up exiters is

that the Veteran accomplished his or her goals or obtained access to services and no longer

needed the program. Eviction or selecting other housing were also identified frequently, although

fewer than one in 10 leased-up exiters left the program for either of those reasons. Nonleased

exiters were more evenly split across exit categories: VA case managers indicated most

commonly that nonleased Veterans left the program because they were no longer interested in

participating, followed by being unable to locate the Veteran or the Veteran’s selection of other

housing (see exhibit 8.2).

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Exhibit 8.2 Reasons for Exits Reported by VA Case Managers, HUD-VASH Participants

(N=4,925) | percent

Accomplished goals/no longer needs program

1.9

42.5

Cannot be located

3.0

16.6

Deceased

1.2

8.7

Evicted by HA or landlord or other housing issues

0.1

9.1

Found/chose other housing

8.1

14.2

3.7

Incarcerated

3.6

No longer financially eligible

4 6.9.0

No longer interested in participating in HUD-VASH

5.7

21.9

Noncompliance with HUD-VASH case management

2.7

10.1

1.6

Too ill to participate in HUD-VASH

1.7

Transferred to another HUD-VASH program site

1.5

2.1

Other

8.4

20.0

Leased-Up Exiters

Non-Leased Exiters

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Note: N includes 3,070 leased-up exiters and 1,855 nonleased exiters.

Source: VA Homeless Operations Management and Evaluation System

Program Staff

During site interviews, staff from local housing authorities and VA case management teams

described their views about the main reasons for program exit for leased-up and nonleased

exiters. Those reasons are outlined in exhibit 8.3.

Detailed descriptions of the most common reasons cited across teams follow.

Challenging Process

Staff in Houston, Los Angeles, and Philadelphia identified the complexity of the application and

housing process as reasons for nonleased exits. Staff reported that Veterans may find the process

too difficult and fail to follow through. Although several sites have tried to improve the process,

they reported that it could still feel intimidating to Veterans.

Incarceration

Staff at each study site mentioned incarceration as a reason for leased-up exits. VA staff in Palo

Alto noted that the VA case management team attempts to work with the Veteran so that she or he

can remain in the program; however, if the Veteran is incarcerated for an extended period of time,

the Veteran must exit the program.

Increase in Income

Staff across the study sites indicated that an increase in income was a positive reason for exiting

the program. For leased-up exiters, increases in income may be related to Veterans accessing

benefits or obtaining employment, either making them ineligible for the program or making the

housing authority’s portion of the rent so small that Veterans voluntarily return their vouchers. For

nonleased exiters, an increase in income, typically also through employment or increases to

benefits, can make Veterans ineligible for the program.

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Exhibit 8.3 Reasons for Exits Identified by Housing Authority and VA Staff

Houston

Los Angeles

Palo Alto

Philadelphia

Leased-

Leased-

Leased-

Leased-

Up

Nonleased

Up

Nonleased

Up

Nonleased

Up

Nonleased

Exiters

Exiters

Exiters

Exiters

Exiters

Exiters

Exiters

Exiters

Challenging process  -

X

-

-

-

X

-

X

Death

-

-

-

-

X

-

X

-

Eviction

X

-

-

-

-

-

-

-

Homeownership

-

-

-

-

-

-

X

-

Housing preference

-

-

-

X

-

-

-

-

Incarceration

X

-

X

-

X

X

X

-

Increase in income

X

-

-

X

X

X

X

X

Isolation

-

X

-

-

-

-

X

-

Lease or program

violations

X

-

X

-

-

-

X

-

Loss of contact

-

X

X

X

X

X

X

-

Mass briefings

-

X

-

-

-

-

-

-

Mental illness

-

-

-

X

-

X

-

-

Motivation

-

X

-

-

-

X

-

X

Move/port

-

-

-

-

-

-

X

-

Noncompliance with

VA case management  X

-

-

-

-

-

-

-

Nonpayment of rent  X

-

-

-

-

-

X

-

Personal history (for

example, bad credit,  -

-

-

-

-

X

-

-

poor rental record)

Problem with housing

unit

-

-

-

-

-

-

X

-

Readiness

X

-

-

-

X

-

-

X

SUD

X

-

-

X

-

X

-

-

Unit abandonment

X

-

-

-

-

-

X

-

Voucher as safety net  -

X

-

-

-

-

-

-

Withdrawal

-

-

x

X

x

-

X

-

SUD = substance use disorder. VA = U.S. Department of Veterans Affairs.

Source: Staff Interview

Lease or Program Violations

Veterans who violate lease agreements or program requirements may be evicted from their housing

or removed from HUD-VASH, which staff described as a typical reason why leased-up Veterans

exit the program. Lease violations may include behavioral issues that cause problems with

neighbors or property owners, nonpayment of rent, or people not included on the lease living in a

unit, while noncompliance with the housing authority’s recertification process is a common

program requirement violated by participants. VA case managers indicated that they try to mediate

those issues to avoid evictions and program exits. Loss of contact | For leased-up exiters, loss of

contact may be related to noncompliance with VA case management (national regulations require

that participating Veterans communicate with VA case managers or VA case management teams at

least monthly), whereas for nonleased exiters it may simply mean that a Veteran’s voucher expired

and housing authority staff and VA case managers were unable to assist the Veteran in seeking

housing.

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Motivation

Program staff indicated that Veterans’ motivation, or lack thereof, is a reason why many nonleased

exiters do not remain in HUD-VASH; they may not be motivated to complete the processes

required to access housing.

Withdrawal

Leased-up exiters often choose to withdraw from the program because they may no longer need

VA case management after a long period of housing stability and can pass the voucher on to

another Veteran who needs it more. They may also withdraw because they would like to move or

seek a residential assistance program or rehabilitation for substance use.

Study Respondents

When administering surveys to study respondents, interviewers asked Veterans if they decided to

leave the HUD-VASH program or if they were asked to leave. For those who reported that they

decided to leave, interviewers asked if respondents had plans for a place to live after they left the

program. About three in five exiters in both groups reported that they decided to leave HUD-

VASH (58.4 percent of leased-up exiters and 57.9 percent of nonleased exiters). Among those

who decided to leave, the majority of both groups had plans for their living arrangement

following exit (84.3 percent of leased-up exiters and 72.2 percent of nonleased exiters).

Interviewers then presented study respondents with a list of situations that could have

contributed to their leaving HUD-VASH (e.g., issues with housing or personal circumstances,

such as changes in income or health). Veterans were asked which situation best matched the

main reason that they left the HUD-VASH program and which additional factors also

contributed to their exit.

The most common reason for exit reported by leased-up exiters was an increase in income; the

27 percent of respondents who indicated this also reported that an improvement in medical,

mental health, and substance use conditions contributed to their exit from HUD-VASH.

Conversely, the second most common reason for exit among this group was a decline in these

conditions. Respondents who reported a decline in health (20.3 percent) as the primary reason for

exit also reported that housing issues, such as difficulty paying the rent or eviction, contributed

to their exit. Leased-up exiters reported difficulty with housing (i.e., dissatisfaction with the

neighborhood or apartment and conflict with the landlord or neighbors) as the third most

common reason for exit, citing eviction and an increase in income as factors that contributed to

their exits. (See exhibit 8.4.)

Nonleased exiters most often reported that challenges associated with finding housing were their

main reasons for exiting the program prior to moving into a housing unit. Nonleased exiters most

commonly indicated that having the voucher revoked by the housing authority was the main

reason for their exit. These Veterans also indicated that they were unable to find an apartment to

rent with the voucher and were dissatisfied with available apartments. The second most common

category of exit among nonleased respondents was difficulty with housing (i.e., dissatisfaction

with available apartments, inability to find an apartment to rent with the voucher, or the

apartment did not pass inspection); other contributing factors included having insufficient funds

to pay for the security deposit or furniture. Finally, the third most common reason for exit among

this group was an offer from family or friends to move into their housing; lack of money for

move-in costs contributed to some Veterans making this decision. (See exhibit 8.5.)

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Exhibit 8.4 Main Reason for Exit Reported by Leased-up Exiters, Study Respondents (N=74)

| percent

Voucher revoked

Improvement in

Legal trouble

by HA

substance use condition

Difficulty with  4%

4%

1%

HUD-VASH case

management

6%

Evicted from apartment

7%

Increase in income

27%

Difficulty paying rent

8%

Worsening in

medical, mental

health or substance

use condition

20%

Offer from family or friend

Difficulty with

to move in to their

housing*

housing

12%

11%

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Note: *Difficulty with housing includes conflict with landlord, conflict with neighbors, dissatisfaction with apartment, and dissatisfaction with neighborhood.

Source: Veteran Survey

Exhibit 8.5 Main Reason for Exit Reported by Nonleased Exiters, Study Respondents (N=53)

| percent

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Note: *Difficulty with housing includes dissatisfaction with available apartments, inability to find an apartment to rent with the voucher, and apartment did not pass housing authority inspection. **Difficulty with HUD-VASH case management/

services includes conflict with HUD-VASH case manager or program staff and disagreement with program rules.

Source: Veteran Survey

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Qualitative Respondents

Leased-up and nonleased exiters discussed their exit from HUD-VASH in greater detail during

qualitative interviews. Most qualitative respondents cited a series of experiences and multiple

factors that precipitated their exit. Exhibit 8.6 lists common reasons for exit. Leased-up exiters

most frequently cited problems with the program, eviction, or financial issues. Nonleased exiters

listed as important factors in their exit that their voucher had expired; financial issues; lack of or

dissatisfaction with available housing; offers from family or friends to move into their housing;

and worsening in medical, mental health, or substance use conditions.

Exhibit 8.6 Reasons for Exit, Qualitative Respondents

Leased-up exiters

Nonleased exiters

Arrest

Arrest

Disagreement/problem with program

Disagreement/problem with program

Dissatisfaction with unit/conflict with property owner

Disputed housing area or type

Eviction

Eligibility issues (homelessness status, income)

Financial issues

Enrollment issues

Housing authority issues

Financial issues

Increase in income

Increase in income

Medical concerns

Inspection issue

Moved in with family or friend

Lack of housing options/dissatisfaction with units

Noncompliance with housing authority rules

Medical or mental health concerns

Recertification problem

Moved in with family or friend

Substance use

Substance use

VA case management issue/noncompliance

Voucher expired while dealing with personal circumstances

Voucher expired before new unit found

VA = U.S. Department of Veterans Affairs Supportive Housing.

Source: Veteran Interview

Disagreement/Problem with Program

One of the most frequent factors contributing to program exit was issues with the HUD-VASH

program. Leased-up exiters referenced VA case management issues (for example, being

noncompliant with the VA case management requirement and personal issues with individual VA

case managers), as well as problems with the housing authority (for example, not complying with

program rules, such as including all tenants on the lease). They further described HUD-VASH

requirements as burdensome. One Veteran indicated that “it didn’t make sense to keep dealing with

them” for the $100 voucher payment (Leased-up exiter—Los Angeles), and another indicated that

difficulty with recertification led to the voucher being revoked and the Veteran was unable to

remain in the housing unit without rental assistance. Nonleased exiters described problems with

enrollment, including lost paperwork and communication issues with HUD-VASH staff, as well as

concerns over continued eligibility, with one Veteran fearful that working would put his or her

income over the maximum for eligibility.

Well, now the reason why, and this is one thing that really sort of perplexed me—the

reason why I lost my voucher was because I was over here. I had a doctor’s appointment.

And I guess it was basically around the same time that I had that voucher reinstatement

thing. But I’m like, “Okay, if I’m in the voucher program and I get certified, why should I

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have to go through recertification over and over and over?” It’s difficult. I’m a single

parent without transportation, and it’s like, “Are you kidding me? I got to lug my child out

here in the cold?” And I was like,” I’m not going to do it.” (Leased-up exiter—

Philadelphia)

I was on the phone with them. The VASH chick did not know. The VASH’s boss did not

know. The public housing authority did not know. I found out by the time my voucher was

expired—they had an answer for me. (Nonleased exiter—Los Angeles)

Eviction and Financial Issues

A substantial number of leased-up exiters left their HUD-VASH units following eviction. Reasons

for eviction were complex and often intersected with financial problems, legal trouble, and

substance use. One Veteran never paid the security deposit, even after 17 months of living in a

unit, reporting that it was because the Veteran was “actively into” an addiction (Leased-up exiter—

Palo Alto). Others did not pay rent because of changes in employment or benefits payments, the

death of a fiduciary, or arrest. Substantial rent increases or changes to the amount paid through the

voucher also caused difficulties. More than one Veteran described making rent payments for an

incorrect amount and being unable to afford the back rent and late fees when the oversight came to

light. One Veteran resorted to illegal activities in an attempt to get money for rent and avoid

eviction. Veterans who were evicted described losing everything and sometimes ending up on the

street.

She said, “Well, you need to call Section 8. You need to talk to the landlord.” I explained

to her, “Both of us or you would do better than just me, because they are not trying to hear

anything that I have to say.” Anyway, she didn’t do it. I have a bipolar condition. I can’t

take pressure. I wound up being 302 for about a month. This is without pay. I got out of the

hospital, took a spill—I slipped. Anyway, I slipped; that was like another month and a half

out of work. That is like close to 3 months out of work without pay. Now, I got the eviction

notice, which I gave to the case manager. I said, “I would really appreciate it if you would

come down to the court with me.” She didn’t come down there. I went down to Section 8.

They were telling the judge that I owed them back rent and they didn’t want to hear

anything about the letter. I had the letter with me. About 2 weeks later, me and my son got

evicted. I lost everything I had, and as a direct result of that, both of us were sleeping in

my car for about 3 weeks. (Leased-up exiter—Philadelphia)

[My mother] was diagnosed with cancer and she passed away 2 weeks later. It was just so

quick. I did not get a chance to call or set up another arrangement. When she passed

away, I was still getting the hard checks. I was calling every other week. They said they

already processed it. I kept calling and calling. They finally told me to stop calling. I said I

could not stop calling; I could not get evicted. Nobody wanted to help me. It took 3 or 4

months before they even assigned a new fiduciary person to come. That took another 2

months. I even asked if there was a protocol or something, if there was an emergency, in

case of this happening. (Leased-up exiter—Los Angeles)

It had changed so much. At one time, I owed them $4,000, because they said PHA had

went up. First my rent was $38. I was paying that, paying that, paying that. I got locked

up. Me and my girlfriend had a little misunderstanding and the cops locked me up for all

of August. When I got out, I called my landlord to tell them the reason why I didn’t pay the

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rent was because I was locked up. They told me that I owed them $4,000 because my rent

had went up to $138, not $38. But I’d been paying them $38 since I got on unemployment.

And I find out that PHA went up without really—when I already let them know that I

wasn’t working. I’m collecting unemployment, but I had no problem paying that $38 with

my unemployment check, so that’s what I kept doing. Now it’s September and they sent me

this bill from February, March, April, May, June, July, August, September, at $138. They

didn’t even say $100—I did pay $38, you know—but they got $138, $138, $138, $138,

$138, and late fees, too—came to like $4,000-something. (Leased-up exiter—Philadelphia)

I have not seen her since before I was evicted, I think, because I had lost contact with her

almost 2 months before I was evicted, because I was locked out by the sheriffs. And, what

happened was the landlord had served me a 3-day notice after I did not have the money for

the month in advance, and he rejected the 2 months. He served a three-day notice, and I

got no further paperwork stating when to come to court or anything. Two weeks later, I am

locked out of my apartment. So, I had no way of getting paperwork or any of the papers to

try to contact my worker here at the VA. So, we lost contact briefly because of that. And, I

got desperate and tried to make the money illicitly, because I did not want to lose my

place. And, that is how I wound up getting locked up. So, it has all been a nightmare.

(Leased-up exiter—Los Angeles)

I was devastated, I was. Because I lost everything, like I said—my TV, my furniture, my

appliances. I lost everything. (Leased-up exiter—Palo Alto)

Voucher Expired

Voucher expiration was the main reason that nonleased Veterans exited HUD-VASH. Respondents

described many underlying reasons for voucher expiration; however, the reasons were

overwhelmingly negative. Only one Veteran no longer required rental assistance and allowed the

voucher to expire. Others had negative experiences with the program or could not find an

appropriate unit to rent and decided not to move forward. Some described not being able to afford

a unit even with the voucher, or personal issues, such as mental health issues or substance use, that

kept them from engaging in the program and finding a unit.

I just went and said here’s your voucher and all of that. I just told them, “Thank you, but I

don’t need this right now at this present time. You couldn’t help, and I can move on and

give the voucher to somebody else that is much more in-need than I am.” (Nonleased

exiter—Palo Alto)

I hated doing that, because I went so far along to get to where I was, and it was not an

easy thing to do. I changed my mind. I went over to the housing office, and they were really

nice about that too. She’s like, “Well, okay. I’ll just cancel all of the vouchers and

everything.” And I said, “Maybe somebody else needs it and can do it, because I’m okay

now.” She said, “If you ever need to reapply, just go through your VASH person and they

will be there.” So it wasn’t difficult getting out of it—it’s just I felt kind of guilty. I went so far. (Nonleased exiter—Los Angeles)

When I decided to leave, I just explained to my VASH worker what had happened and I

just decided that it would be best for me just to find a place on my own because [of all of

the paperwork], I just did not want to go through that again. I just thought it was easier for

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me to just deal on my own as opposed to dealing with the process. I did not know that I

could do it all over again or continue. So I just said that I would just leave it alone for a

minute ’cause that was a pretty draining experience for me. And I just did not want to, at

that point, I just did not want to continue anymore—to deal with it. (Nonleased exiter—Los

Angeles)

Your voucher is based on the percentage of disability that you receive. At the end of the

month, once I received my check, I still was not able to afford it. I received a voucher for a

two bedroom and [had] difficulties finding a two bedroom that was suitable for my family,

my two boys. Because of financial purposes, my case manager advised me to go to a one

bedroom. I went back to the housing authority to get an extension and get a voucher for a

one bedroom. I turned in my paperwork and never received a call back about it. Once I

followed up on it, I was told that I was kicked out of the program and I had to start all over

again. (Nonleased exiter—Houston)

I was feeding my addiction and I didn’t come back for about 2 months. I fell off the grid. I

just went on with my addiction for a while—drinking. I lost contact with everybody.

(Nonleased exiter—Palo Alto)

CHARACTERISTICS PREDICTING EXIT

To determine characteristics that may predict whether a Veteran exits HUD-VASH, the research

team ran two logistic regressions: the first one modeled whether a Veteran who moved into

HUD-VASH housing later exited the program (that is, whether the Veteran was considered a

leased-up exiter or a stayer), and the second modeled, among exiters, whether the Veteran exited

the program before leasing a housing unit. A detailed description of the methods for this analysis

is included in appendix C.

Exhibit 8.7 provides results from the two logistic regressions. The first panel lists the odds ratios

for characteristics that were associated with Veterans exiting the program after accessing

housing; in addition to several control variables (that is, study site and male sex), having a

service-connected disability increased the odds by 37 percent that Veterans who moved into

housing would exit. The second panel lists the odds ratios for characteristics that were associated

with Veterans exiting the program after receiving a voucher but before accessing housing; in this

case, a diagnosis of PTSD increased the odds by 25 percent that a Veteran would exit HUD-

VASH before moving into a unit.

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Exhibit 8.7 Logistic Regression Modeling Exits From HUD-VASH, HUD-VASH Participants

Leased-Up Exit vs. Stay

Nonleased vs. Leased-Up Exit

N=5,850

N=4,565

OR

95% CI

OR

95% CI

Houston

2.65

2.32–3.03

0.38

0.33–0.45

Palo Alto

2.90

2.48–3.40

0.55

0.46–0.65

Philadelphia

0.58

0.47–0.71

0.83

0.62–1.11

Age

0.99

0.99–1.00

0.99

0.99–1.00

Male

1.22

1.02–1.46

1.09

0.87–1.36

White

1.01

0.90–1.14

1.54

1.35–1.77

Other race

1.03

0.81–1.32

1.45

1.12–1.89

Service-connected disability

1.37

1.22–1.53

0.93

0.82–1.07

PTSD

—

—

1.25

1.01–1.56

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing. CI = confidence interval. OR = odds ratio. PTSD = post-traumatic stress disorder.

Notes: Reference categories: Study site—Los Angeles; Gender—Female; Race—Black; Service-connected disability—No service-connected disability; PTSD—No diagnosis; Schizophrenia—No diagnosis. Statistical significance is indicated by bold font (p ≤ 0.05).

Sources: VA Homeless Operations Management and Evaluation System; VA Medical Record

PROFILES OF EXITERS

To better understand and describe Veterans who exited HUD-VASH and the nature of their exit,

the research team conducted a series of latent class analyses (LCAs). This type of analysis uses

data that describe the study sample—in this case, demographics, health conditions, reason for

exiting the program—to group the members of the study sample into subgroups. The results

describe the heterogeneity among exiters, which is useful in understanding how the

characteristics and circumstances of exits may vary greatly within the population of exiters,

informing potential policy and practice responses tailored to Veterans who meet a certain profile.

A detailed description of the methods for this analysis is included in appendix C.

Exhibits 8.8 and 8.9 describe the subgroups or classes of leased and nonleased exiters, arranged

in order of most to least successful exits. Classes where a majority of Veterans exited the

program because they had accomplished their goals or became financially ineligible—possibly

related to an increase in income through employment or some other means—are considered more

successful than classes where decidedly negative exit reasons such as eviction or incarceration

are more common.

Exhibit 8.8 describes five classes of leased-up exiters. The first three classes varied

demographically, but those Veterans generally left HUD-VASH because they had accomplished

their goals or became financially ineligible. The smallest and least successful class of Veterans

had high needs and little income and used acute or intensive services more frequently; those

Veterans tended to exit the program for reasons such as noncompliance or incarceration. (See

exhibit 8.10 for details).

Exhibit 8.9 describes the three classes of nonleased exiters. Approximately one-fourth of

nonleased exiters seemed to have few needs, had access to income, and left the program before

accessing housing as a result of other opportunities. The other two classes seemed to have a

range of needs and left the program for a variety of reasons, least frequently because they had

accomplished their goals (see exhibit 8.11 for details).

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Exhibit 8.8 Profiles of Leased-Up Exiters, HUD-VASH Participants (N=2,959) | percent

Demographics

Clinical Characteristics

Reasons for Exit

Younger

Accomplished goals

Class 1

Low rates of chronic medical and

20.9%

Female

behavioral health conditions

Found other housing

SC disability

Financially ineligible

Older

Class 2

Male

Low rates of chronic medical and

16.4%

behavioral health conditions

Accomplished goals

No SC disability

Class 3

Middle-aged

High rates of behavioral health

Accomplished goals

16.6%

Male & female

conditions; chronic medical conditions

SC disability

Financially ineligible

Older

Accomplished goals

Class 4

Male

Low rates of chronic medical and

Lost contact, incarcerated

32.2%

behavioral health conditions

No SC disability

Non-compliance, eviction

Older

Class 5

High rates of chronic medical and

Lost contact, incarcerated

Male

behavioral health conditions, inpatient

13.9%

No SC disability

care

Non-compliance, eviction

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Homeless Operations Management and Evaluation System

Exhibit 8.9 Profiles of Nonleased Exiters, HUD-VASH Participants (N=1,037) | percent

Class 1

Younger

Found housing elsewhere

Low rates of mental\behavioral health

25.2%

Female

and/or substance abuse problems

Were no longer interested in

SC disability

HUD-VASH

Class 2

Older

Low rates of mental/behavioral health

44.9%

Male

and/or substance abuse problems

Typically did not accomplish goals

No SC disability

Younger to middle-

Class 3

aged

High rates of mental/behavioral health  Loss of contact (with VA)

and/or substance abuse problems

29.9%

Male

Illness

No SC disability or

Use of inpatient care prior to exit

Incarceration

>50% disability

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Homeless Operations Management and Evaluation System

Taken together, the two LCAs describe three categories of exiters. The most successful leased-up

exiters and nonleased exiters had similar profiles: younger, black, female Veterans with a

service-connected disability who had minimal medical problems or mental, or behavioral health

problems and demonstrated that they no longer needed the program. The least successful

Veterans in the two exiter groups also shared several characteristics: those Veterans less

frequently had a service-connected disability but had very high rates of medical, mental or

behavioral health, or substance use conditions and somewhat frequent use of inpatient care

before exiting HUD-VASH, often exiting because they were unable to be located, ill, or

incarcerated. A third category of exiters—consistent with leased-up exiter class 4 and nonleased

exiter class 2—were also similar: older, black, male Veterans without a service-connected

disability, who were less successful than Veterans in other classes, and who typically did not

leave HUD-VASH for positive reasons.

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Exhibit 8.10 Latent Class Analysis of Leased-Up Exiters, HUD-VASH Participants

Class 1

Class 2

Class 3

Class 4

Class 5

N=666,

N=536, 16.4%  N=507, 16.6%  N=833, 32.2%  N=417, 13.9%

20.9%

N

%

N

%

N

%

N

%

N

%

Study site

Houston

316

47.5

0

0.0

199

39.3

352

42.3

122

29.3

Los Angeles

268

40.3

172

32

147

29.0

429

51.5

173

41.5

Palo Alto

45

6.7

364

68

151

29.8

0

0.0

88

21.1

Philadelphia

37

5.5

0

0.0

10

1.9

52

6.2

34

8.2

Gender

Female

223

33.5

24

4.5

66

13.0

8

1.0

5

1.2

Male

443

66.5

512

95.5

441

87.0

825

99.0

412

98.9

Age

<35

230

34.6

30

5.6

77

15.1

0

0.0

0

0.0

35–44

194

29.1

41

7.6

100

19.8

22

2.7

1

0.2

45–54

150

22.5

205

38.3

200

39.5

302

36.2

146

35.1

55–64

90

13.5

196

36.5

115

22.7

418

50.2

239

57.3

≥65

2

0.3

64

11.9

15

3.0

92

11.0

31

7.4

Race

Black

478

71.7

169

31.6

234

46.2

592

71.1

224

53.6

White

161

24.1

322

60.0  233

45.9

197

23.7

181

43.3

Other

28

4.2

46

8.5

40

7.9

44

5.3

13

3.1

Enrollment priority group

≥50% service-connected

disability

314

47.2

102

19.1

251

49.5

78

9.4

51

12.3

<50% service-connected

disability

145

21.8

84

15.6

107

21.2

133

16.0

58

14.0

No service-connected disability  168

25.3

321

59.8

134

26.4

558

67.0

286

68.5

Other

38

5.7

29

5.5

15

2.9

63

7.6

22

5.2

Medical conditions and mental or behavioral health conditions and service use

Any medical condition

37

5.5

75

14

247

48.8

130

15.6

343

82.2

Any mental health condition

34

5.1

41

7.7

415

81.9

53

6.4

316

75.7

Any substance use condition

23

3.4

53

9.8

401

79.1

142

17.1

354

84.8

Any inpatient stay before exit

13

2.0

31

5.8

45

8.9

75

9.0

103

24.8

VA case managers’ reason for exit

Accomplished goals

282

42.4

349

65.1

237

46.7

314

37.7

80

19.1

Cannot be located, too ill,

incarcerated, or deceased

28

4.2

62

11.6

47

9.2

197

23.6

166

39.8

No longer financially eligible

69

10.3

6

1.2

58

11.5

11

1.3

1

0.3

Noncompliant with VA case

management or evicted

87

13.1

27

5.1

41

8.1

111

13.3

86

20.6

Transferred to another HUD-

VASH program or found other  91

13.6

31

5.8

55

10.8

77

9.3

30

7.3

housing

Unhappy with housing or no

longer interested in participating 52

7.8

24

4.4

37

7.3

47

5.6

26

6.3

Other

58

8.7

38

7

77

9.2

28

6.6

32

6.4

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Sources: VA Homeless Operations Management and Evaluation System; VA Medical Record

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Exhibit 8.11 Latent Class Analysis of Nonleased Exiters, HUD-VASH Participants

Class 1

Class 2

Class 3

N=273, 25.2%

N=451, 44.9%  N=313, 29.9%

N

%

N

%

N

%

Study site

Houston

54

19.9

66

14.7

46

14.7

Los Angeles

176

64.5

298

66.1

180

57.5

Palo Alto

35

13.0

73

16.1

73

23.3

Philadelphia

7

2.6

16

3.5

14

4.5

Gender

Female

79

28.8

7

1.5

11

3.4

Male

194

71.2

444

98.5

303

96.7

Age group

<35

95

34.9

10

2.3

49

15.5

35–44

89

32.6

16

3.5

33

10.6

45–54

52

19.2

150

33.3

102

32.5

55–64

37

13.4

200

44.3

113

36.0

≥65

0

0.0

75

16.6

17

5.5

Race

Black

130

47.6

230

51.0

116

37.1

White

105

38.4

206

45.7

171

54.7

Other

38

14.1

15

3.3

26

8.2

Enrollment priority group

≥50% SC

124

45.3

53

11.8

104

33.2

<50% SC

78

28.6

68

15.0

50

16.1

No SC

64

23.4

294

65.2

148

47.4

Other

7

2.7

36

8.0

11

3.4

Medical conditions and mental or behavioral health

conditions and service use

Any medical condition

18

6.5

62

13.8

203

64.8

Any mental health condition

26

9.5

17

3.8

271

86.6

Any substance use condition

11

4.0

38

8.4

270

86.2

Any inpatient stay before exit

27

6.0

75

24.0

15

5.4

VA case managers’ reason for exit

Accomplished goals

10

3.5

9

1.9

4

1.2

Cannot be located, too ill, incarcerated, or deceased

38

14.1

124

27.6

99

31.6

No longer financially eligible

17

6.1

18

4.0

8

2.6

Noncompliant with VA case management or evicted

37

13.6

55

12.1

41

13.2

Transferred to another HUD-VASH program or found other

housing

61

22.5

71

15.7

49

15.6

Unhappy with housing or no longer interested in

participating

56

20.6

93

20.7

57

18.1

Other

54

19.7

81

17.9

55

17.7

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing. SC = service-connected disability.

Sources: VA Homeless Operations Management and Evaluation System; VA Medical Record

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VETERANS’ STATUS AFTER EXIT

At the time of program exit, Veterans exited HUD-VASH case management; however, 17.7

percent of leased-up exiters and 10.7 percent of nonleased exiters reported during surveys that

they received assistance from their VA case manager in finding a place to stay after they exited

the program. Fewer than one in five study respondents reported having ongoing contact with

their VA case manager (16.5 percent of leased-up exiters and 18.2 percent of nonleased exiters),

but the majority planned to continue using VA services after their exit from HUD-VASH (94.9

percent of leased-up exiters and 96.5 percent of nonleased exiters).

RETURNS TO HOMELESSNESS

Returns to VA Homeless Programs

HUD-VASH participants who exited the program could use VA homeless programs after their

exit. Exhibit 8.12 illustrates the proportion of Veterans who exited HUD-VASH and returned to

homelessness during the year after exiting the program. Almost 93 percent of leased-up exiters

and 90 percent of nonleased exiters did not return to VA homeless programs during the

observation period. Veterans may have accessed other community-based homelessness

assistance programs; however, the research team did not have access to data related to local

Homeless Management Information Systems (HMIS) or unsheltered homelessness.

Exhibit 8.12 Avoiding Returns to VA Homeless Programs 360 Days After Exit, HUD-VASH

Participants (N=4,595) | count

1.00

0.75

vivalur

0.50

ative s

Cumul

0.25

0.00 0

50

100

150

200

250

300

350

Leased-Up Exiters

Non-Leased Exiters

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs (VA)

Supportive Housing.

Source: VA Homeless Operations Management and Evaluation System

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The results of the Cox Proportional Hazards survival analysis presented in exhibit 8.13 indicate

factors associated with Veterans’ return to a VA homeless program after exiting HUD-VASH.

The hazard ratios indicate that, compared with leased-up exiters, nonleased exiters were more

likely to return to homelessness. Women were significantly less likely than men to return to

homelessness. Veterans with a service-connected disability were less likely to return to

homelessness following program exit, whereas those with a drug abuse disorder were more likely

to return to homelessness following program exit. A detailed description of the methods for this

analysis is included in appendix C.

Exhibit 8.13 Cox Proportional Hazards Survival Analysis for Time To Return to

Homelessness Within 360 Days, HUD-VASH Participants (N = 303)

Estimate

Standard Error  Hazard Ratio

p

Houston

-0.261

0.144

0.770

0.070

Palo Alto

-0.314

0.160

0.731

0.050

Philadelphia

0.060

0.246

1.062

0.807

Nonleased exiters

0.371

0.121

1.449

0.002

Age

-0.007

0.006

0.993

0.183

Male

0.563

0.258

1.757

0.029

White

-0.117

0.126

0.890

0.353

Other race

-0.069

0.245

0.934

0.779

Service-connected disability

-0.339

0.122

0.713

0.006

Drug abuse

0.859

0.118

2.360

0.000

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Notes: Reference categories: Study site—Los Angeles; Study group—Leased-up exiters; Gender—Female; Race—Black; Service-connected disability—No service-connected disability; Drug abuse condition—No diagnosis. Statistical significance is indicated by bold font (p ≤ 0.05).

Source: VA Medical Record

Returns to HUD-VASH

Very few HUD-VASH participants returned to HUD-VASH after an initial exit (N = 11, 0.2

percent). During qualitative interviews, some Veterans noted that they would return to the program

if they received better VA case management or housing options in other geographic areas. Several

nonleased exiters were not interested in returning to HUD-VASH, however, because it did not suit

their current housing needs or did not work well for them.

I have nothing bad to say about HUD-VASH, nothing. They did what they were supposed

to do. I, on the other hand, didn’t get a chance to really do what I was supposed to do. I

didn’t make the meetings. I didn’t make the recertification. So, you know, I’m just going to

have to swallow that pill. (Leased-up exiter—Philadelphia)

If it was an opportunity where I could have grown some more intellectually, morally, or

socially. All those things are important. To stay in the program—to continue to help a

Veteran, I would have stayed in. If they would have had more options—I had to keep going

on and doing what I had to do. (Leased-up exiter—Houston)

[I would need] someone that actually followed through. Maybe not like every week, but at

least a phone call every other week, like, “Okay, over the last week, how many places did

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you go to? How many of them accept Section 8? Did you find any that you like?” I never

got that. It was always like, wait, wait, call. I haven’t heard from her in 2 months and,

“Are you still my caseworker?” It got to the point where it felt like that I had a piece of

paper and a nice little wave goodbye and the middle finger saying, “FU. Go have fun.”

(Nonleased exiter—Los Angeles)

SUMMARY

Among HUD-VASH participants at each of the four study sites, 37.8 percent were considered

stayers, 41.8 percent leased-up exiters, and 20.4 percent nonleased exiters. Leased-up exiters

remained in the program for an average of 658 days, or a little less than 2 years, whereas

nonleased exiters participated in the program—from receipt of voucher to exit—for almost 5

months.

Several factors were associated with HUD-VASH participants not staying in the program.

Veterans with a service-connected disability were more likely to exit the program after being

housed. Veterans who had a diagnosis of post-traumatic stress disorder (PTSD) were more likely

to leave the program after they received a HUD-VASH voucher but before accessing permanent

housing. Study respondents provided evidence that having a helpful VA case manager who

agreed with the Veteran’s goals increased the likelihood that the Veteran would obtain housing

and stay in the program for at least several years; having a diagnosis of depression or

schizophrenia decreased that likelihood.

VA case managers and Veterans identified a number of reasons why Veterans exited the HUD-

VASH program. According to VA case managers, the majority of leased-up exiters left their

HUD-VASH housing unit because they had accomplished their goals, found other housing, or

were no longer eligible for the program. Nonleased exiters, on the other hand, were no longer

interested in the program, could not be located, or found other housing before leasing a unit with

their voucher.

Study respondents also provided information on their reason for leaving HUD-VASH. Leased-up

exiters most frequently reported an increase in income as the main reason for their exit—which

would be considered a success as these Veterans were able to live independently—but worsening

in a medical, mental health, or substance use condition and difficulties with housing were also

common among this group. Nonleased exiters most commonly cited having the voucher revoked

by the housing authority or challenges with finding housing, including dissatisfaction with

available units and not being able to find a unit to rent with the voucher, which qualitative

respondents described as often leading to their voucher expiring before they could access

housing. Nonleased exiters also commonly received offers from friends or family to move into

their housing, particularly when they didn’t have money for move-in costs.

To better understand program exits, the research team identified profiles of types of exiters, with

three types emerging among both leased-up and nonleased Veterans:

1.  Younger, female Veterans with a service-connected disability who had minimal

medical problems or mental, or behavioral problems and demonstrated that they

no longer needed the program.

2.  Older, male Veterans without a service-connected disability who exited HUD-

VASH for reasons other than accomplishing their goals or identified housing that

was a better fit.

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3.  Veterans who had lower levels of service-connected disabilities but very high

rates of medical, mental or behavioral health, and substance use conditions;

somewhat frequently used inpatient care; and often left the program because they

could not be located, were ill, or were incarcerated.

After their exit from the program, the vast majority of Veterans—almost 93 percent of leased-up

exiters and 90 percent of nonleased exiters—did not return to VA homeless programs within 1

year. Nonleased exiters were more likely to return to homelessness, as were Veterans with a

substance use disorder. Having a service-connected disability, which indicates that the Veteran is

receiving cash benefits, seemed to be a protective factor.

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CHAPTER 9:

PROGRAM FACILITATORS AND BARRIERS

During site visits, the research team elicited perspectives from local housing authority and VA

case management staff on program facilitators and barriers. Veterans’ views on those topics were

gathered during qualitative interviews. In addition, program staff and Veterans offered their

recommendations for how to improve HUD-VASH.

FACILITATORS

Program Staff Perspectives

The research team asked housing authority and VA staff from each study site what they believed

facilitated successful outcomes in the HUD-VASH program. Responses included facilitators

based on communication and collaboration, program processes and staffing, and Veterans’

relationships with program staff. The facilitators identified by each study site are shown in

exhibit 9.1. This section provides further detail on the most common facilitators mentioned

across all sites.

Collaboration with Community Partners

In Houston, community partners have been essential in reaching citywide goals to end

homelessness. In Palo Alto, community-based organizations are integral to every step of HUD-

VASH, including identifying Veterans experiencing homelessness through outreach efforts, as well

as providing medical services, transportation, and financial move-in assistance. Staff in

Philadelphia noted that community connections, such as co-locating HUD and VA services at the

Veterans Multi-Service Center and maintaining relationships with community service providers

and local property owners, have been invaluable to Veterans served through HUD-VASH.

Connecting Veterans to Wrap-Around Services and Community Resources

In Los Angeles, the VA case management teams include a nurse who can help Veterans with

ongoing medical issues, sometimes directly in their homes. In Palo Alto, HUD-VASH offers

Veterans the opportunity to participate in life skills groups that help them get and stay housed.

The Philadelphia VA team described housing, peer support, and substance use disorder (SUD)

specialists as vital to their team, as well as community resources that assist Veterans interested in

furthering their education or finding employment or volunteer work that may help them

transition out of HUD-VASH.

HUD-VASH Boot Camps

Houston, Palo Alto, and Philadelphia described the utility of participating in HUD-VASH Boot

Camps that bring HUD, VA, and community providers together to collaborate and discover better

ways to serve Veterans.

Program Flexibility

Staff mentioned that program flexibility is key to facilitating faster housing outcomes for Veterans.

The Houston Housing Authority (HHA), for example, has a waiver that enables the housing

authority to pay up to 110 percent Fair Market Rents (FMR) in opportunity areas, enabling

Veterans to move to areas that often have better schools and more community resources. The

Housing Authority of the County of Los Angeles (HACoLA) also described flexibility in

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regulatory requirements for HUD-VASH participants that have allowed them to eliminate

unnecessary or redundant processes, making the program easier to navigate. Likewise, the Housing

Authority of the City of Camden (HACC) indicated that their smaller size allows the housing

authority to have more flexibility to tailor the services they offer to Veterans.

Exhibit 9.1 Program Facilitators Identified by Housing Authority and VA Staff

Houston  Los Angeles  Palo Alto  Philadelphia

Community collaboration

Collaboration with community partners

X

-

X

X

Connecting Veteran to wraparound services and

community resources

-

X

X

X

HUD and VA collaboration

Co-location of housing authority and VA case management  X

-

-

-

Communication between HUD and VA

-

-

X

X

HUD-VASH Boot Camps

X

-

X

X

One main point of contact between HUD and VA

-

-

X

Program processes

Decrease in initial voucher issuance period

-

-

-

X

Decrease in time to housing (preparing Veteran for housing

search, decreasing process times)

-

X

-

-

Group meetings (housing groups, life skills)

-

-

X

-

Opportunity areas within housing authority jurisdiction

X

-

-

-

Preinspected units

-

-

-

X

Program flexibility

X

X

-

X

Streamlined internal processes (one core application across

housing authorities, prioritizing Veteran applicants, daily

-

X

X

X

VA case management huddles)

VA case management

VA case manager as advocate/intermediary

X

-

X

-

VA case manager assisting with application or advising

during meetings with housing authority

-

-

X

-

Motivational interviewing

X

X

-

Smaller VA caseloads

-

-

-

X

VA specialists (employment, housing, peer support, SUD)  X

-

X

X

Veteran relationship with program staff

X

X

-

X

Veteran strengths

Veteran motivation

X

-

-

-

HUD = U.S. Department of Housing and Urban Development. VA = U.S. Department of Veterans Affairs.

Source: Staff Interview

Streamlined Internal Processes

HACLA and HACoLA have worked to create a single, uniform HUD-VASH application, which

makes it easier for VA staff to assist Veterans in completing the application and providing

necessary documents. Similarly, VA staff complete the voucher application for the Housing

Authority of the county of Monterey (HACM), making turnaround time shorter for HUD-VASH

participants than for other households served by the housing authority, and the Philadelphia

Housing Authority (PHA) provides VA and Veterans with checklists to ensure that all application

materials are clear and completed correctly.

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VA Specialists

Staff in Houston, Palo Alto, and Philadelphia mentioned the value of VA specialists trained to

assist Veterans in specific areas. Those VA case management teams rely on VA specialists in

employment, housing, peer support, and SUD to provide Veterans with individualized services.

Veterans’ Relationship With Program Staff

Building a relationship of trust between Veterans and program staff is integral to Veterans’ success

in HUD-VASH. Housing stability often is an outcome of that relationship because VA staff can

assist Veterans with issues and, as staff in Houston described, Veterans who have good contact and

communication with VA staff often follow program rules and requirements. Los Angeles further

indicated that the VA team environment provided a supportive network for Veterans, and the

Philadelphia team noted that a close relationship between Veterans and VA case managers may

allow VA case managers to identify issues that Veterans are experiencing before they escalate.

Veteran Perspectives

During qualitative interviews, Veterans discussed how the program’s facilitation of both housing

(for example, reestablishing a renting record) and nonhousing factors (for example, connections

with social support services; meeting educational, work-related, or personal goals) affected their

experience in the HUD-VASH program (see exhibit 9.2).

Exhibit 9.2 Program Facilitators Identified by Qualitative Respondents

Connecting to community resources

Household assistance

Promoting Veteran independence

Source: Veteran Interview

Connecting to Community Resources

Respondents discussed accessing a variety of programs and social supports that aided in their

community connections. Those programs included attending meetings to remain sober; classes on

managing anger, therapy, or money; and pursuing opportunities for educational or vocational growth.

They have classes, you know. They have computer classes. There is just a lot of things that

they have going on. Some things you may be eligible for and without them you would not

know about it. (Stayer—Philadelphia)

Honestly, HUD-VASH here has a lot of very helpful information as far as going back to

school, as far as gaining employment within the city. They are really good for that. Like I

said, with me it’s kind of a different case, because my mother is still my number one

priority. So, I had to take different routes, and a lot of the help that I received has been

through VUB, Veterans Upward Bound. It’s a program for Veterans who want to go back

to college. So, being in that program really helped me out a lot as far as employment, and

going back to school. And they work together as a matter of fact like HUD-VASH, the VA

and the VUB—they work together. It’s like a lot of the people who are in HUD-VASH are

students at the VUB and vice versa, because at the VUB, I met a lot of homeless Veterans.

(Stayer—Philadelphia)

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They give out information about different places. Maybe there was another place you

could move to, or maybe hotels were giving discounts on furniture and stuff, or if there was

a flea market somewhere or other kind of information, or somebody that is providing some

food or something. They would give information for that. (Leased-up exiter—Philadelphia)

Household Assistance

Respondents reported a variety of ways they received housing assistance through HUD-VASH.

Access to furniture and other household items often was necessary once a Veteran was housed.

Respondents also were often connected to other programs to help with move-in deposits, rental

costs, utility bills, phone expenses, and food assistance.

I went to [a local organization]. They gave me some kitchen stuff that people had donated.

It took me like a month to get my bed, though, after that because I wasn’t going to get a

bed from that place. I accumulated my stuff within a couple of months. But my basic stuff,

like a couple pots and pans and some kitchen utensils, I got that when I moved in. So I got

most of that from the [local organization]. (Stayer—Philadelphia)

They gave us—they helped us with the furniture voucher, and these vouchers are based on

the size of your family and your requirements. I got everything that I needed to move in at

the time, basically—beds, tables, a sofa, and the basic things. I was able to move in

comfortably. (Stayer—Philadelphia)

The time when I was having some money difficulties, they helped me with finding a

program that would assist me in paying a bill. And on top of that, the VASH did help me

with—I had a lot of tickets that I had. So I was going to roll them to some homeless court

program through the VASH, which was very helpful. (Stayer—Los Angeles)

Promoting Veteran Independence

Respondents described how the program helped them reestablish their rental and credit histories

and assisted with other factors that promoted their independence. One respondent reported

becoming self-sufficient and no longer needing the HUD-VASH program for support.

I had an eviction and that hindered me from renting from anyone and I had no income.

Basically, once I started receiving income then it was a matter of not having any

background rental history, so we had to start, so VASH helped me get started. Now I got 5

years of me paying rent on my own. (Leased-up exiter—Los Angeles)

They help you with your credit and stuff, to correct your credit. And once you get that

completed, then if you want to, you can apply for a house. (Stayer—Philadelphia)

They give you programs where they send us to different seminars we can approach to buy

our own homes, get our credit repaired, and these things. In other words, they’re not

leaving stuff here when you leave forever. You could if you wanted to stay in the program,

but if you want to advance and go out of the program, they’re making ways that you could

have an opportunity to leave out of it, and it’s very good. As a matter of fact we have a

meeting that we have to go to. It’s a mandatory meeting. We will meet with bank lenders

and business people and housing people to see how they can best help us to acquire our

own property. (Stayer—Philadelphia)

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BARRIERS

Program Staff Perspectives

Housing authority and VA staff noted barriers faced by the HUD-VASH program and its

participants: access to resources, program issues, property owners and housing, and Veteran

issues. Exhibit 9.3 provides further detail for the most common barriers mentioned across sites.

Veteran Mental Health or Substance Use Conditions

Staff in Houston indicated that Veterans with PTSD, traumatic brain injury, or SUD may have

difficulty accessing and maintaining housing. The Los Angeles VA case management team

reported an insufficient number of VA SUD specialists; the specialists must primarily focus on

crisis management rather than supporting Veterans before they fall into crisis. VA staff also

described how Veterans with SUD are more likely to abandon their units and may face losing their

housing while in treatment. In addition, HACSC staff reported that Veterans with mental health

issues, such as PTSD, often have difficulty communicating and may become easily agitated and,

although those Veterans are receiving services through VA, may not be compliant with their

treatment or refuse to follow up with providers. Finally, staff in Philadelphia mentioned that

Veterans in recovery may relapse when they have a space of their own; some experience a

“honeymoon period” when they first move into housing and feel that their lives are in order, but

the pressure to maintain it may lead to relapse.

Veteran Readiness

In Houston, staff described how the transition from living on the streets to renting a housing unit is

easier for some Veterans than for others, particularly because it requires some Veterans to learn a

new way of interacting in the world that they may find challenging and stressful. Additionally,

staff in Los Angeles described the difficulty of providing case management to this hard-to-serve

population, many of whom do not engage well with VA case managers and the community. Given

their Housing First approach, staff in Palo Alto indicated that they are not working on housing

readiness and that as the program enrolls more chronically homeless Veterans, Veteran readiness

has become an increasing challenge. Philadelphia staff echoed the sentiment that some Veterans

who are experiencing homelessness are not ready to accept the assistance being offered because of

personal circumstances, particularly mental health challenges or drug dependency.

Move-In Costs

Staff described move-in costs and access to assistance for Veterans in need as a common barrier. In

Houston, many property owners will not let Veterans move into housing without a letter from a

service provider that is offering financial assistance. Many providers require specific documents,

however, such as proof of a passed inspection, which can delay a Veteran’s moving into the unit.

Palo Alto staff further indicated that although a Veteran with no income can be approved for HUD-

VASH, community partners, including Supportive Services for Veteran Families (SSVF), are not

required to provide move-in assistance. Because Veterans with zero income cannot prove that they

can sustain payments, many organizations do not want to provide move-in assistance.

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Exhibit 9.3 Program Barriers Identified by Housing Authority and VA Staff

Houston  Los Angeles  Palo Alto  Philadelphia

Access to resources

Lack of available move-in assistance (funds, furniture)

X

-

-

-

Move-in costs (application fees, security deposit)

X

X

X

Program issues

Differing program requirements across housing

authorities

-

X

-

-

Inefficient processes

X

-

-

X

Inspection timeline

-

X

-

-

Insufficient staff

-

-

X

-

Mass briefings

X

-

-

-

Multiple points of contact

-

X

-

-

Program regulations (data entry, changes to payment

standards)

-

-

X

-

Reduction in voucher amount

-

-

-

X

Tension between HUD and VA performance measures

-

-

-

X

VA case manager as overzealous in advocacy efforts

-

X

-

-

Property owners and housing

Lack of affordable housing

-

X

X

-

Location of affordable units

-

X

-

-

Retaining support from property owners

-

-

-

X

Unethical property owners

X

-

-

-

Veteran issues

Lack of communication between Veteran and VA case

manager

-

X

-

-

Veteran background characteristics (past evictions, poor

credit, criminal background)

X

-

X

X

Veteran financial issues (zero/low income, money

mismanagement)

X

-

-

X

Veteran medical conditions

-

X

-

-

Veteran mental health conditions

X

X

X

X

Veteran misunderstanding of program rules and

requirements

-

X

-

-

Veteran motivation

-

-

-

X

Veteran readiness

X

X

X

X

Veteran substance use conditions

X

X

X

X

HUD = U.S. Department of Housing and Urban Development. VA = U.S. Department of Veterans Affairs.

Source: Staff Interview

Veteran Background Characteristics

Common barriers to housing outlined by Houston staff included past evictions, previous broken

leases, poor credit, and criminal background. Additionally, staff mentioned that Veterans in

recovery may have felony charges, and the only property owners willing to rent to them are in

locations that compromise their recovery. Staff in Palo Alto also indicated that Veterans with those

types of background characteristics often have difficulty finding a property owner who will rent to

them and Veterans who are frequently denied housing because of those issues may become

discouraged by the process.

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Veteran Perspectives

Study respondents discussed aspects of the HUD-VASH program that they found challenging to

their housing stability: negative experiences while enrolling in or participating in HUD-VASH;

not having adequate support both in terms of rental assistance and ancillary needs, such as

deposits, utilities, moving costs, or food; and difficulties with processing their applications or

other procedural issues. Themes that emerged in this category are listed in Exhibit 9.4.

Exhibit 9.4 Program Barriers Identified by Qualitative Respondents

Discrimination

Program rules

Transportation

Need for additional support

Staff interactions

Source: Veteran Interview

Discrimination

Some respondents felt that they experienced discrimination because of their background. Instances

included being charged higher amounts for security deposits, having difficulty securing housing,

and feeling judged by potential property owners. Other respondents had difficulty securing housing

because of their disabilities, and some respondents described feeling discriminated against simply

because they had a HUD-VASH voucher.

People and society, they have a stigma about Veterans, especially the homeless or [ones]

with mental health issues. So, the stigma is really when people are trying to get some

things. People look at, “oh, they’re a disabled Veteran with health issues,” and people

fear and push you away instead of helping. So, all these people that are trying to

reintegrate and trying to readjust are having issues because society is pushing back while

we are just trying to find out what’s available to us. If you have some gang member, he

could get Section 8. Why can’t a disabled Vet? (Nonleased exiter—Los Angeles)

Three places I got to putting in an application. None of them got back to me, so I got back

to them. Then finally one landlord told me what time it was, “You ain’t got a job. How

would you pay your rent?” And that was basically it, that “We ain’t gonna rent to you

because you ain’t got a job.” The other one is the story too, but they wouldn’t say it

because it’s discrimination, because I got a voucher. (Nonleased exiter—Palo Alto)

It was so-so. I went down to pick up another package to look for housing, places to stay—

and a lot of them, they go back 10 years on your background. (Stayer—Houston)

Those apartment listings that they give you—if I had known then that those listings do not

help Veterans with background issues, then I probably would have looked at it a little

differently. That was one of my reasons. My primary reason was that I did not want to go

back to being homeless. Two, I did not want to still be staying with my sister. Three, I knew

I had background issues. I know in [the county], not the housing authority but [the county]

in general, they frown upon people with x’s on their head. I wish that as a Veteran like

myself, I wish I could change that across the board. (Leased-up exiter—Houston)

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Need for Additional Support

When discussing challenges and barriers, respondents discussed the need for additional support,

primarily financial or programmatic. Some Veterans were unaware of any available assistance,

such as help with moving furniture or financial assistance with move-in costs, which they

reportedly could have used. Some respondents needed help paying their rent as a result of

unforeseen rent increases.

I needed everything… When I came down to the program, I moved, because I was staying

in the Salvation Army. I was in there. I waited for a VA slot to open up. So I had a suitcase

and that was it. (Stayer—Palo Alto)

Just the resources. I mean you have organizations that fake that they have references and

they go to ask people for money to help them find [stuff] and all those leads are nothing.

You have people that you know post on Craigslist or different things—all those lead to

nothing. And it just makes it difficult because, you have to—all these places are like, “Give

us this much money. We’ll help you find an apartment.” And you have all these resources

in society, but when it comes to a Vet trying to find those resources, those resources are

just like taking advantage of Vets, and then the resource that was supposed to help Vets

aren’t promoting them enough, so Vets can be like, “Okay. I want this. I want that.” You

have to go and ask. Nobody is promoting. You don’t see a sign at the hospital saying, “Oh,

are you homeless? Sign-up for—.” You know, you don’t see those. (Nonleased exiter—Los

Angeles)

Program Rules

Some Veterans expressed difficulty complying with the program’s rules for maintaining housing,

such as staying sober, finding suitable housing that met their needs within the time allotted, or not

allowing friends or family to live in the apartment with them. Several respondents mentioned

difficulties attending VA case management meetings because of other responsibilities or simply

finding them onerous.

I was ready to have company. I was ready to have visitors or whatever so that they would

not be scrutinized. They get into some points they want to check people’s bags coming in

there or whatever. We are not in a prison. You are not going to take over my rights—check

anybody’s bags when they dealing with a house. That apartment is a house. They under an

apartment—under their place, under their apartment. So it is not any different than any

other apartments, so people do stuff they should not do. They violate a lot of our rights.

(Leased-up exiter —Houston)

I do not know how much the agency that supplements us gives them, but for the places we

live in. I mean, the places you are actually getting to live in, it is poverty already there. It

exists. So how are you supposed to get out when you are kept in a society to where, hey,

this is it. Good for you. You are not worth moving up or put you in a more expensive place

because you are who you are. You are stuck there. You should be glad that you got a place

to live. I am grateful for that, but I mean, I believe for the money that they are getting by

the federal government, and in the places where we are only allowed to live, because the

cost of living and stuff, I would try to move. In my personal opinion, I think we are getting

ripped off man. Because I am sure that our government gives a whole lot of money, man, to

help us. And here we are, keeping us at poverty level. Because Section 8 has their own

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rules and regulations and the state has their own rules and regulations. … I am sad. I hate

to say it, but it is sad. I honestly do feel we, well, not us, because I am grateful. I have a

place to live. But the money that these men receive—the federal agencies, even the states

receive to help us out—they are getting ripped off, man. I mean, they are. If our

government is going to take that time to help us out and get us out of the streets and do

everything, why are we so limited? Because of the rules and regulations that Section 8 or

the state or the county or the city have? I mean, why? You are getting paid. You are not

getting a whole bunch. You are being helped out here. Come on. You know, I am sorry. It

does not work like that. (Stayer—Houston)

Staff Interactions

Respondents described difficulty getting in touch with VA case managers, dealing with hostile

staff at the housing authority, or simply not getting enough information out of overworked staff.

They kept saying that they were going to come. They did not show up and I called. At one

time, they had been on the phone for an hour and 10 minutes. They never answered it. At

one point I called back another day; it was almost an hour and someone picked up the

phone and hung up. I had to keep starting the process over. It was hell getting through.

Finally, I could not believe it, she emailed them and got a message back from them that

they would be there, but she failed to call and let me know. (Leased-up exiter—Houston)

They were very cold and unsupportive. It was like we were bothering them; I was

bothering them. But I got a new case manager at the [housing authority]. I do not know

what she is like yet; I have not met her yet. See how challenging that one will be. I did not

realize that I had to be so concise with them and everything, how everything is like, “Do

not bother us about that. Do not bother. You give us one of those.” You know, I still would

like to get a part-time job and I still do not understand where I have to—I know the income

limits, but it is like I have to bring them the receipts? And if I am making too much, then

what? Do they just throw me off the program? They do not tell me. They do not explain

things to me. At least this woman did not, the case manager that I am dealing with right

now. (Stayer—Philadelphia)

Transportation

Respondents who spoke about transportation often reported difficulty with it in the context of their

housing search and move-in experience. Lack of a vehicle was also a factor that limited some

Veterans to selecting housing close to public transportation rather than in their preferred location.

Individuals not close to transportation centers expressed discontent with their ability to get around.

Other transportation concerns included needing a reliable way to get to work or other meetings, the

expenses associated with taking public transportation, and the inability to use public transportation

because they were ill.

[Move-in] was difficult because I had to do it all myself. I specifically bought an old pick-

up truck for that purpose because I knew I wouldn’t have the money to rent one and to hire

anyone else to help me, so I bought a dolly and an old pick-up truck and I moved

everything in there myself. It was more difficult. It did deplete all of my resources, but I

didn’t have a choice. (Stayer—Los Angeles)

I would just say [the most difficult part] just inability to really get around like I needed to.

Even though I do have a bus pass, it is time consuming; public transportation is time

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consuming. So, having to get off this bus, that bus, this bus, it lessens the amount of places

that you could get to in a day’s time. (Leased-up exiter—Los Angeles)

One of the reasons I stay there was just because of the fact of the transportation. That if I

would have gotten a job, since I do not drive, it would have been easy for me to get from

point A to point B. But in reality, the place we live in, I mean, I do not like it at all really. I am there because, don’t get me wrong, like I said, I am grateful, I am very grateful that I

got a place to live and everything else. But I do not like that place. (Stayer—Houston)

You end up, as you get the Internet, using that as one way to get a lot of apartment

complexes. You have to do some serious phone campaigns, if you really want to find

apartments that accept felonies. If you are on public transportation, you cannot really go

to all of them. You can only pick out three or four you can do on a Saturday. (Leased-up

exiter—Houston)

RECOMMENDATIONS

Program Staff

Program recommendations provided by housing authority and VA staff generally fell into the

following categories: communication and collaboration, process improvements, property owner

incentives, resources, and VA staffing (see exhibit 9.5).

Communication and Collaboration

Program staff identified collaboration as a key factor in the success of HUD-VASH.

Recommendations offered by staff included the following:

•  Coordinate HUD-VASH Boot Camps and events—Events that bring together staff from

HUD, VA, and the community foster a collaborative spirit. PHA staff said that the Boot

Camp opened dialogue between service providers and enabled the program to operate

more quickly and effectively.

•  Identify solutions to resolve tension between HUD and VA performance measures—

Housing authorities gauge the success of HUD-VASH by the number of Veterans who

lease housing through the program, whereas VA measures performance by the number of

Veterans enrolled in the program; however, Veterans who are enrolled in HUD-VASH

are not necessarily housed. Enrollment in the program means that Veterans, many of

whom have been chronically homeless, are receiving VA case management and typically

require a great deal of support and encouragement to reach the point of leasing an

apartment. The biggest challenge for HCHA, for example, is receiving enough referrals

from VA to keep all of their vouchers in use. HCHA reports that they have requested

additional referrals but do not receive them.

•  Improve data use and sharing—HHA suggested that HUD and VA ensure that each has

access to the same information about Veterans. HHA said that, at times, information in

the VA HOMES system, including consent forms, would be useful to HHA staff who are

unable to access the system. Having one system would make HUD-VASH operate more

effectively and efficiently. HACC also mentioned the importance of data sharing between

HUD and VA to ensure that the program is meeting its goals.

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•  Revise definition/implementation of chronically homeless—HACoLA indicated that the

definition of chronically homeless has made serving the large homeless population in Los

Angeles difficult. In effect, Veterans may be told that they are not “homeless enough” to

meet program eligibility requirements; however, particularly for Veterans with children,

meeting the federal definition may not be in the best interest of their family. If Veterans

stay in a shelter, they may be separated from their children. Similarly, families cannot

stay in parks or cars because the Department of Children and Family Services will

remove the children.

Exhibit 9.5 Recommendations Identified by Housing Authority and VA Staff

Houston

Los Angeles

Palo Alto

Philadelphia

Communication and collaboration

HUD-VASH Boot Camps and events

-

-

-

X

Identify solutions to resolve tension between HUD

and VA performance measures

X

-

X

-

Improve data use and sharing

X

-

-

X

Revise definition/implementation of “chronically

homeless”

-

X

-

-

Process improvements

Checklists for processes

-

-

X

-

Deputize VA staff to conduct inspections

-

-

X

-

Flexibility in program requirements

X

X

X

-

Improve coordinated access and use of assessment

tools to determine Veterans’ level of need

X

-

-

-

Include VA on notices sent to Veterans by housing

authority

-

X

-

-

More frequent Veteran assessments for wraparound

services

-

X

-

-

One-on-one VA case management meetings with

Veterans at start of program

X

-

-

-

Property owner incentives

Certify property owners who consistently meet

inspection guidelines and debar property owners

X

-

-

-

who engage in unethical practices

Housing fairs/events to recruit property owners

-

X

-

-

Resources

Move-in assistance

-

X

X

X

Transportation

-

-

-

X

Veteran computer access

-

-

-

X

VA staffing

Continuing education for staff on evidence-based

practices

-

X

X

-

VA specialists (benefits, employment, housing)

X

X

-

-

HUD-VASH = U.S. Department of Housing and Urban Development (HUD)-U.S. Department of Veterans Affairs (VA) Supportive Housing.

Source: Staff Interview

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Process Improvements

All of the study sites described how they work to improve their processes to better serve Veterans.

Process improvements, some implemented and others on the “wish list,” are included below.

•  Create checklists for processes—In an effort to streamline procedures, HACSC and VA

staff mapped out the HUD-VASH processes and highlighted the barriers for both teams.

They discussed ways to make the process more efficient, such as including a documents

checklist to assist VA case managers with completing the voucher application.

•  Deputize VA staff to conduct inspections—The Palo Alto VA team suggested that in

areas where it can take a long time to schedule inspections because of geographic

limitations, having VA housin g specialists conduct inspections would be helpful. In

some areas, that could reduce the lease-up time by 3 to 4 weeks.

•  Make program requirements more flexible—HUD-VASH participants would benefit

from more flexibility in program requirements. According to HHA, Veterans would

ideally be involved in a minimal number of interactions with HHA during enrollment and

housing; however, additional interactions often are necessary to fulfill program

requirements. For example, Veterans may have difficulty providing income verifications,

which can delay the housing process. If HHA can confirm that the Veteran is eligible and

will be paying a standard amount, waiving the HUD-VASH income verification

requirement would be beneficial. HACLA has been granted a waiver from HUD that has

streamlined the recertification process. Rather than providing all of the verifications for

bank accounts, Veterans may self-certify accounts less than $5,000.

Current guidelines require income verification documents to have been issued within 60

days of the voucher release date. Veterans may provide current documents when they

initially enroll in HUD-VASH, but by the time a voucher is issued, they are no longer

current. HACoLA suggested that the guidelines be adjusted to record the date that the

income verification documents are received, independent of the time of voucher issuance.

Other suggestions regarding program flexibility included a cost-of-living allowance for

expensive housing markets. VA case managers in Alameda, for example, struggle to

house Veterans in that area. Often, Veterans are encouraged to find a unit that is

acceptable in the short term, even if only for a 6-month lease, and then continue their

housing search once they have moved in. That allows Veterans to get housed and then

look for a place that meets their long-term housing criteria.

•  Improve coordinated access and use of assessment tools to determine Veterans’ level of

need—HHA suggested using the Vulnerability Index to determine the appropriate level

of housing for individual Veterans. For example, some Veterans may do better in

transitional housing than living independently through the HUD-VASH program. Using

the coordinated access intake to inform the services that Veterans receive—possibly

including questions regarding the Veterans’ preferred type of living situation (for

example, group housing, independent)—would be helpful.

•  Include VA case management staff on notices sent to Veterans by the housing

authority—In the past, HACLA made an effort to copy a VA case management point of

contact on all correspondence sent to Veterans. Now HACLA is in the process of

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purchasing a program that will allow their system to automatically generate third-party

notices, enabling the housing authority to include individual VA case managers, as well

as general VA contacts, on notices. That capability will allow VA case managers to stay

abreast of any communications that Veterans in HUD-VASH receive from the housing

authority (for example, upcoming recertification, notification of program violations).

•  Complete more frequent Veteran assessments for wraparound services—HACoLA

believes that offering additional wraparound services for Veterans is important and

suggests completing more frequent assessments and reassessments as Veterans’ needs

change. The housing authority indicated that more frequent check-ins with Veterans and

assistance helping them communicate with property owners would be useful for Veterans

with housing issues.

•  Offer one-on-one VA case management meetings with Veterans as they enter the

program—The Houston VA case management team recommends meeting with Veterans

individually at the start of the program. The team indicated that mass briefings make

assisting Veterans and ensuring their understanding of the program difficult.

Property Owner Incentives

Property owners are a key component of HUD-VASH. Good relationships with property owners

often are instrumental in securing Veterans’ long-term housing sustainability, whereas property

owners who take advantage of Veterans or fail to maintain properties are a barrier to that outcome.

•  Certify property owners who consistently meet inspection guidelines, and debar property

owners who engage in unethical practices—HHA has found that inspections and

reinspections often delay housing and recertification processes. The housing authority

would like to certify property owners who consistently meet inspection guidelines.

Conversely, HHA is aware that some property owners exploit HUD-VASH Veterans—

often because they have few housing options—and would like to be able to debar them.

•  Recruit property owners through housing fairs or other events—HACoLA is in the

process of organizing a property owner service fair. The housing authority anticipates

inviting all property owners currently involved with the housing authority to set up a

booth at either the housing authority or VAMC to advertise their housing to voucher

holders. Depending on the success of the initial fair, the housing authority would consider

hosting this event bimonthly.

Resources

VA case managers assist Veterans in a variety of ways. Program staff recommend access to

additional resources, whether through the program directly or through outside community providers.

•  Move-in assistance—Additional funding for move-in assistance was one of the most

common recommendations made by program staff. In Palo Alto, for example, VA case

management teams suggested expanding SSVF to all counties in the service area.

Additionally, the VA teams would like the allocations to be larger for SSVF so that those

agencies do not run the risk of expending all of the assistance available for Veterans in

HUD-VASH. Using SSVF funds for application fees would also be helpful, particularly

for Veterans with zero income or no savings. This site also suggested having each

voucher allocation come with a set amount of funds to be used for move-in expenses,

ideally an amount equal to the area’s median rent.

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The Philadelphia VA case management team reported that additional resources for

furniture and other items Veterans need for move-in would improve that process. The

team said that furniture and funding for household items are difficult to find, often

leading to Veterans renting furniture, which is cost prohibitive.

•  Transportation—VA case managers in Philadelphia must share cars and vans. If each VA

case manager had a car, the staff would be able to better serve Veterans.

•  Computer access—Computer access for Veterans would enable the Philadelphia program

to help Veterans with job searches and e-mail communications. Veterans currently use

VA case managers’ computers for those tasks, which is not ideal.

VA Staffing

VA case management teams have been adding specialized staff to better serve Veterans with a

variety of needs. Several sites suggested hiring additional specialized VA staff trained to assist

Veterans in specific areas, such as benefits, employment, and housing, and keeping all staff

updated on evidence-based practices.

•  Continuing education for staff on evidence-based practices—Members of the Los

Angeles VA case management team participated in the cognitive behavioral therapy

(CBT) training provided by National Center on Homelessness Among Veterans

(NCHAV), which allows staff to provide therapy for Veterans in their homes. The team

indicated that additional funding to educate staff on other evidence-based treatments

would be useful moving forward. Similarly, the Palo Alto VA case management team

described the benefits of motivational interviewing. They said it has been useful for

addressing issues ranging from substance use to housing to Veteran ambivalence. VA

teams suggested further training to enable VA case managers to become more proficient

with this technique.

•  VA specialists (benefits, employment, housing)—Many staff considered VA specialists to

be program facilitators; several suggested adding specialists to their staff to improve

program outcomes. The Houston VA case management team would like to incorporate

additional housing specialists, which may be particularly helpful for Veterans with special

needs or felony records, as both present challenges to accessing appropriate housing. In

addition to assisting with the housing search, VA housing specialists could speak to

property owners on Veterans’ behalf. Likewise, the Los Angeles VA team believes that

having specialized staff to assist Veterans in obtaining benefits would be helpful and an

occupational therapist would be useful for Veterans in West Los Angeles. HACoLA is also

interested in adding housing specialists to the team to maximize lease-ups.

Veteran

Interviewers asked respondents to share their recommendations for the program; those

recommendations were related to additional assistance, process improvements, and staffing

issues (see exhibit 9.6).

Exhibit 9.6 Recommendations Identified by Qualitative Respondents

Additional assistance

Process improvements

Changes to program qualifications and requirements  Staffing

Outreach and communication

Source: Veteran Interview

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Additional Assistance

Many respondents recommended that the program provide more assistance to Veterans for rent,

finding and purchasing furniture and food, and move-in costs, such as security and utility deposits.

If the Veteran’s money should get cut off or anything should happen to their pay, I would

have something set up to help the Veteran until they get this situation back in order again.

Because the way they are doing now is just like okay, I am going to help you get in the

apartment but then when it comes time to pay—[if] I do not have the money to pay them, I

have to get out. (Stayer—Houston)

There was getting all the furniture in and stuff—having chairs and having beds for [my

family]. Making an improvement for me, I would say would be maybe offer more

assistance for families developing. I have a three bedroom where it is hard to fill up a

three bedroom house with what little money I have. You can get stuff second-hand, but you

can’t get a bed second-hand, so that was a little difficult. We shared beds for a while. That

was difficult. (Stayer—Palo Alto)

Like when you are trying to get groceries and food. Food, we really need food. There are

places that we can go, but it’s too bad that the VA don’t have places where Veterans can

go. (Leased-up exiter—Palo Alto)

HUD-VASH program covers the rent, but there is nothing for them as far as deposits are

concerned. A lot of those guys, they are having to go to churches and places asking for

help. A lot of them don’t get it. They might get lucky and find somebody that allows them to

pay $50 a month payment toward the deposit. (Leased-up exiter—Palo Alto)

Changes to Program Qualifications and Requirements

Many respondents recommended changes to the qualifications for entering the program or the rules

for maintaining housing under HUD-VASH. Veterans suggested improving approaches to

determine financial need and support, such as deducting child support payments from income

calculations; providing more time to find an apartment; limiting rules about housing qualifications;

enforcing less harsh consequences for failing to meet program requirements; providing better care

for Veterans’ spouses; and developing easier processes for changing locations.

The guidelines for gross net income; change it from gross income down to net. That’d be

the only thing that I’d change because if you’re going by your gross, you’re not thinking

about well, they’re taking $200/week out of his check. He’s not going to have any money

left. That would be the one thing that I would change. (Stayer—Los Angeles)

If the 90-day limit wasn’t there and it wasn’t so picky about where you are going to live.

(Nonleased exiter—Palo Alto)

It is a shame we have to go all the way to [City], or going to a county we do not even want

to live in, just because they do not have it in [County 2]. The VA here, they should have

branches for you to deal with in [County 2], not just [County 1]. I have lived in [County 2]

for 16 years. Why should I have to go to [County 1]? It is my thing, you know. They should

have something for us in [County 2]. When I first came to the VA, I found out I was

supposed to come over here and deal with this. I came from [County 2]. That is when I got

signed up for it. I had my own house and all that. This is the big hospital nearest to us. If

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you can take me to that, then why don’t you have somebody assigned to take care of the

housing? (Leased-up exiter—Philadelphia)

Outreach and Communication

Several respondents asked for more outreach and information about HUD-VASH and additional

services available to Veterans experiencing homelessness. They suggested that the program engage

Veterans on the street and increase face-to-face interactions.

I wish it was more publicized within the VA, on message boards or whatever. You know,

like, “Hey are you at risk for homelessness? Are you homeless? There is a program for

you.” I am always telling everybody that. (Leased-up exiter—Palo Alto)

They didn’t actually tell me—she didn’t actually tell me that I would have assistance as far

as the deposit and all that. It was my friend that was in the program. She told me and she

took me to the place. You know it’s hard to get that anyhow. (Nonleased exiter—Los

Angeles)

If it is possible, find someone—a Veteran—who would not mind volunteering to hang some

flyers up. I think that would probably really help Veterans. There are a lot of Veterans

standing on corners. If they knew about VASH, they would probably just say, “I don’t have

to stand on the corner and panhandle. I could probably go over here and maybe they’ll

help get me a place.” They are scared and they do not know where to go. That is the big

thing for most Veterans. They are scared. They do not know how to talk to people. If there

are programs that can make them talk to other Veterans and see other Veterans who have

problems, then they will start listening up. It is kind of like that stress program, a program

where they can go and sit among each other. It is not that bad. You can talk to people. You

need stuff like that. I would say more advertising and more interaction. (Leased-up

exiter—Los Angeles)

I am the type that I cannot do it over the phone. I just cannot say what is on my mind. I

have to be there in person. And a lot of times, they want you to do it over the phone; they

do not want you to come in. But they could set up a day and we could sit down. We could

go over stuff and how I feel about certain things. Better communication. (Leased-up

exiter—Los Angeles)

Process Improvements

Respondents made recommendations about improving the process of applying for and using HUD-

VASH vouchers; Veterans wished to see more streamlined paperwork processes, along with a

quicker turnaround of their applications and better coordination among the parties involved.

Veterans requested additional assistance with the housing search, including transportation to

prospective apartments, help locating suitable housing units that accept vouchers, and assistance

physically moving into their new apartment.

Sometimes, the housing authority would not be on the same page as the HUD-VASH case

manager, and then you have to have the apartment people, sometimes they do not be on the

same page, and sometimes the apartment people do not know what the housing authority—

what kind of paperwork—they really want, because they change. Like, they will change

and then they do not tell nobody. When you go, you got to go get this paper signed, or get

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this here, and you do not know, because it is something they done changed, that the

apartment people do not know about. (Stayer—Houston)

I think it should be quicker than the whole 30 days or 45 days before you actually can

move in because you never know, unless you are staying at a shelter or stay at a friend’s,

you never know the criteria how that is going. (Leased-up exiter—Houston)

I suppose it is coordination. There is a built-in difficulty with coordinating between four

agencies, so whatever you want to call it—better communication? Frankly, it is advocacy.

Frankly, vetting—VA vetting of landlords so that if you are card-carrying slumlord with

investigative articles written about them. [If] you can Google the man’s name and his

address and read about him for 57 pages, probably people should not be taking vets there.

(Leased-up exiter—Los Angeles)

If you’re going to help somebody, you help them all of the way. Part of being sufficient is

having transportation. [My VA case manager] was telling me that that’s a privilege. I

don’t see it like that. That’s why a lot of these dudes get in the situations that they’re in

because they don’t have anybody. They’ve got to depend on other people for basic stuff.

Having a car should be—that should be a privilege that everybody can enjoy. (Stayer—

Houston)

It would have been nice to have some people on the side that would help you—we are

going to move him in this day—depending on a person’s condition. I could have used some

help, but I ended up doing it all by myself. But then again—perseverance—that is how bad

I wanted it. (Nonleased exiter—Los Angeles)

Staffing

Respondents spoke about the importance of working with staff who know and understand their

needs and experiences, suggesting that the program should engage more VA peer mentors.

Veterans suggested including more Veterans on VA case management teams, ensuring that staff

are empathetic to Veterans with complex background issues, decreasing VA case managers’

caseloads, and having VA case managers spend more time with their clients. Respondents also

noted the frequent turnover of VA case managers and wanted to see the VA address that issue.

They also spoke about the value of posthousing support, suggesting that the involvement of the VA

case manager is important even after housing is secured.

It is nothing better than for Veterans to help other Veterans. The thing is this: I think on

the housing side for HUD-VASH and VA counselors, they need to listen to Veterans talk

like this. They need to hear Veterans. Whether it is public transportation, clothing, food,

housing, or just getting some blood pressure medicine—listen to us. In order for you to

network with us, you have to listen to some of the stuff that goes on out there. Some of the

HUD-VASH counselors and workers are not out there on the pavement like that. Th ey are

not really out there. They do not know the frustration that some of the Veterans may go

through, looking for places. I am not saying be so sympathetic that you just turn a blind

eye to it. What I am saying is be sympathetic to the idea of this guy having some things

going on in his life. Help us out. The way to help us out is finding apartment complexes, or

working with other Veterans, that know people that help Veterans with background issues.

They are willing to help Veterans that have handicaps, blind Veterans, Veterans with

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wheelchair accessibility. All that stuff is great. They have a lot of that stuff out there for

you. They do not have complexes that help Veterans with background issues. I wish they

would help us with that kind of stuff. (Leased-up exiter—Houston)

Overall I think that the information should be given properly. People who will be assisting

Veterans need to be more kind and give different options if it is possible. Listen to the

people to see what they have as concerns. If you could not help, then you could direct them

where they might get help. (Nonleased exiter—Philadelphia)

If I would have been able to talk to my new case manager about the decision that I made

and find me somewhere to go when I left from there, it would have been extremely helpful.

But we did not have a conversation like my first case manager. I think if she would have

been paying close attention—I do not know how many people she have on her log—but if

she had been paying attention to what was really going on, like she came and said, “Okay,

we need to discuss this here.” Because the only thing she came over was about my

company that I was having. (Leased-up exiter—Houston)

But the thing is, once you get your apartment, you’re kind of on your own after that. I think

HUD-VASH should try to spend more time with their clients; the caseworkers try to spend

more time because once a month is not enough. A lot of times, I waited for my meetings

with him to tell him something. (Leased-up exiter—Palo Alto)

Stop changing people, stop changing these branches. Get somebody in there that’s going

to do something and let them stay there. Every time I turn around—I’m serious, the last 4

years we’ve went through five people. I’m serious. And that’s the thing that bothers me. I

want to say that. They’re not there long enough to do anything. (Stayer—Philadelphia)

SUMMARY

Housing authority and VA staff identified as key facilitators the importance of leveraging

relationships with community partners and connecting Veterans to wraparound services and

community resources. They specifically described HUD-VASH Boot Camps as effective.

Program staff acknowledged flexible program requirements (for example, 110 percent Fair

Market Rents [FMR] in opportunity areas) and streamlined processes (for example, application

checklists) that have emerged from collaborative efforts and led to better program outcomes.

Veterans also described the importance of outside resources, both for household assistance (for

example, move-in deposits) and social supports (for example, educational opportunities).

Both program staff and Veterans described the relationship between VA case managers and

Veterans as an important program facilitator. A relationship of trust allows VA case managers to

identify issues Veterans are experiencing, advocate on their behalf, and motivate Veterans to

meet their goals. Program staff have found that a team approach using specialized VA staff can

provide more individualized attention for Veterans who may need it, and Veterans described how

their relationship with VA case managers can promote their independence and ability to find and

maintain housing.

Program staff and Veterans commonly identified the need for additional financial support; both

groups focused on the need to provide assistance for move-in costs, and Veterans also mentioned

needing transportation during the housing search and assistance with furnishing their apartments.

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Veterans’ mental or behavioral health issues and or substance use issues, as well as other

background characteristics (for example, criminal backgrounds), may pose barriers to accessing

and maintaining housing. Some Veterans reported facing discrimination during their housing

searches because of those issues. Similarly, program staff identified Veterans’ lack of readiness

as a barrier, and Veterans expressed difficulty complying with program rules (for example,

difficulty meeting VA case management requirements).

Finally, respondents recounted difficult staff interactions—with the housing authority and with

VA case managers—as a program barrier. Veterans recommended decreasing VA case

managers’ caseloads and addressing their frequent turnover.

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CHAPTER 10:

CONCLUSIONS

This study illustrated how and why Veterans exit the HUD-VASH program, identified obstacles

to their obtaining and maintaining housing with a HUD-VASH voucher, described the value of

services within the context of PSH, and distinguished facilitators and barriers to successful

collaboration between VA and HUD in the administration of the program. This final chapter

summarizes the findings presented in this report and identifies opportunities for program

improvements as well as potential next steps.

HUD-VASH IS SUCCESSFUL

Among HUD-VASH participants who met the study criteria and moved into voucher-supported

housing—both stayers and leased-up exiters—86.6 percent remained in the program for at least 1

year and 60.4 percent for at least 2 years.

HUD-VASH participants—regardless of whether they moved into housing—received their

vouchers, on average, within 3 months of program admission; both admission to the program

after HUD-VASH’s transition to a Housing First approach and the frequency of VA case

management contact significantly contributed to a decrease in the number of days required for a

Veteran to receive a voucher for permanent housing. During that time, Veterans received the

most frequent VA case management, with a gradual decrease following move-in. In general,

study respondents reported that HUD-VASH was a good fit for their needs.

HUD-VASH participants who remained in their housing tended to be older. Although one-fourth

(25.3 percent) had at least one medical condition and approximately one-third (33.5 percent) had

a mental or behavioral health condition—most frequently a history of alcohol or substance

abuse—stayers were less likely to have a service-connected disability than were Veterans who

exited the program. Veteran respondents who stayed in HUD-VASH most frequently reported

receiving their vouchers while living in a supportive environment, such as transitional housing or

a treatment facility (47.3 percent). They also reported slightly higher levels of satisfaction with

VA case management, stating that their VA case managers were able to help them and that they

agreed on goals.

VETERANS LEAVE HUD-VASH HOUSING FOR A VARIETY OF REASONS

Although 52.6 percent of the HUD-VASH participants who moved into permanent housing later

exited the program for a variety of reasons, 74.8 percent of leased-up exiters remained in housing

for at least 1 year, and 36.1 percent remained in housing for 2 years or more. Their average

length of stay in the program was 658 days. After leaving HUD-VASH, almost 93 percent of

leased-up exiters did not access a VA homeless program within 1 year.

Reasons for Exiting HUD-VASH After Obtaining Housing

When a Veteran exits HUD-VASH, VA case managers indicate one of 12 reasons why Veterans

ended their involvement in HUD-VASH case management. According to VA case managers, the

majority (55 percent) of leased-up exiters left the HUD-VASH program because they had

accomplished their goals or obtained access to other services and no longer had a need for the

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program (42.5 percent), found other housing (8.1 percent), or were no longer eligible for a HUD-

VASH voucher (4.9 percent). Among study respondents,slightly more than one-half of leased-up

exiters reported that they decided to leave HUD-VASH as opposed to being asked to leave and

most frequently reported that an increase in income (27.0 percent), the worsening in a medical,

mental health or substance use condition (20.3 percent), or difficulty with housing (12.2 percent)

were the main reason for their exit.

Characteristics of Leased-Up Exiters

Leased-up exiters were the most likely of any study group to have a medical (27.7 percent) or

mental or behavioral health condition (40.4 percent). Nearly one-half of all leased-up exiter

respondents (48.7 percent) received their HUD-VASH vouchers while living in a supportive

environment; those Veterans also used emergent and acute care at higher rates before program

entry than did Veterans who stayed in housing, which may have implications for their transition

to independent living. Their more frequent use of acute care before program entry, however, was

followed by declines after housing placement, suggesting that their needs were being addressed.

HUD-VASH participants with a service-connected disability were 37 percent more likely to

leave HUD-VASH after obtaining housing, perhaps indicating that they had sufficient income to

live independently.

Profiles of Leased-Up Exiters

Five distinct profiles described leased-up exiters and indicated a range of success in the program:

more than one-half (53.9 percent) of Veterans who left their HUD-VASH after obtaining housing

matched profiles that had largely successful exits. Three profiles identified leased-up exiters

who, for the most part, accomplished their goals, identified other housing, or left housing after

becoming financially ineligible to participate in the program, implying that their income had

increased. Members of those groups seemed to require neither the intensive services nor the

subsidy provided by HUD-VASH. The profiles suggest that HUD-VASH serves as a throughput

to independent housing for many Veterans who are able to accomplish their goals and move on

without the support the program offers. Other Veterans, however, may need additional support;

the remaining two profiles of leased-up exiters were likely very low income and had a high level

of need related to medical issues, mental or behavioral health, or substance use.

SOME VETERANS NEVER USE THEIR HUD-VASH VOUCHERS

Approximately one in five HUD-VASH participants exited HUD-VASH after receiving a

voucher but before leasing a housing unit. Only one of 10 Veterans who were admitted to HUD-

VASH but did not use their voucher, however, accessed a VA homeless program within 1 year

following their exit from HUD-VASH. Although those Veterans never accessed housing through

HUD-VASH, they also did not return to homelessness.

Reasons for Exiting HUD-VASH Before Accessing Housing

According to VA case managers, nonleased exiters most frequently left the program because

they were no longer interested in participating (21.9 percent), could not be located (16.6 percent),

or found other housing (14.2 percent). Almost three in five nonleased respondents reported that

they decided to leave the program, most commonly because the voucher has been revoked by the

housing authority (22.6 percent) or other difficulties related to the housing search, including

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dissastifaction with available apartments, inability to find an available apartment with the

voucher, or the apartment that was found not passing the housing authority inspection (20.8

percent). Nonleased respondents also exited due to offers from family or friends to move into

their housing (15.1 percent).

Characteristics of Nonleased Exiters

Compared with Veterans who accessed permanent housing, nonleased exiters were younger and

most likely to have been deployed during Operations Enduring Freedom (OEF), Iraqi Freedom

(OIF), and New Dawn (OND). Nearly one-third of nonleased exiters received their vouchers at a

time when they were literally homeless (30.0 percent), the same proportion as those who entered

HUD-VASH from a supportive environment. They received less frequent VA case management

between referral to the housing authority and voucher receipt compared with Veterans who

accessed housing and reported finding the housing process more difficult. Nonleased exiters

were the most likely to report poor health during their time in the program and used emergency

and acute care more frequently both before and after entry than did Veterans who moved into

housing. Veterans with a diagnosis of post-traumatic stress disorder (PTSD) and a history of

suicide or self-inflicted injury had increased odds of not moving into housing.

Profiles of Nonleased Exiters

Three distinct profiles described nonleased exiters, indicating a range of success in the program.

Those profiles suggest that approximately one-fourth of nonleased exiters did not need HUD-

VASH—they were younger, had access to income related to service-connected disabilities, and

had low rates of medical, mental or behavioral health, or substance use conditions—and they

most frequently left the program because they found other housing, or were no longer interested

in participating in HUD-VASH. The remaining nonleased exiters had very low incomes or a high

level of need related to medical, mental or behavioral health, or substance use; more than 40

percent left the program before obtaining permanent housing because the program could not

locate them or they were too ill, incarcerated, deceased, or noncompliant with VA case

management.

Those profiles indicate that some Veterans who were admitted to HUD-VASH likely could find

housing on their own without the assistance of a VA case manager. In contrast, Veterans with

more severe medical, mental or behavioral health, or substance use issues may have required

more intensive services than they received.

FACILITATORS AND BARRIERS

Both housing authority and VA staff identified the importance of collaborating with community

partners and connecting Veterans to wrap-around services and community resources as key

facilitators of housing; one particularly useful resource was Supportive Services for Veteran

Families (SSVF). Collaborative efforts between HUD and VA have led to system changes, such

as flexible program requirements and streamlined processes for Veterans to access vouchers,

leading to better housing outcomes. Program staff and Veterans described the relationship

between VA case managers and Veterans as important in helping Veterans access and maintain

permanent housing; a team approach that uses specialized VA staff can provide more

individualized attention for Veterans who need it.

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Program staff and Veterans commonly identified the need for additional financial support for

Veterans as a barrier to housing. Program staff identified assistance with move-in costs as a

significant need, and Veterans also requested transportation assistance during the housing search

and assistance with furnishing their apartments. Program staff described Veterans’ mental or

behavioral health or substance use issues and readiness for independent housing as barriers to

accessing and maintaining housing. Often Veterans’ background characteristics (for example,

criminal history) made finding housing hard for them, and they expressed having difficulty

complying with program rules (for example, meeting VA case management requirements).

Finally, respondents recounted difficult staff interactions—with the housing authority and with

VA case managers—and recommended decreasing VA case managers’ caseloads and addressing

their frequent turnover.

OPPORTUNITIES FOR PROGRAM IMPROVEMENTS

This study found that HUD-VASH is successful, demonstrated by high rates of retention in

housing and, for Veterans who leave their housing or never access permanent housing, low rates

of returns to VA homeless programs. The program serves Veterans with a variety of

characteristics and a range of needs: more than one-fourth of the HUD-VASH participants had at

least one medical condition, and more than one-third had a mental or behavioral health condition.

The implementation of several policies—most notably Housing First and SSVF—have

contributed to high-need Veterans accessing permanent housing more quickly, validating the

evolution of VA’s homelessness programs. Moving forward, HUD-VASH should also focus on

regularly assessing Veterans’ needs, increasing their income and benefits, and encouraging

ongoing collaboration between HUD and VA, as well as community-based providers.

Use SSVF to Facilitate Entries and Exits

SSVF has the capacity to address important barriers affecting Veterans’ abilities to access

housing, stay in housing, and successfully exit subsidized housing. One of the most frequently

identified barriers to housing—by program staff as well as Veterans—was difficulty accessing

move-in resources, leading to Veterans’ inability to use their vouchers and their exiting the

program before being housed. Continuing to use SSVF for move-in expenses and developing

deep collaborations with community-based organizations that administer SSVF grants may

reduce the rate at which Veterans exit the program before accessing housing.

In addition to using SSVF as a move-in resource, this program can be used to keep Veterans in

housing by assisting with utility bills or unpaid rent. Among Veterans who were evicted from

their HUD-VASH housing, 60 percent identified difficulty paying rent as a contributing factor.

Recognizing that issue in a timely manner and connecting Veterans to appropriate resources can

decrease the frequency of evictions.

One way that SSVF does not currently seem to be used is to help Veterans successfully transition

out of HUD-VASH once they no longer need case management or more intensive services.

SSVF could be used to provide shallow subsidies, along with lower intensity supportive services,

for Veterans wishing to transition to housing that is not subsidized with a HUD-VASH voucher.

That level of intervention also could be used for Veterans who leave HUD-VASH to live with

friends or family or in other housing; rather than using HUD-VASH as a throughput to other

permanent housing, a longer-term shallow subsidy could assist Veterans in their transition out of

the program into other stable housing. Having such an alternative would allow scarce and

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expensive resources such as HUD-VASH to be targeted to Veterans with the greatest need and

promote Veterans’ independence and choice (Tempel, 2013). Several jurisdictions have had

some success with such a program, targeting individuals living in PSH with long-term rental

histories and no rental or utility arrears, who have ongoing benefits and income, are medically

(including mentally and behaviorally) stable, and have not recently required crisis intervention

(Haley, 2013).

Continue Using a Housing First Approach with the Option of Increased Transition Assistance

Veterans who were admitted to HUD-VASH during the years following HUD-VASH’s

transition to a Housing First approach accessed housing more quickly (and those who did not

access housing received their vouchers more quickly) compared with those who entered the

program during earlier years. That paradigm shift included increased intensity of VA case

management services (as evidenced in this report), important system changes for HUD and VA,

and conscious efforts to link governmental agencies together and with community-based

organizations—with the common goal of quickly housing Veterans experiencing homelessness

and then supporting their long-term housing stability. Several options may increase the

effectiveness of that approach, including a focus on team-based case management, increased

assistance during the housing search, more intensive assistance during Veterans’ transitions to

independent housing, and use of project-based vouchers.

Team-Based Case Management

Program staff and Veterans described the relationship between VA case managers and Veterans as

an important program facilitator. Program staff identified using a team-based approach—

incorporating employment, housing, peer support, and SUD specialists—as best practice and

reflective of the strong clinical approach that Housing First promotes. Using VA specialists to

assist with Veterans’ case management needs on the front end (for example, using VA housing

specialists during the housing search) and on the back end (for example, offering practical supports

to assist with independent living) can help Veterans find and sustain housing. A team-based

approach also can address the break in continuity that Veterans experience when staff leave the

program, a challenge that Veterans repeatedly voiced during in-person interviews. In addition, VA

staff training related to trauma-informed care, motivational interviewing, cognitive behavioral

therapy, and other evidence-based practices may further facilitate successful outcomes for

Veterans.

The Housing Search

VA case managers and housing authority staff must balance the housing search with Veterans’

other case management needs (Austin et al., 2014). In general, Veterans who were unable to access

permanent housing found the HUD-VASH housing process more difficult; although nearly one-

half of nonleased exiter study respondents visited four or more apartments during their housing

search, they ultimately did not move into permanent housing, and the majority reported not

receiving assistance with that process. This study identified a number of best practices to facilitate

the process: maintaining relationships with property owners, which can facilitate acceptance of

Veterans with undesirable background characteristics (for example, criminal history) into housing;

identifying and preinspecting housing units so they are ready for rapid move-in; and offering “ride-

alongs,” in which VA staff regularly accompany groups of Veterans on housing searches. VA peer

support and housing specialists also have been beneficial to that process.

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Critical Time Intervention

During the 90 days preceding Veterans’ admission to HUD-VASH, larger proportions of Veterans

who left the program—either before or after accessing permanent housing—used inpatient or

emergency care services compared with those who stayed in the program. Additionally, Veterans

who accessed housing were more likely to enter the program from a somewhat supported living

situation, such as transitional housing or a substance use treatment facility or detox center, whereas

Veterans who did not were more likely to have been living on the streets. A more intensive level of

support to transition to independent living using Critical Time Intervention (CTI) may be

appropriate for some Veterans who are transitioning out of inpatient or emergency services, out of

correctional programs, or from the streets to housing.

CTI is a focused, time-limited case management model that uses formal and informal supports to

transition people to an integrated life in the community. CTI was developed in response to the

observation that formerly homeless individuals with serious mental illness were reappearing in the

homeless system during their transition from more to less supportive housing situations (Caton,

Wyatt, and Felix, 1992; Gounis and Susser, 1990). To address that phenomenon, CTI provides

highly focused, time-limited support during the transition period; the primary goals are to build the

individual’s connections to formal and informal sources of community support while helping to

develop the individual’s independent living skills (Herman et al., 2000). Evidence of CTI’s effect

includes a significant reduction in days homeless and improvement in psychiatric symptoms

among those who received CTI compared with controls (Herman et al., 2011; Hermanet al., 2000;

Susser et al., 1997).

Project-Based Housing

Although the vast majority of Veterans participating in HUD-VASH use a tenant-based voucher to

access scattered-site housing, a project-based modality may be more appropriate—and the

preference—for Veterans with particularly high needs. Previous research has found that programs

that offer a Housing First approach to PSH using project-based housing can increase housing

stability (Pearson, Montgomery, and Locke, 2009) and decrease substance use issues among hard-

to-serve and high-need populations (Collinset al., 2012). Staff affiliated with project-based PSH

have indicated that this housing configuration provides the “opportunity to serve clients who had

previously failed in independent housing arrangements and would be difficult to place directly into

mainstream units” and allows for additional support and interventions to sustain housing stability

(Kresky-Wolff et al., 2010, p. 219).

Regularly Assess Veterans’ Needs

Appropriately targeting Veterans for HUD-VASH who need higher levels of case management is

also important. Veterans with less need for case management assistance may be better served by

SSVF or other lighter-touch VA programs. The profiles of Veterans who left HUD-VASH before

accessing housing because they found other housing or were no longer interested in participating

indicate that younger Veterans with few medical issues or mental or behavioral health issues may

be able to resolve their homelessness through a less intensive intervention, reserving HUD-

VASH for more vulnerable Veterans.

Accurately assessing Veterans’ needs, strengths, abilities, and preferences at program admission

and then throughout their participation in and exit from the program is also important. This

information will identify the types of services that the Veteran may need, the level of assistance a

Veteran may require to transition to independent living (for example, CTI), as well as preferences

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in terms of housing type (for example, project based versus scattered site) and location. Continued

assessment throughout the Veteran’s participation in HUD-VASH is critical to determine which

and how much of the two components of HUD-VASH—housing and services—the Veteran needs.

As the profiles of Veterans who exited HUD-VASH indicate, some Veterans seem to have fewer

needs and often leave the program as they exceed the income limit or identify other permanent

housing, whereas other Veterans have experiences that lead to less successful program exits.

Consistent with criminal justice literature that posits the need to assess the risk of recidivism to

determine the appropriate level of services to reduce future criminal activity (Andrews and

Bonta, 2010), assessing the risk of negative exit at program entry could help VA case managers

determine the intensity of support that should be provided to HUD-VASH Veterans. Doing so

would enable VA case managers to allocate their time and resources based on the individual’s

risk of exiting the program, thereby providing more intensive service to those most at risk.

Assessment before and after program exit is also essential. As identified in this report, many

Veterans left HUD-VASH both during the housing process and after accessing permanent

housing to live with family or friends or in some other housing situation. Veterans should be

supported to access housing that is appropriate for them, which may include reuniting with their

families. In addition, more accurate metrics should be developed to identify those Veterans who

are ready to “graduate” from HUD-VASH.

Finally, continuing to serve Veterans effectively requires knowing more about the circumstances

of their exit from the program. Although VA case managers currently report the reasons why

Veterans exit HUD-VASH, information from the program’s perspective may not tell the full

story. Consistent with VA’s renewed focus on Veteran-centric care, a useful approach would be

to conduct exiter surveys among samples of Veterans leaving the program to identify what

worked, what did not work, what could work, and whether the Veteran’s exit indicates that the

program was successful.

Increase Veterans’ Access to Benefits and Income

A repeated finding throughout this study was that many Veterans successfully exited HUD-

VASH when they became ineligible as a result of an increase in income, which indicates that a

significant portion of the population’s income security changes over time, perhaps through

employment or access to benefits. Additionally, the findings suggest that because stayers were

less likely to have a service-connected disability—and likely had a lower income—they may

have had fewer options beyond HUD-VASH, whereas leased-up exiters with a service-connected

disability may have had a higher income that afforded them more housing options.

Other studies have found that Veterans with a service-connected disability are less likely to

experience homelessness or ongoing housing instability compared with those who do not have a

service-connected disability and are very low income (Byrne et al., 2015; Montgomery et al.,

2015). The findings from the present study are similar: having a service-connected disability was

significantly associated with Veterans successfully leaving HUD-VASH.

Two key objectives of Opening Doors: Federal Strategic Plan to Prevent and End Homelessness

are to “increase meaningful and sustainable employment” and “improve access to mainstream

programs and services to reduce people’s financial vulnerability” (USICH, 2010, pp. 40–41).

Working with Veterans to increase their economic security to support successful entries to and

exits from HUD-VASH may take a number of forms, including accessing benefits and securing

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vocational training and employment. In addition to benefits from the Veteran Benefits

Administration (VBA), Veterans may be eligible for benefits through the Social Security

Administration (SSA): Supplemental Security Income (SSI) for Veterans who are aging or disabled

and have low incomes and Social Security Disability Insurance (SSDI) for those who are unable to

participate in “substantial gainful activity” as a result of a disabling condition (Elder, 2014).

SSA has launched two initiatives to expedite Veterans’ applications for SSI and SSDI. The 100%

Permanent and Total Veterans Initiative places a high priority on applications from Veterans

who have been identified by VA as having a 100 percent permanent and total disability (SSA,

2016). The Wounded Warriors initiative also expedites disability claims for Veterans who were

disabled during active military service on or before October 1, 2001 (Elder, 2014).

In addition to financial benefits, Veterans may receive employment-related support. Several

federal agencies—including VA and the Department of Labor (DOL)—support programs

intended to increase employment opportunities for Veterans:

•  Homeless Veteran Supported Employment Program (HVSEP)—This program, initiated

by VA in FFY 2011, employs formerly homeless or at-risk Veterans to serve as

vocational rehabilitation specialists to support Veterans in obtaining and sustaining

employment (Heitzman, 2015).

•  Compensated Work Therapy (CWT) Program—CWT, another program funded by VA

but not specifically for Veterans experiencing homelessness, places “work-ready”

Veterans in competitive employment positions and works with employers to support

Veterans in their employment and to determine employers’ staffing needs (VA, 2015).

•  Vocational Rehabilitation and Employment (VR&E) program—A third VA program

works with Veterans who have service-connected disabilities and an “employment

handicap” to access and sustain employment (Riley et al., 2014).

•  Homeless Veterans Reintegration Program (HVRP)—DOL provides grants to public and

private governmental and nonprofit organizations to assist Veterans experiencing

homelessness in “reintegrating into society and the labor force” (USICH, 2014, p. 23).

Accessing these resources is particularly important for Veterans with no income. Program staff

indicated that although those Veterans are eligible to participate in HUD-VASH, accessing

housing is very difficult for them without funds for application fees, utility deposits, and the

necessities required to move into a home.

STRENGTHS AND LIMITATIONS

This study used a mixed methods approach with multiple perspectives—Veterans and staff from

both HUD and VA—and a wide array of data, including primary quantitative and qualitative data

and secondary data collected through VA homeless programs and medical records. Using

primary data allowed the research team to interpret findings from administrative data in the

context of Veterans’ and staff’s experience and opinions. In addition, using multiple study sites

increased the generalizability of the findings.

Although the wealth of data is a strength of this study, it also presents several limitations. First,

because a considerable amount of data were missing, the research team was unable to assess

Veterans’ history and chronicity of homelessness, incarceration, family composition, and other

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characteristics that add to the complex understanding of homelessness and housing stability.

Second, primary data collected from Veterans and program staff are subject to recall and social

desirability biases. Third, although multiple perspectives are useful in understanding the HUD-

VASH programs and the nature of Veterans’ exit from the program, no “gold standard”

determines which perspective is accurate; rather, considering multiple perspectives contributes to

a more complex understanding of the issues.

In addition, including multiple sites for primary data collection has some limitations. Although

NCHAV staff conducted a number of quality assurance activities, the study methodology may

have been carried out inconsistently across sites. In addition, the sites were quite heterogeneous

in terms of geography, housing markets, and systems. Even though adhering to federal HUD-

VASH requirements, each site administered HUD-VASH differently at all levels, from Veteran

engagement to interactions between large, community-level governmental agencies. Further,

each site was at a different stage in its evolution to a Housing First approach.

Finally, an important limitation of the study is that a Veteran was considered to have exited

HUD-VASH when the Veteran exited HUD-VASH case management and was no longer

receiving supportive services from the program. The definition is based on the exit status

indicated by VA case managers in VA administrative data systems, which does not include an

indication of whether the Veteran continued to use their HUD-VASH voucher to subsidize

housing expenses. Therefore, this study did not explore the relationship between an exit from

HUD-VASH case management and an exit from voucher-subsidized housing.

NEXT STEPS

The present study identified two areas for significant future research: developing assessments

and testing interventions. Future work should focus on developing more accurate metrics to be

used at assessment or program admission, throughout the housing process, and regularly while

Veterans are in housing as well as during program exit. These instruments could help to ensure

that Veterans are appropriately targeted for the program and that they receive the level of

assistance they need to access and maintain permanent housing. Assessments should be informed

by not only existing administrative data but also best practices used in the mainstream

community and pilot testing and rigorous evaluation of new measures. In addition to assessing

Veterans’ needs throughout their tenure in the program, the program also must assess Veterans’

satisfaction with HUD-VASH and the circumstances surrounding their exit. Surveying Veterans

directly would provide a deeper understanding regarding what constitutes success in HUD-

VASH and Veterans’ perceptions of what is needed to attain it.

In terms of supporting Veterans once they are in the program, interventions with two levels of

intensity should be considered. Veterans who may not need the full complement of services

afforded in the HUD-VASH program may benefit from a lower intensity intervention, including

shallow subsidies for Veterans transitioning out of the program. Veterans transitioning from a

literally homeless or institutional environment may require more intensive services, such as CTI,

for a longer period of time. Both levels of service provision should be formulated and evaluated

within the context of VA and HUD-VASH. In addition, the role of project-based vouchers in

addressing the needs of particularly vulnerable populations should be considered. Each of these

recommendations is intended to support Veterans’ successful housing outcome.

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APPENDIX A:

GLOSSARY

Assertive Community Treatment (ACT) Team—Team treatment approach designed to

provide comprehensive, community-based psychiatric treatment, rehabilitation, and support to

persons with serious and persistent mental illness

Chronic homelessness—An individual or family with a disabling condition who has been

continuously homeless for a year or more or has had at least four episodes of homelessness in the

past three years

DD-214—Form issued to Veterans by the Defense Department, identifying condition of

discharge: honorable, general, other than honorable, dishonorable or bad conduct

Fair Market Rent (FMR)—Gross rent estimate used to determine payment standard amounts

for HCV program, which includes the cost of rent plus the cost of all tenant-paid utilities, except

telephones, cable or satellite television service, and internet service; based on either the 40th or

50th percentile of rents charged for standard rental housing in the FMR area

Hardship extension—According to HUD-VASH program rules, the initial search term for

locating housing using a HUD-VASH voucher must be at least 60 calendar days; in recognition

of the potential challenges associated with locating appropriate housing, this search can be

extended to 120 days or longer if a Veteran requests a hardship extension

Housing Assistance Payment (HAP) contract—The HAP contract is executed between the

housing authority and the property owner renting to a HUD-VASH client; contract must be in the

form required by HUD and include the same term as the lease executed between the property

owner and the HUD-VASH client

Housing Choice Voucher (HCV) program—The HCV Program is the federal government's

main housing assistance program, administered locally by public housing agencies; it allows

participants to choose any housing that meets the requirements of the program and is not limited

to units located in subsidized housing projects; rental units must meet minimum standards of

health and safety, as determined by the housing authority

Housing First—Housing model based on a philosophy of focusing on getting participants into

housing without first requiring treatment

Housing Quality Standards (HQS)—Basic standards, outlined by HUD, that units rented

through HCV must meet before assistance can be paid on behalf of a family; HQSs establish the

minimum criteria for the health and safety of program participants

HUD-VASH Boot Camps—Multi-day events with HUD, VA, and community providers

focused on improving housing placement rates for homeless Veterans in the community

Lease—The lease agreement is executed between the property owner and the Veteran

participating in HUD-VASH; outlines terms of the property rental

Moving to Work (MTW)—A demonstration program for housing authorities that provides them

the opportunity to design and test innovative, locally-designed, and cost-effective strategies;

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MTW grants PHAs more flexibility in how federal funds are spent and offers exemptions from

existing rules

Pathways to Housing—A housing program based on the Housing First model to address

homelessness among people with psychiatric disabilities

Payment standard—Payment standards are used to calculate the rent paid by the housing

authority for a HUD-VASH client; the range of possible payment standard amounts is based on

HUD’s published FMR schedule

Port—Transfer process that enables HCV holders to relocate and select housing in other

locations in the United States

Public Housing Authority (HA)—A government agency, generally affiliated with a local

government, whose responsibility is the ownership and operation of subsidized housing and

rental assistance programs

Recertification—The process by which the housing authority re-verifies income and completes

a housing unit inspection, typically on an annual basis, for HCV holders

Reexaminations—The process by which a Veteran informs the housing authority of a change to

income or household composition

Rent comparables—In conducting rent reasonableness, the housing authority must determine

whether the rent the property owner has requested is reasonable in comparison to rent for other

comparable unassisted units; in determining comparability, the housing authority must consider:

(1) location, quality, size, unit type, and age of the contract unit, and (2) amenities, housing

services, maintenance, and utilities the owner must provide under the lease

Rent reasonableness—Housing authorities must ensure that rents charged by owners to HCV

program participants are reasonable; this determination involves two comparisons: (1) a

comparison of the rent for the voucher unit to rents for similar unassisted units in the

marketplace, and (2) a comparison to the rents for similar units on the premises

Request for Tenancy Approval (RFTA)—Required HUD form completed by HCV clients

with details on a desired rental unit and property owner; completed by HUD-VASH clients

and/or property owner and submitted to housing authority as the first step in formalizing the

lease and HAP contract

Service-connected disability—VA’s enrollment priority groups indicate the extent to which a

Veteran is receiving compensation as a result of a disability incurred during military service, as

well as whether a Veteran is very low income. Higher service-connected disability ratings likely

reflect a greater level of disability, as well as higher income received by the Veteran from the

VA.

Voucher briefing—Housing authorities require that HUD-VASH clients participate in this

informational session prior to providing the Veteran a HUD-VASH voucher

Vulnerability Index—A tool for identifying and prioritizing the street homeless populations for

housing according to the fragility of their health; may take into account issues such as age;

chronic medical conditions; co-occurring psychiatric, substance abuse, and chronic medical

conditions; and/or number of hospitalizations or emergency room visits during the past year

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APPENDIX B:

TERMS

ACT—Assertive Community Treatment

CBOC—Community-Based Outpatient Clinic

CoC—Continuum of Care

CPRS—VA Computerized Patient Record System

CTI—Critical Time Intervention

CWT—Compensated Work Therapy

FFY—Federal Fiscal Year

FMR—Fair Market Rent

DCHV—Domiciliary Care for Homeless Veterans

DOL—Department of Labor

GPD—Grant and Per Diem

HA—Housing Authority

HACA—Housing Authority of the County of Alameda

HACC—Housing Authority of the City of Camden

HACLA—Housing Authority of the City of Los Angeles

HACM—Housing Authority of Monterey County

HACoLA—Housing Authority of the County of Los Angeles

HACSC—Housing Authority of the County of Santa Clara

HACSCUZ—Housing Authority of the County of Santa Cruz

HACSJ—Housing Authority of the County of San Joaquin

HACSM—Housing Authority of the County of San Mateo

HACSTAN—Housing Authority of the County of Stanislaus

HAP—Housing Assistance Payment

HCHA—Harris County Housing Authority

HCHV—Healthcare for Homeless Veterans

HCV—Housing Choice Voucher

HEARTH Act—Homeless Emergency Assistance and Rapid Transition to Housing Act

HHA—Houston Housing Authority

HMIS—Homeless Management Information System

HOMES—VA Homeless Management and Evaluation System

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Appendix B: Terms

HPACT—Homeless Patient Aligned Care Team

HUD—U.S. Department of Housing and Urban Development

HUD-VASH—Housing and Urban Development-Veterans Affairs Supportive Housing

HVRP—Homeless Veterans Rehabilitation Program

HVSEP—Homeless Veteran Supported Employment Program

IRB—Institutional Review Board

LCA—Latent Class Analysis

MMRL—Mixed Methods Research Lab at the University of Pennsylvania

MTW—Moving to Work

NCHAV—VA National Center on Homelessness Among Veterans

OEF—Operation Enduring Freedom

OIF—Operation Iraqi Freedom

OND—Operation New Dawn

PHA—Either Public Housing Authority or Philadelphia Housing Authority

PIT—Point-in-Time

PSH—Permanent Supportive Housing

PTSD—Post-Traumatic Stress Disorder

RFTA—Request for Tenancy Approval

ROI—Release of Information

SPA—Service Planning Area

SSI/SSDI—Supplemental Security Income/Social Security Disability Insurance

SSVF—Supportive Services for Veteran Families

SUD—Substance Use Disorder

TBI—Traumatic Brain Injury

USICH—U.S. Interagency Council on Homelessness

VA—U.S. Department of Veterans Affairs

VAMC—Veterans Affairs Medical Center

VHA—Veterans Health Administration

VISN—Veterans Integrated Service Networks

VJO—Veterans Justice Outreach

VR&E—Vocational Rehabilitation and Employment Program

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APPENDIX C:

METHODS

VETERAN INTERVIEW MATERIALS

Veteran Questionnaire -- Cover Page

1.  Are you currently enrolled in the HUD-VASH program?

1)  Yes

2)  No

If “Yes” check “Stayer” below and continue to “Stayer” interview questionnaire.

If “No” continue to question 2.

2.  On approximately what date did you exit the HUD-VASH program?

Date: _________________

3.  Before you left the program, did you sign a lease on an apartment?

1)  Yes

2)  No

If “Yes,” check “Leased-Up Exiter” below, use Leased-Up Exiter questionnaire.

If “No” check “Non-Leased Exiter” below, use Non-Leased Exiter questionnaire.

Veteran Questionnaire -- Stayer

Housing and Homelessness History

1.  I want you to think about where you have been living since you enrolled in the HUD-VASH program. We would like to know all of the places where you’ve stayed during this time, including hospitals. Let’s look at this calendar together, and I’ll make notes as you talk.  Why don’t we start with where you are living now and work backwards from there, place by place.  [Refer to CARD 1]

Location  Date Moved In

Date Moved Out

Location Type (code)

Composition (code)

Letter

A.

B.

C.

D.

E.

F.

G.

H.

2.  Using the chart, please point out where you were staying when you obtained a HUD-VASH Voucher.

Choose Location Letter from list above: ____________________________________

3.  Using the chart, please point out where you were staying when you found an apartment with your HUD-VASH voucher Choose Location Letter from list above: ____________________________________

•  HUD-VASH Housing Process

4.  How would you describe the different steps involved in getting a voucher?

[Refer to CARD 2 to code each step from Very Difficult to Very Easy]

Step

Code (from CARD 2)

A.

Enrolling in the HUD-VASH program

B.

Submitting application to PHA

C.

Providing documentation of identity and income to Public

Housing Authority

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Appendix C: Methods

5.  Did you receive help from your HUD-VASH case manager or other HUD-VASH staff in either of the following steps in obtaining a voucher?  [Check yes or no for each step]

Step

Yes (Received Help)

No (Did not receive help)

A.

Getting and attending appointment with

the PHA

B.

Providing proof of identity or income

C.

Completing and submitting the PHA

application

6.  Now I want to ask you about your impressions of the condition and location of the apartments that you visited during your housing search.  Approximately how many apartments did you visit during your housing search?

_______ apartments

7.  Of those apartments, how many did you think were:

Acceptable_________

Unacceptable_______

8.  How would you describe the different steps involved in obtaining a lease?

[Refer to CARD 2 to code each step from Very Difficult to Very Easy]

Step

Code (from CARD 2)

A.

Finding listings of available apartments

B.

Finding an acceptable apartment option

C.

Getting an apartment inspected by PHA

D.

Being selected as a tenant by a landlord

E.

Obtaining money for rent, security deposit or moving costs

9.  How did you find the apartment options you chose from?

a.  On my own

b.  With help of friends or family

c.  With help of HUD-VASH program staff such as case manager or housing specialist

d.  With help of staff from the PHA

e.  VASH program staff conducted the apartment search for me

10.  What was your primary reason for choosing your apartment?

a.  Location/neighborhood

b.  Good repair/quality

c.  Particular features of apartment  (e.g. appliances, space, appearance, pets OK)

d.  I didn't have a choice

11.  Did you have any of the following for your move into the apartment?   Check yes or no for each item Item

Yes

No

A.

Basic items essential to move in (e.g. bed, table, sheets)

B.

Assistance from HUD-VASH program staff in getting essential move-in items

C.

Help from HUD-VASH program staff moving belongings into the apartment

D.

Help from HUD-VASH program with setting up your utilities (e.g. phone,

electricity, gas, cable)

Housing Satisfaction: HUD-VASH apartment

12.  How comfortable did you feel staying in the apartment on your first few days there?

a.  Not comfortable

b.  Moderately comfortable

c.  Very comfortable

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Appendix C: Methods

13.  How satisfied are you with the following qualities of your apartment?   Refer to CARD 3 to code satisfaction with each quality

Quality

Code

A.

Apartment condition

B.

Affordability

C.

Building safety and security

D.

Access to shopping

E

Access to public transportation

E.

Neighborhood safety

F.

Opportunities to socialize

14.  Do you think the HUD-VASH program is a good fit for your needs?

a.  Yes

b.  No

15.  If you answered "No" to the previous question, what is your primary reason?

a.  I don’t need as much support as the program offered

b.  I need greater support than the program offers

c.  Program has more rules than is acceptable to me

d.  Housing unit does not fit my needs

e.  Other

Income, work and school: While enrolled in HUD-VASH

16.  What are your current sources of income?  Circle all that apply

a.  VA Compensation

b.  VA Pension

c.  Social Security Retirement

d.  SSI

e.  SSD/I

f.  Full-time work

g.  Part-time work

h.  Other _______________________________

•

17.  Are you involved in any educational or vocational program?

a.  Yes

b.  No

HUD-VASH Case Manager Relationship

18.  On average, how many times a month do you meet with your case manager?

________ times per month

19.  How often do the following statements apply to you?   Refer to CARD 4 to code level of agreement with each statement.

Statement

Code

A.

My case manager is able to help me.

B.

My case manager and I agree on goals.

C.

My case manager and I have different ideas about what my problems are.

D.

My case manager and I trust one another.

Medical Condition

20.  Have you had any serious medical problems while in the HUD-VASH program?

a.  Yes

b.  No

21.  Have you ever hospitalized for any medical problem while in the HUD-VASH program?

a.  Yes

b.  No

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Appendix C: Methods

22.  In general, during your time in the HUD-VASH program, how would you describe your health?

a.  Excellent

b.  Very good

c.  Good

d.  Fair

e.  Poor

23.  During your time in HUD-VASH, has your health ever limited you from doing any of the following?   Refer to CARD

4 to code how often the Veteran has been limited from each task

Activity

Code

A.

Bathing or dressing yourself

B.

Climbing one flight of stairs

C.

Lifting or carrying groceries

D.

Cooking for yourself

Mental Health Condition

24.  While in the HUD-VASH program, have you had any serious mental health problems?

a.  Yes

b.  No

25.  Have you been hospitalized for any mental health problem while in HUD-VASH?

a.  Yes

b.  No

26.  During your time in HUD-VASH, how often have you had the following feelings?  Refer to CARD 4 to code how often the Veteran has experienced each feeling

Feeling

Code

A.

Your mood was good

B.

Under strain, stress, or pressure

C.

Bothered by nervousness

D.

Sad, discouraged, or hopeless

E.

Like you were losing control over the way you acted, talked, or thought

Substance Abuse Status

27.  While in the HUD-VASH program, how troubled or bothered have you been by drugs or alcohol?

a.  Not at all

b.  Slightly

c.  Moderately

d.  Considerably

e.  Extremely

28.  Have you received any inpatient or outpatient treatment for drug or alcohol use while in the HUD-VASH program?

a.  Inpatient treatment

b.  Outpatient treatment

c.  Both inpatient and outpatient treatment

d.  No treatment

Veteran Questionnaire -- Stayer, Open-Ended

Introduction

I’d like to start the interview by having you walk me through your experiences in the HUD-VASH program. I’m going to start by asking about how you first learned about the program, and then ask you more specifically about the different steps and components of the program. After that, I will ask you some survey questions about these experiences.

Open-Ended Questions

First, I’d like to ask you some questions about how you learned about HUD-VASH and your initial experiences with the program.

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Probes: How did you learn about HUD-VASH? How long did it take for you to enroll in HUD-VASH? Did it take longer than you expected, about what you expected, or less time than you expected? Why?

After you enrolled in HUD-VASH, tell me how you learned about how the program works.  Describe your first meeting with your case manager. Did you have an orientation? If so, who was the orientation with (HUD-VASH and/or PHA, jointly/separately)? Was it helpful?  Were there things you would have liked to know about the program that you didn’t learn about until later in the process? What would you have wanted to know and why?

From the time that you first enrolled in HUD-VASH, describe the process for completing the PHA application and receiving your housing voucher. Is there anything that you feel could have been improved about this process?

Next, tell me about your housing search.

Probes: Was it difficult to find a suitable housing option? Why?

Tell me more about being selected as a tenant by the landlord of the property.  Did you have to go through any specific screening processes to be selected as a tenant, such as a criminal background check, credit check or drug test? Were you told about any requirements that you would need to meet in order to stay in permanent housing? If so, what were they (e.g., abstinence, sobriety, treatment)? Were you worried that these requirements would make staying in the program hard for you? If so, which one(s)?

Once you decided on an apartment, describe the process for getting the apartment inspected, and preparing for move-in.

Is there anything that you feel could have been improved about this process? Did you receive any additional assistance for move-in, such as assistance with move-in costs or furniture?  If so, where did you receive assistance from? How did you learn about available assistance? If not, would you have liked to receive assistance? What kind of assistance would have been helpful?

Where did you stay prior to moving into your HUD-VASH housing unit?

Describe your relationship with your case manager.

Probes: What aspects of your relationship with your case manager were helpful? What aspects were unhelpful? What are some things you would change about your relationship with your case manager and/or the HUD-VASH team?

Did you develop a Housing Recovery Plan with your case manager? If so, when did you make it? How did you decide what to include in your plan? Did you ever change your plan? Why?

Was the HUD-VASH team able to help you reach your goals / be successful in maintaining your housing? If not, what else do you wish the HUD-VASH team could have done to help you?

What kind of services did you receive through HUD-VASH (e.g., peer support, supported employment)?  Did you participate in any HUD-VASH groups? If so, what groups did you participate in?

Tell me about any parts of the HUD-VASH program that you found challenging.

Probes: Did you have any housing issues or problems after moving into your apartment? If so, were the HUD-VASH

team and/or PHA able to assist you to ensure you were able to maintain your housing? If not, why weren’t they able to help you?

Did you find it difficult to follow any of the rules from the HUD-VASH team, PHA or landlord? If so, which one(s)?

Now I’d like to talk for a few minutes about your general feelings about the HUD-VASH program.

Probes: What have been the most helpful aspects of the program? What have been the least helpful? Why? If there was one thing that you could change about the HUD-VASH program, what would it be?

Closed-Ended Questions

Thanks for telling me about your experiences with HUD-VASH. Now, I’m going to ask you some additional survey questions about these experiences. (See Appendix A.2a.)

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•  Conclusion

Alright, so I asked very generally about your experiences in HUD-VASH, and then I asked you some survey questions related to your experience. Is there anything else you would like to say about your experience with the program that I haven’t asked?

Veteran Questionnaire -- Leased-Up Exiter

Housing and Homelessness History

1.  I want you to think about where you have been living since you enrolled in the HUD-VASH program. We would like to know all of the places where you’ve stayed during this time, including hospitals. Let’s look at this calendar together, and I’ll make notes as you talk.  Why don’t we start with where you are living now and work backwards from there, place by place.  [Refer to CARD 1]

Location  Date Moved In

Date Moved Out

Location Type (code)

Composition (code)

Letter

A.

B.

C.

D.

E.

F.

G.

H.

2.  Using the chart, please point out where you were staying when you obtained a HUD-VASH Voucher.

Choose Location Letter from list above: ____________________________________

3.  Using the chart, please point out where you were staying when you found an apartment with your HUD-VASH voucher Choose Location Letter from list above: ____________________________________

HUD-VASH Housing Process

4.  How would you describe the different steps involved in getting a voucher?

[Refer to CARD 2 to code each step from Very Difficult to Very Easy]

Step

Code (from CARD 2)

A.

Enrolling in the HUD-VASH program

B.

Submitting application to PHA

C.

Providing documentation of identity and income to Public

Housing Authority

5.  Did you receive help from your HUD-VASH case manager or other HUD-VASH staff in either of the following steps in obtaining a voucher?  [Check yes or no for each step]

Step

Yes (Received Help)

No (Did not receive help)

A.

Getting and attending appointment with the

PHA

B.

Providing proof of identity or income

C.

Completing and submitting the PHA

application

6.  Now I want to ask you about your impressions of the condition and location of the apartments that you visited during your housing search.  Approximately how many apartments did you visit during your housing search?

_______ apartments

7.  Of those apartments, how many did you think were:

Acceptable_________

Unacceptable_______

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8.  How would you describe the different steps involved in obtaining a lease?

[Refer to CARD 2 to code each step from Very Difficult to Very Easy]

Step

Code (from CARD 2)

A

Finding listings of available apartments

B

Finding an acceptable apartment option

C

Getting an apartment inspected by PHA

D

Being selected as a tenant by a landlord

E

Obtaining money for rent, security deposit or moving costs

9.  How did you find the apartment options you chose from?

a.  On my own

b.  With help of friends or family

c.  With help of HUD-VASH program staff such as case manager or housing specialist

d.  With help of staff from the PHA

e.  VASH program staff conducted the apartment search for me

10.  What was your primary reason for choosing your apartment?

a.  Location/neighborhood

b.  Good repair/quality

c.  Particular features of apartment  (e.g. appliances, space, appearance, pets OK)

d.  I didn't have a choice

11.  Did you have any of the following for your move into the apartment?   Check yes or no for each item Item

Yes

No

A.

Basic items essential to move in (e.g. bed, table, sheets)

B.

Assistance from HUD-VASH program staff in getting essential move-in items

C.

Help from HUD-VASH program staff moving belongings into the apartment

D.

Help from HUD-VASH program with setting up your utilities (e.g. phone,

electricity, gas, cable)

Housing Satisfaction: HUD-VASH apartment

12.  How comfortable did you feel staying in the apartment on your first few days there?

a.  Not comfortable

b.  Moderately comfortable

c.  Very comfortable

13.  How satisfied were you with the following qualities of your apartment?  Refer to CARD 3 to code satisfaction with each quality

Quality

Code

A.

Apartment condition

B.

Affordability

C.

Building safety and security

D.

Access to shopping

E

Access to public transportation

E.

Neighborhood safety

F.

Opportunities to socialize

14.  Do you think the HUD-VASH program was a good fit for your needs?

a.  Yes

b.  No

15.  If you answered "No" to the previous question, what is your primary reason?

a.  I didn’t need as much support as the program offered

b.  I needed greater support than the program offered

c.  Program had more rules than was acceptable to me

d.  Housing unit did not fit my needs

e.  Other

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Income, work and school: While enrolled in HUD-VASH

16.  What were your sources of income while you were in the HUD-VASH program?  Circle all that apply a.  VA Compensation

b.  VA Pension

c.  Social Security Retirement

d.  SSI

e.  SSD/I

f.  Full-time work

g.  Part-time work

h.  Other _______________________________

17.  Were you involved in any educational or vocational program while enrolled in HUD-VASH?

a.  Yes

b.  No

HUD-VASH Case Manager Relationship

18.  On average, how many times a month did you meet with your case manager when you were enrolled in the program?

________ times per month

19.  While you were in the HUD-VASH program, how often did the following statements apply to you?

Refer to CARD 4 to code level of agreement with each statement.

Statement

Code

A.

My case manager was able to help me.

B.

My case manager and I agreed on goals.

C.

My case manager and I had different ideas about what my problems were.

D.

My case manager and I trusted one another.

Medical Condition

20.  While in the HUD-VASH program, did you have any serious medical problems?

a.  Yes

b.  No

21.  Were you ever hospitalized for any medical problem while in HUD-VASH?

a.  Yes

b.  No

22.  In general, during your time in the HUD-VASH program, how would you describe your health?

a.  Excellent

b.  Very good

c.  Good

d.  Fair

e.  Poor

23.  During your time in HUD-VASH, did your health ever limit you from doing any of the following?   Refer to CARD 4 to code how often the Veteran was limited from each task

Activity

Code

A.

Bathing or dressing yourself

B.

Climbing one flight of stairs

C.

Lifting or carrying groceries

D.

Cooking for yourself

Mental Health Condition

24.  While in the HUD-VASH program, did you have any serious mental health problems?

a.  Yes

b.  No

25.  Were you hospitalized for any mental health problem while in HUD-VASH?

a.  Yes

b.  No

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26.  During your time in HUD-VASH, how often did you have the following feelings?  Refer to CARD 4 to code how often the Veteran experienced each feeling

Feeling

Code

A.

Your mood was good

B.

Under strain, stress, or pressure

C.

Bothered by nervousness

D.

Sad, discouraged, or hopeless

E.

Like you were losing control over the way you acted, talked, or thought

Substance Abuse Status

27.  While in the HUD-VASH program, how troubled or bothered were you by drugs or alcohol

a.  Not at all

b.  Slightly

c.  Moderately

d.  Considerably

e.  Extremely

28.  Did you receive any inpatient or outpatient treatment for drug or alcohol use while in the HUD-VASH program?

a.  Inpatient treatment

b.  Outpatient treatment

c.  Both inpatient and outpatient treatment

d.  No treatment

Program Exit

29.  Did you decide to leave the HUD-VASH program, or were you asked to leave?

I decided to leave

I was asked to leave

If you answered “I decided to leave” continue to Question 30. If you answered “I was asked to leave” skip to Question 31.

30.  When you decided to leave, did you have plans for a place to live after you left?

a.  Yes

b.  No

31.  In your own words, what was the main reason you left the HUD-VASH program?

32.  Which of the following situations contributed to you leaving the HUD-VASH program?  Check all that apply a.  Difficulty paying the rent

b.  Increase in income

c.  Dissatisfaction with apartment

d.  Dissatisfaction with neighborhood

e.  Conflict with neighbors

f.  Conflict with landlord

g.  Conflict with HUD-VASH case manager or other program staff

h.  Disagreement with program rules

i.  Worsening in medical condition

j.  Worsening in mental health condition

k.  Worsening in substance abuse condition

l.  Improvement in health condition

m.  Improvement in mental health condition

n.  Improvement in substance abuse condition

o.  Legal trouble such as arrest, jail, warrant, probation, lawsuit or trial

p.  Offer from family or friend to move in to their housing

q.  Evicted from apartment

r.  Voucher revoked by PHA

33.  Of the reasons listed, which one best matches the main reason that you left the HUD-VASH program?    [Write the letter corresponding to the reason from list above]  ___________

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34.  Did HUD-VASH staff help you find a new place to stay when you left the program?

a.  Yes

b.  No

Housing Satisfaction: Current Housing

35.  How satisfied are you with the following qualities of your current housing?

Quality

Code

A.

Apartment condition

B.

Affordability

C.

Building safety and security

D.

Access to shopping

E.

Access to public transportation

F.

Neighborhood safety

G.

Opportunities to socialize

Post-Exit Contact with VA

36.  Have you used or do you plan to use VA medical services after leaving the HUD-VASH program?

a.  Yes

b.  No

37.  After leaving the HUD-VASH program, are you still in contact with your HUD-VASH case manager?

a.  Yes

b.  No

Income, Work and School: Post-Exit

38.  What are your current sources of income?

a.  VA Compensation

b.  VA Pension

c.  Social Security Retirement

d.  SSI

e.  SSD/I

f.  Full-time work

g.  Part-time work

h.  Other _______________________________

39.  Are you currently involved in any educational or vocational program?

a.  Yes

b.  No

Veteran Questionnaire -- Leased-Up Exiter, Open-Ended

Introduction

I’d like to start the interview by having you walk me through your experiences in the HUD-VASH program. I’m going to start by asking about how you first learned about the program, and then ask you more specifically about the different steps and components of the program. After that, I will ask you some survey questions about these experiences.

Open-Ended Questions

First, I’d like to ask you some questions about how you learned about HUD-VASH and your initial experiences with the program.

Probes: How did you learn about HUD-VASH? How long did it take for you to enroll in HUD-VASH? Did it take longer than you expected, about what you expected, or less time than you expected? Why?

After you enrolled in HUD-VASH, tell me how you learned about how the program works.  Describe your first meeting with your case manager. Did you have an orientation? If so, who was the orientation with (HUD-VASH and/or PHA, jointly/separately)? Was it helpful?  Were there things you would have liked to know about the program that you didn’t learn about until later in the process? What would you have wanted to know and why?

From the time that you first enrolled in HUD-VASH, describe the process for completing the PHA application and receiving your housing voucher. Is there anything that you feel could have been improved about this process?

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Next, tell me about your housing search.

Probes: Was it difficult to find a suitable housing option? Why?

Tell me more about being selected as a tenant by the landlord of the property.  Did you have to go through any specific screening processes to be selected as a tenant, such as a criminal background check, credit check or drug test? Were you told about any requirements that you would need to meet in order to stay in permanent housing? If so, what were they (e.g., abstinence, sobriety, treatment)? Were you worried that these requirements would make staying in the program hard for you? If so, which one(s)?

Once you decided on an apartment, describe the process for getting the apartment inspected, and preparing for move-in.

Is there anything that you feel could have been improved about this process? Did you receive any additional assistance for move-in, such as assistance with move-in costs or furniture?  If so, where did you receive assistance from? How did you learn about available assistance? If not, would you have liked to receive assistance? What kind of assistance would have been helpful?

Where did you stay prior to moving into your HUD-VASH housing unit?

Describe your relationship with your case manager.

Probes: What aspects of your relationship with your case manager were helpful? What aspects were unhelpful? What are some things you would change about your relationship with your case manager and/or the HUD-VASH team?

Did you develop a Housing Recovery Plan with your case manager? If so, when did you make it? How did you decide what to include in your plan? Did you ever change your plan? Why?

Was the HUD-VASH team able to help you reach your goals / be successful in maintaining your housing? If not, what else do you wish the HUD-VASH team could have done to help you?

What kind of services did you receive through HUD-VASH (e.g., peer support, supported employment)?  Did you participate in any HUD-VASH groups? If so, what groups did you participate in?

Tell me about any parts of the HUD-VASH program that you found challenging.

Probes: Did you have any housing issues or problems after moving into your apartment? If so, were the HUD-VASH

team and/or PHA able to assist you to ensure you were able to maintain your housing? If not, why weren’t they able to help you?

Did you find it difficult to follow any of the rules from the HUD-VASH team, PHA or landlord? If so, which one(s)?

Now I’d like to talk for a few minutes about the time when you left the HUD-VASH program.

Probes: When did you first think of leaving the program? Tell me how you came to that decision.  What were your feelings about leaving the program?  Were you happy to be leaving? Did you want to stay in the program? Why or why not? How were things going for you at the time you left the program? Did any of those things affect your housing situation?

What could have changed that would have made you decide to stay in HUD-VASH? If there was one thing that you could change about the HUD-VASH program, what would it be?

Would you participate in HUD-VASH again? Why or why not?

Closed-Ended Questions

Thanks for telling me about your experiences with HUD-VASH. Now I’m going to ask you some more specific survey questions about your housing history and experiences in HUD-VASH. (See Appendix A.3a.)

Conclusion

Alright, so I asked very generally about your experiences in HUD-VASH, and then I asked you some survey questions related to your experience. Is there anything else you would like to say about your experience with the program that I haven’t asked?

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Veteran Questionnaire -- Non-Leased Exiter

Housing and Homelessness History

1.  I want you to think about where you have been living since you enrolled in the HUD-VASH program. We would like to know all of the places where you’ve stayed during this time, including hospitals. Let’s look at this calendar together, and I’ll make notes as you talk.  Why don’t we start with where you are living now and work backwards from there, place by place.  [Refer to CARD 1]

Location  Date Moved In

Date Moved Out

Location Type (code)

Composition (code)

Letter

A.

B.

C.

D.

E.

F.

G.

H.

2.  Using the chart, please point out where you were staying when you obtained a HUD-VASH Voucher.

Choose Location Letter from list above: ____________________________________

3.  Using the chart, please point out where you were staying when you found an apartment with your HUD-VASH voucher Choose Location Letter from list above: ____________________________________

HUD-VASH Housing Process

4.  How would you describe the different steps involved in getting a voucher?

[Refer to CARD 2 to code each step from Very Difficult to Very Easy]

Step

Code (from CARD 2)

A.

Enrolling in the HUD-VASH program

B.

Submitting application to PHA

C.

Providing documentation of identity and income to Public Housing

Authority

5.  Did you receive help from your HUD-VASH case manager or other HUD-VASH staff in either of the following steps in obtaining a voucher?  [Check yes or no for each step]

Step

Yes (Received Help)

No (Did not receive help)

A.

Getting and attending appointment with the

PHA

B.

Providing proof of identity or income

C.

Completing and submitting the PHA

application

6.  Now I want to ask you about your impressions of the condition and location of the apartments that you visited during your housing search.  Approximately how many apartments did you visit during your housing search?

_______ apartments

7.  Of those apartments, how many did you think were:

Acceptable_________

Unacceptable_______

8.  Had you completed any of the following steps in the housing process before you left the HUD-VASH program?

[Check all steps that Veteran completed before exiting]

Step

Completed

A

Finding listings of available apartments

B

Finding an acceptable apartment option

C

Getting an apartment inspected by PHA

D

Being selected as a tenant by a landlord

E

Obtaining money for rent, security deposit or moving costs

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9.  Did you receive any assistance looking for apartments?

a.  No, I searched on my own

b.  Yes, from friends or family

c.  Yes, from HUD-VASH program staff such as case manager or housing specialist

d.  Yes, from staff from the PHA

10.  Do you think the HUD-VASH program was a good fit for your needs?

a.  Yes

b.  No

11.  If you answered "No" to the previous question, what is your primary reason?

a.  I didn’t need as much support as the program offered

b.  I needed greater support than the program offered

c.  Program had more rules than was acceptable to me

d.  Housing options I found did not fit my needs

e.  Other___________________________________________________________________________________

Income, work and school: While enrolled in HUD-VASH

12.  What were your sources of income while you were in the HUD-VASH program?  Circle all that apply a.  VA Compensation

b.  VA Pension

c.  Social Security Retirement

d.  SSI

e.  SSD/I

f.  Full-time work

g.  Part-time work

h.  Other _______________________________

13.  Were you involved in any educational or vocational program while enrolled in HUD-VASH?

a.  Yes

b.  No

HUD-VASH Case Manager Relationship

14.  On average, how many times a month did you meet with your case manager when you were enrolled in the program?

________ times per month

15.  While you were in the HUD-VASH program, how often did the following statements apply to you?  Refer to CARD 4

to code level of agreement with each statement.

Statement

Code

A.

My case manager was able to help me.

B.

My case manager and I agreed on goals.

C.

My case manager and I had different ideas about what my problems were.

D.

My case manager and I trusted one another.

Medical Condition

16.  While in the HUD-VASH program, did you have any serious medical problems?

a.  Yes

b.  No

17.  Were you ever hospitalized for any medical problem while in HUD-VASH?

a.  Yes

b.  No

18.  In general, during your time in the HUD-VASH program, how would you describe your health?

a.  Excellent

b.  Very good

c.  Good

d.  Fair

e.  Poor

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19.  During your time in HUD-VASH, did your health ever limit you from doing any of the following?   Refer to CARD 4 to code how often the Veteran was limited from each task

Activity

Code

A.

Bathing or dressing yourself

B.

Climbing one flight of stairs

C.

Lifting or carrying groceries

D.

Cooking for yourself

Mental Health Condition

20.  While in the HUD-VASH program, did you have any serious mental health problems?

a.  Yes

b.  No

21.  Were you hospitalized for any mental health problem while in HUD-VASH?

a.  Yes

b.  No

22.  During your time in HUD-VASH, how often did you have the following feelings?  Refer to CARD 4 to code how often the Veteran experienced each feeling

Feeling

Code

A.

Your mood was good

B.

Under strain, stress, or pressure

C.

Bothered by nervousness

D.

Sad, discouraged, or hopeless

E.

Like you were losing control over the way you acted, talked, or thought

Substance Abuse Status

23.  While in the HUD-VASH program, how troubled or bothered were you by drugs or alcohol

a.  Not at all

b.  Slightly

c.  Moderately

d.  Considerably

e.  Extremely

24.  Did you receive any inpatient or outpatient treatment for drug or alcohol use while in the HUD-VASH program?

a.  Inpatient treatment

b.  Outpatient treatment

c.  Both inpatient and outpatient treatment

d.  No treatment

•  Program Exit

25.  Did you decide to leave the HUD-VASH program, or were you asked to leave?

I decided to leave

I was asked to leave

If you answered “I decided to leave” continue to Question 30. If you answered “I was asked to leave” skip to Question 31.

26.  When you decided to leave, did you have plans for a place to live after you left?

a.  Yes

b.  No

27.  In your own words, what was the main reason you left the HUD-VASH program?

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28.  Which of the following situations contributed to you leaving the HUD-VASH program?  Check all that apply a.  Couldn’t find an available apartment to rent with the HUD-VASH voucher

b.  Dissatisfaction with available apartments

c.  Apartment that was found did not pass PHA inspection

d.  Did not have money to pay for security deposit or furniture

e.  Increase in income

f.  Conflict with HUD-VASH case manager or other program staff

g.  Disagreement with program rules

h.  Worsening in medical condition

i.  Worsening in mental health condition

j.  Worsening in substance abuse condition

k.  Improvement in health condition

l.  Improvement in mental health condition

m.  Improvement in substance abuse condition

n.  Legal trouble such as arrest, jail, warrant, probation, lawsuit or trial

o.  Offer from family or friend to move in to their housing

p.  Voucher revoked by PHA

29.  Of the reasons listed, which one best matches the main reason that you left the HUD-VASH program?    [Write the letter corresponding to the reason from list above]  ___________

30.  Did HUD-VASH staff help you find a new place to stay when you left the program?

a.  Yes

b.  No

Housing Satisfaction: Current Housing

31.  How satisfied are you with the following qualities of your current housing?

Quality

Code

A.

Apartment condition

B.

Affordability

C.

Building safety and security

D.

Access to shopping

E.

Access to public transportation

F.

Neighborhood safety

G.

Opportunities to socialize

Post-Exit Contact with VA

32.  Have you used or do you plan to use VA medical services after leaving the HUD-VASH program?

a.  Yes

b.  No

33.  After leaving the HUD-VASH program, are you still in contact with your HUD-VASH case manager?

a.  Yes

b.  No

Income, Work and School: Post-Exit

34.  What are your current sources of income?

a.  VA Compensation

b.  VA Pension

c.  Social Security Retirement

d.  SSI

e.  SSD/I

f.  Full-time work

g.  Part-time work

h.  Other _______________________________

35.  Are you currently involved in any educational or vocational program?

a.  Yes

b.  No

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Veteran Questionnaire -- Non-Leased Exiter, Open-Ended

Introduction

I’d like to start the interview by having you walk me through your experiences in the HUD-VASH program. I’m going to start by asking about how you first learned about the program, and then ask you more specifically about the different steps and components of the program. After that, I will ask you some survey questions about these experiences.

Open-Ended Questions

First, I’d like to ask you some questions about how you learned about HUD-VASH and your initial experiences with the program.

Probes: How did you learn about HUD-VASH? How long did it take for you to enroll in HUD-VASH? Did it take longer than you expected, about what you expected, or less time than you expected? Why?

After you enrolled in HUD-VASH, tell me how you learned about how the program works.  Describe your first meeting with your case manager. Did you have an orientation? If so, who was the orientation with (HUD-VASH and/or PHA, jointly/separately)? Was it helpful?  Were there things you would have liked to know about the program that you didn’t learn about until later in the process? What would you have wanted to know and why?

From the time that you first enrolled in HUD-VASH, describe the process for completing the PHA application and receiving your housing voucher. Is there anything that you feel could have been improved about this process?

Next, tell me about your housing search.

Probes: Was it difficult to find a suitable housing option? Why?

Tell me more about being selected as a tenant by the landlord of the property.  Did you have to go through any specific screening processes to be selected as a tenant, such as a criminal background check, credit check or drug test? Were you told about any requirements that you would need to meet in order to stay in permanent housing? If so, what were they (e.g., abstinence, sobriety, treatment)? Were you worried that these requirements would make staying in the program hard for you? If so, which one(s)?

Once you decided on an apartment, describe the process for getting the apartment inspected, and preparing for move-in.

Is there anything that you feel could have been improved about this process? Did you receive any additional assistance for move-in, such as assistance with move-in costs or furniture?  If so, where did you receive assistance from? How did you learn about available assistance? If not, would you have liked to receive assistance? What kind of assistance would have been helpful?

Where did you stay prior to moving into your HUD-VASH housing unit?

Describe your relationship with your case manager.

Probes: What aspects of your relationship with your case manager were helpful? What aspects were unhelpful? What are some things you would change about your relationship with your case manager and/or the HUD-VASH team?

Did you develop a Housing Recovery Plan with your case manager? If so, when did you make it? How did you decide what to include in your plan? Did you ever change your plan? Why?

What kind of services did you receive through HUD-VASH (e.g., peer support, supported employment)?  Did you participate in any HUD-VASH groups? If so, what groups did you participate in?

Tell me about any parts of the HUD-VASH program that you found challenging.

Did you find it difficult to follow any of the rules from the HUD-VASH team or PHA? If so, which one(s)?

Now I’d like to talk for a few minutes about the time when you left the HUD-VASH program.

Probes: When did you first think of leaving the program? Tell me how you came to that decision.  What were your feelings about leaving the program?  Were you happy to be leaving? Did you want to stay in the program? Why or why not? How were things going for you at the time you left the program? Did any of those things affect your housing situation?

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What could have changed that would have made you decide to stay in HUD-VASH? If there was one thing that you could change about the HUD-VASH program, what would it be?

Would you participate in HUD-VASH again? Why or why not?

Closed-Ended Questions

Thanks for telling me about your experiences with HUD-VASH. Now, I’m going to ask you some additional survey questions about these experiences. (See Appendix A.4a.)

Conclusion

Alright, so I asked very generally about your experiences in HUD-VASH, and then I asked you some survey questions related to your experience. Is there anything else you would like to say about your experience with the program that I haven’t asked?

Veteran Questionnaire -- Response Cards

CARD 1

Location Codes

01

Emergency shelter, including hotel or motel paid for with emergency shelter voucher

02

Transitional housing for homeless persons

03

Permanent housing for formerly homeless persons

04

Psychiatric hospital or other psychiatric facility

05

Substance abuse treatment facility or detox center

06

Hospital (non-psychiatric)

07

Jail, prison or juvenile detention facility

08

Family member’s room, apartment or house

09

Friend’s room, apartment or house

10

Hotel or motel paid for without emergency shelter voucher

11

Foster care home or foster care group home

12

Place not meant for habitation (e.g., a vehicle, an abandoned building, a train station)

13

Safe Haven

14

Rental by client, with HUD-VASH housing subsidy

15

Rental by client, with other (non-VASH) ongoing housing subsidy

16

Owned by client, with ongoing housing subsidy:

17

Rental by client, no ongoing housing subsidy

18

Owned by client, no ongoing housing subsidy

19

Other

Composition Codes

01

Alone

02

With family

03

With friends

04

With other(s), not friends or family

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CARD 2

Very difficult    Somewhat difficult    Neither easy nor difficult    Somewhat easy   Very easy

1

2

3

4

5

CARD 3

Very dissatisfied   Somewhat dissatisfied    Mostly satisfied    Very satisfied    Completely satisfied 1

2

3

4

5

CARD 4

•  Never  •  Rarely  •  Sometimes  •  Usually  •  Always

1

2

3

4

5

STAFF INTERVIEW MATERIALS

Housing Authority Questionnaire

Introductions

What is your role at the PHA?  How long have you worked at the PHA?  What is your background and training?

What is your role in housing and services for homeless Veterans?

Describe the general environment for housing homeless Veterans in this community (e.g., discussion of local PHA, landlords, rental market, support from community partners).

Program Overview

First, I’d like to just get a basic idea about how your HUD-VASH program works.

Refer to “Steps in the HUD-VASH Selection, Housing, and Case Management Process” to review steps that may be helpful in describing local practices.

1.  Does the PHA have staff dedicated (100% of their time) to HUD-VASH? If so, how many staff? What are staff titles/roles?

2.  Imagine you receive a new HUD-VASH referral today. Take me through what happens from now until the Veteran is housed with a HUD-VASH voucher.

3.  Has this process changed over time? If so, how (e.g., revised leasing process that functions differently from HCV

program)?

4.  Does the PHA offer a HUD-VASH orientation for Veterans? If so, how is the orientation conducted? Does the VA case management team play a role in this orientation process?

Eligibility & Application Process

Now let’s talk a bit more specifically about how determine Veterans’ eligibility for the program and the HUD-VASH voucher application process.

5.  What are the eligibility requirements to be considered for a HUD-VASH voucher? Are there any specific local requirements?

6.  What are clients required to demonstrate in order obtain a HUD-VASH voucher (e.g., housing readiness)?

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7.  Does your program have specific performance measures it aims to reach (i.e., does the program aim to enroll a specific number or percentage of participants from the targeted population(s))?

8.  How does the PHA process referrals?

9.  What is the process for meeting with Veterans and helping them obtain housing vouchers?

10.  What do Veterans need to provide in order to complete the PHA application (e.g., proof of identity and income, credit history)?

11.  How is Veterans’ monthly rental contributions determined? What types of income/benefits are included in determining the rental contribution? Could this amount change? If so, under what circumstances?

Housing Process

Next, I’d like to ask you to describe the housing process in more detail.

12.  Does the PHA assist Veterans in their housing search? If so, how?

13.  Does the PHA maintain a list of units or landlords that will accept HUD-VASH voucher in order to expedite the leasing process? If so, are the units pre-inspected? How often is the list updated?

14.  Do Veterans receive assistance from the PHA in setting up appointments and viewing housing options? If so, what type of assistance, and how is it provided (e.g., transportation by community partner)?

15.  How many apartments are typically viewed by each Veteran before a unit is selected?

16.  Does the PHA assist Veterans in being selected by landlords for housing? If so, how?

17.  Describe the process for scheduling a HUD Housing Quality Standards (HQS) Inspection. On average, how long does it take for an inspection to be scheduled after the Veteran makes a housing selection? If a unit fails inspection, how long does it take to schedule a reinspection? Does the PHA allow case managers to ensure that all issues have been resolved to expedite reinspection (i.e., deputize case managers)?

18.  Describe the process for setting up the Housing Assistance Payment (HAP) Contract.

19.  What are the challenges that might lead to Veterans exiting the HUD-VASH program before being housed? What has your team done to address these challenges?

20.  How many different staff at the PHA typically interact with the Veteran during the application and lease-up process? How many times does each Veteran typically meet with the PHA before they are housed?

21.  On average, how long does it take a Veteran to obtain housing (from admission to move-in)? What is the typical range? Are there common barriers that tend to make this process take longer? What barriers are specific to the PHA and VA? How can they be addressed by either the PHA or VA?

22.  Tell me about the annual HUD-VASH recertification and HQS inspection process.

Communication with VA

I’d now like to get a better idea of your overall communication with VA.

23.  Describe the communication the PHA has with the VA case management team. Does the HUD field office assist in facilitating communication?

24.  Does PHA staff meet regularly with the VA case management team? If so, how often do meetings take place? What is discussed during meetings?

25.  Is training provided to PHA staff (either by the PHA or VA) to review local policies and procedures? If so, describe the training.

26.  Do the PHA and VA case management team exchange data on participants? If so, what type of data is shared (e.g., participant outcomes), how often is data reviewed, and what is the process for reviewing data?

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Program Exits

We’re also interested on your thoughts as to why Veterans exit HUD-VASH—both for positive and negative reasons.

27.  What are the most common reasons that Veterans exit the HUD-VASH program?

28.  Are there any requirements that Veterans must meet to stay in permanent housing that could be related to Veteran exits? If so, what are they (e.g., sobriety/treatment)? Are they PHA or VA rules?

29.  How do PHA staff typically find out a client is experiencing housing problems (e.g., Veteran, VA, landlords)? Do the PHA and VA case management team communicate about existing or potential housing problems? If housing issues arise, does the PHA and/or VA case management team get involved? What is done to help ensure that the Veteran maintains their housing (e.g., PHA notifies VA case management team prior to taking adverse action against Veteran)?

30.  In general, what could be done by the PHA and/or the VA to mitigate negative exits and ensure more Veterans successfully maintain housing? Could further assistance be provided by HUD, VA, or other community partners? What type of assistance is needed?

31.  What is the process for terminating a Veteran from the HUD-VASH program? Are different processes applied for HUD-VASH than the regular voucher program? If so, why?

32.  Describe the process that takes place when the termination of a Veteran’s HUD-VASH voucher by the PHA is imminent.

Does the PHA contact the VA case management team to try to mitigate the cause for termination prior to taking adverse action? Describe the communication that takes place between the PHA and the VA case management team. Could this process be improved? If so, how?

Organizational Aspects

Finally, let’s talk about the PHA’s goals for HUD-VASH and any challenges staff might face in reaching those goals.

33.  What are the stated goals for the HUD-VASH program at this PHA (e.g., utilizing vouchers, housing the most vulnerable Veterans, eliminating Veteran homelessness)? Do these goals differ for VA and/or other community partners? If so, how?

34.  Are these goals supported by senior leadership at the PHA? If so, how?

35.  Are these goals supported by VA and/or other community partners? If so, how?

36.  Does the PHA have the resources necessary to meet these goals? If not, what other resources are necessary?

37.  How do you measure/evaluate the program’s progress in meeting its goals? Has this changed over time? If so, why?

38.  How would you “rate” your progress in meeting these goals to date?

39.  What are the consequences for insufficient progress in meeting the program’s goals?

40.  Do you review processes and make process improvements?  If so, how is the review done? How often? How are improvements made? Are the VA case management team and/or other community partners included in these reviews and process improvements? If so, what is their role?

41.  How does the PHA support strong networks within the PHA and with the VA and other community partners to ensure that everyone involved in housing homeless Veterans is working together?

42.  What are the key facilitators and barriers to housing homeless Veterans at the PHA?

43.  What do you see as the biggest challenge the PHA faces in trying to house homeless Veterans?

Wrap-up

44.  Is there anything else you would like to share about the HUD-VASH program?

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VA Case Management Team Pre-Interview Questionnaire

Please complete the following questionnaire, and provide a copy of Veteran screening and/or eligibility tools with your responses.

Program Characteristics

How many HUD-             # Vouchers Allocated (FY08-Present)

VASH vouchers

# Filled / In Use

# Not filled / Available for Use

are allocated to

Of those vouchers currently available for use, how many are:

your facility?

Pending PHA process

Not yet assigned

Other

What is your average VA case management / HUD-VASH staff to Veteran ratio?

:

From which VA settings are Veterans recruited or outreached? Check all that apply.

VA Settings:

Street outreach initiated by VA staff

Justice system outreach initiated by VA staff

Other community outreach by VA staff

Stand Down

VA MH RRTP (DCHV, CWT / TR, SARRTP, General RRTP)

VA substance abuse outpatient unit

VA mental health outpatient unit

VA medical outpatient unit

VA emergency room

VA inpatient unit

Vet Center / Drop-In Clinic

VBA

VA Homeless Veterans Hotline

Other, specify:

From which non-VA settings are Veterans recruited or outreached? Check all that apply.

Non-VA Settings:

a.  Street outreach initiated by non-VA staff

b.  Criminal justice system

c.  Shelter staff or other community homeless services provider

d.  VA Grant and Per Diem

e.  Non-VA community mental health center or clinic

f.  Non-VA emergency room

g.  Other federal agency (HUD, DoL, HHS)

h.  Family member

i.  Self

j.  Other, specify:

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Which population(s) does your facility target for admission to the HUD-VASH program? Check all that apply.

Veterans experiencing homelessness continuously for 1 year or longer

Veterans having 4 or more separate episodes of homelessness over a 3 year period

Veterans at risk for becoming homeless (e.g., doubled up, coming out of jail or hospital, couch

surfing, temporarily with friends / family)

Female Veterans

OEF / OIF / OND Veterans

Young adults, ages 18-25

Older adults, ages 55 and over

Families

Substance abuse or dependence only

Mentally ill only

Co-occurring substance use and mental illness

Other, specify:

Services

Please indicate the types of staff your agency makes available to HUD-VASH participants, indicating whether the position is funded through HUD-VASH, the VA, or a community partner. Check all that apply.

Funded by

Primary Service Location

HUD-VASH

VA

Funded

Funded

Community

(VA, community, Veteran

Partner

home)

Psychiatrist

Psychologist

Social worker

Substance abuse counselor

Mental health counselor / Professional

counselor

Mental illness / Chemical abuse (MICA)

counselor

Trauma specialist

Vocational specialist

Housing specialist

Case manager

Peer advocate / Peer specialist

Physician

Nurse

Discharge planning specialist

Psychosocial rehabilitation counselor

Education specialist

Other, specify:

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Please indicate if Veterans receive any of the following services, and if so, whether the services are provided directly through the VAMC or through referral to other community organizations. Check all that apply.

Provided to HUD-VASH

Name of Service

Provided to HUD-VASH

Veterans at VAMC

Veterans by other community

organizations

OUTREACH & ENGAGEMENT

SCREENING

Leave blank. Respond to sub-items individually.

Mental disorders

Substance abuse or dependence

Co-occurring substance use and mental disorder

Trauma

TREATMENT SERVICES - Substance abuse (SA)

Leave blank. Respond to sub-items individually.

treatment

Assessment (e.g., diagnostic and more in depth)

SA outpatient treatment

SA inpatient / residential treatment

Pharmacotherapy (e.g., Methadone / Buprenorphine)

Detox

TREATMENT SERVICES - Mental health (MH) treatment

Leave blank. Respond to sub-items individually.

Assessment (e.g., diagnostic and more in depth)

MH outpatient treatment

MH inpatient / residential treatment

Pharmacotherapy (e.g., anti-depressants, anti-

psychotics, anti-anxiety medications)

TREATMENT SERVICES - Integrated substance abuse

and mental health treatment

TREATMENT SERVICES - Trauma / PTSD

MEDICAL SERVICES

Leave blank. Respond to sub-items individually.

General medical treatment

Specialized medical care for women

Medication / medication management

WRAP AROUND SERVICES

Leave blank. Respond to sub-items individually.

Case management

Discharge planning

Crisis care (e.g., 24 hour crisis response service)

Peer-to-peer support / Self-help groups (e.g., AA / NA,

other 12-step peer support, non 12-step approaches)

Peer mentoring

Vocation and employment services

Education / GED program

Transportation

Legal assistance

Support services for families (e.g., parenting skills /

education, childcare, domestic violence services)

Benefits application (e.g., SSI / SSD, food stamps)

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HOUSING SERVICES

Leave blank. Respond to sub-items individually.

Assistance in getting and attending appointment(s)

with the PHA

Assistance in providing documents required for the

PHA application (e.g., proof of identity or income)

Assistance in completing and submitting the PHA

application

Housing search assistance

Independent living skills / Daily living skills (e.g.,

budgeting, food shopping, cleaning, hygiene)

Assistance with getting essential move-in items

Assistance with moving belongings into the apartment

Assistance with setting up utilities

Community integration

What Evidence-Based Practices (EBPs) are you implementing at your site?

EBP / Promising or Best Practice Name

Has your agency ever implemented this EBP?

Assertive Community Treatment (ACT)

Cognitive Behavioral Therapy (CBT)

Harm Reduction

Motivational Interviewing (MI)

Transtheoretical Model (TTM) / Stages of Change

Twelve Step Facilitation

Critical Time Intervention (CTI)

Intensive Case Management (ICM)

Peer Support / Mentoring

SSI / SSDI Outreach, Access and Recovery (SOAR)

Supported Employment

Housing First

Challenges

Please indicate the extent to which you agree or disagree that the following barriers impact implementation and / or service delivery for the HUD-VASH program.

Strongly

Agree

Agree

Neither

Disagree

Strongly

Disagree

Difficulties hiring qualified staff

Difficulties retaining qualified staff

Shortfalls in recruiting or enrolling target Veterans

Veteran reluctance to access HUD-VASH services

Difficulties retaining target Veterans in HUD-VASH

program

Difficulties following up with Veterans in HUD-VASH

program

Difficulties providing services as planned

Existing agency rules or regulations

Other, specify:

Copy of Veteran screening and/or eligibility tools with responses to this questionnaire attached.

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VA Case Management Team Questionnaire

Introductions

What is your role at VA?  How long have you worked at VA? What is your background and training?

What is your role in housing and services for homeless Veterans?

Describe the general environment for housing homeless Veterans in this community (e.g., discussion of local PHA, landlords, rental market, support from community partners).

Program Overview

First, I’d like to just get a basic idea about how your HUD-VASH program works.

Refer to “Steps in the HUD-VASH Selection, Housing, and Case Management Process” to review steps that may be helpful in describing local practices.

45.  How many staff are dedicated to HUD-VASH? What are staff titles/roles?

2.  Imagine a new client walks in today. Take me through what happens from now until the Veteran is housed with a HUD-VASH voucher.

3.  Has this process changed over time? If so, how?

Targeting & Eligibility

Now let’s talk a bit more specifically about how you target Veterans for the program and determine their eligibility.

Refer to VA Pre-Interview Questionnaire to review target populations.

4.  How do you identify and outreach to Veterans who need housing?

5.  What are the eligibility requirements to be considered for a HUD-VASH voucher? Are there any specific local requirements?

6.  How do you determine who should be targeted for admission to HUD-VASH (e.g., federal requirements, input from community partners)?

7.  To what degree does your program serve these targeted groups? Do you…

•  Recruit and enroll only participants who match all of your target population criteria?

•  Recruit participants who match target population criteria and give them priority enrollment, but if there are open slots, accept others who don’t match some criteria?

•  Not focus recruitment based on target population criteria but give priority enrollment to those who meet the criteria?

•  Not focus recruitment based on target population criteria and enroll anyone who needs and will benefit from your services and programs?

8.  Does your program have specific performance measures it aims to reach (i.e., does the program aim to enroll a specific number or percentage of participants from the targeted population(s))?

9.  What, if anything, are clients required to demonstrate in order to be eligible for admission to the program (e.g., sobriety/treatment)? What, if anything, are clients required to demonstrate in order obtain a HUD-VASH voucher (e.g., housing readiness)?

Housing Process

Next, I’d like to ask you to describe the housing process in more detail–from referral to the PHA for a HUD-VASH voucher through housing selection and move-in.

Refer to VA Pre-Interview Questionnaire to review housing services.

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10.  Does the VA case management team offer a HUD-VASH orientation for Veterans? If so, how is the orientation conducted?

Does the PHA play a role in this orientation process?

11.  Does the VA case management team assist clients with their PHA applications? If so, how?

12.  Does the VA case management team assist Veterans in their housing search? If so, how?

13.  Does the VA case management team maintain a list of units or landlords that will accept HUD-VASH voucher in order to expedite the leasing process? If so, are the units pre-inspected? How often is the list updated?

14.  Do Veterans receive assistance from the VA case management team in setting up appointments and viewing housing options? If so, what type of assistance, and how is it provided (e.g., transportation by community partner)?

15.  How many apartments are typically viewed by each Veteran before a unit is selected?

16.  Does the VA case management team assist Veterans in being selected by landlords for housing? If so, how?

17.  Describe the process for working with the PHA to schedule a HUD Housing Quality Standards (HQS) Inspection. On average, how long does it take for an inspection to be scheduled after the Veteran makes a housing selection? If a unit fails inspection, how long does it take to schedule a reinspection? Does the PHA allow case managers to ensure that all issues have been resolved to expedite reinspection (i.e., deputize case managers)?

18.  Describe the process for working with the PHA to set up a Housing Assistance Payment (HAP) Contract.

19.  What are the challenges that might lead to Veterans exiting the HUD-VASH program before being housed? What has your team done to address these challenges?

20.  Do clients receive any type of move-in assistance? If so, what type of assistance is provided (e.g., financial assistance, provision of household goods)? How is it funded/provided (e.g., community partners)?

21.  How many different staff at the VA typically interact with each Veteran during the application and lease-up process? How many times does each Veteran typically meet with the VA case management team before they are housed?

22.  On average, how long does it take a Veteran to obtain housing (from admission to move-in)? What is the typical range? Are there common barriers that tend to make this process take longer? What barriers are specific to VA and the PHA? How can they be addressed by either VA or the PHA?

23.  Tell me about the annual HUD-VASH recertification and HQS inspection process.

Communication with PHA

I’d now like to get a better idea of your overall communication with the PHA.

24.  Describe the communication the VA case management team has with the PHA. Does the HUD field office assist in facilitating communication?

25.  Does the VA case management team meet regularly with PHA staff? If so, how often do meetings take place? What is discussed during meetings?

26.  Is training provided to the VA case management team (either by the VA or PHA) to review local policies and procedures?

If so, describe the training.

27.  Do the VA case management team and PHA staff exchange data on participants? If so, what type of data is shared (e.g., participant outcomes), how often is data reviewed, and what is the process for reviewing data?

VA Case Management

Let’s speak a little bit more about Veterans’ interactions with the VA case management team. I encourage you to reflect on Veterans’ experiences with case management for their full time in the program, from enrollment, through the housing selection process, and on until their final exit from the program.

Refer to VA Pre-Interview Questionnaire to ask for further details on VA staff and services.

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28.  Do VA case managers meet regularly with clients? If so, describe a typical meeting. How often are meetings held? Does the number of meetings change over time? If so, how? Where do VA case managers meet with clients?

29.  Do VA case managers develop Housing Recovery Plans with Veterans? If so, what is the process for creating these plans?

At what point in the housing process is this done?

a.  What is the process for determining Veteran goals?  (Stated HUD-VASH Housing Recovery Plan Goals =

Establishing housing stability (rent paid, following rules, etc.); Meeting employment and income needs; Resolving legal and financial issues (credit history); Supporting physical, mental, social health)

b.  How is progress towards goals monitored?

c.  Can the Housing Recovery Plan be revised? If so, when would the plan be revised, and what is the process for revising it?  (Stated examples of necessary revision = Goals reached; Treatment needs change; Veteran goals change; Veteran becomes more independent; Level of care changes)

30.  Once Veterans are housed, what are the next steps? How do you engage Veterans in services? How do you keep them engaged?

31.  How are Veterans referred to services? Who provides services? Is there a coordinated effort between VA and other community partners?

32.  How does the VA case management team help integrate Veterans into the local community?

33.  How does the VA case management team typically find out a client is in crisis/experiencing personal problems (e.g., Veteran, PHA, landlord)? How do VA case managers respond to clients in crisis? Are services available 24/7? If so, how (e.g., case manager on-call, via on-call psychologist)?

34.  How does the VA case management team typically find out a client is experiencing housing problems (e.g., Veteran, PHA, landlord)? Do the VA case management team and the PHA communicate about existing or potential housing problems? If housing issues arise, do the VA case management team and/or PHA get involved? What is done to help ensure that the Veteran maintains their housing (e.g., PHA notifies VA case management team prior to taking adverse action against Veteran)?

Program Exiters

We’re also interested on your thoughts as to why Veterans exit HUD-VASH—both for positive and negative reasons.

35.  What are the most common reasons that Veterans exit the HUD-VASH program?

36.  Can Veterans “graduate” from the program? If so, how? What are the factors that help Veterans successfully exit the program for positive reasons?

37.  What are the most common reasons that Veterans fail to lease housing or are terminated from the program for negative reasons? What are the factors that make it challenging for Veteran to stay in the program?

38.  Are there any requirements that Veterans must meet to stay in permanent housing that could be related to Veteran exits? If so, what are they (e.g., sobriety/treatment)? Are they VA or PHA rules?

39.  How are exiters categorized as positive or negative in HOMES? Are there additional categories of exits that should be added to HOMES?

HOMES Categories

Accomplish goals and no longer has a need for program

Transferred to another program site

Found other housing

Did not comply with case management

Eviction or other housing related issues or problems

Unhappy with housing

No longer financially eligible

No longer interested in participating

Cannot be located

Too ill to participate in program

Incarceration

Death

40.  In general, what could be done by the VA and/or the PHA to mitigate negative exits and ensure more Veterans successfully maintain housing? Could further assistance be provided by VA, HUD or other community partners? What type of assistance is needed?

41.  What is the process for terminating a Veteran from the HUD-VASH program?

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42.  Describe the process that takes place when the termination of a Veteran’s HUD-VASH voucher by the PHA is imminent.

Does the PHA contact the VA case management team to try to mitigate the cause for termination prior to taking adverse action? Describe the communication that takes place between the PHA and the VA case management team. Could this process be improved? If so, how?

43.  When Veterans exit the program, are they referred to VA services to ensure continuity of care (e.g., primary care, specialty care, etc.)?

44.  Do VA case managers continue to stay in touch with participants after they have left the HUD-VASH program?

Organizational Aspects

Finally, let’s talk about the team’s goals for HUD-VASH and any challenges the team might face in reaching those goals.

45.  What are the stated goals for your HUD-VASH program here at this VA (e.g., utilizing vouchers, housing the most vulnerable Veterans, eliminating Veteran homelessness)? Do these goals differ for the PHA and/or other community partners? If so, how?

46.  Are these goals supported by senior leadership at the VA? If so, how?

47.  Are these goals supported by the PHA and/or other community partners? If so, how?

48.  Does the VA case management team have the resources necessary to meet these goals? If not, what other resources are necessary?

49.  How do you measure and evaluate the program’s progress in meeting its goals? Has this changed over time? If so, why?

50.  How would you “rate” your progress to date?

51.  What are the consequences for insufficient progress in meeting the program’s goals?

52.  Do you review processes to make process improvements?  If so, how is the review done? How often? How are improvements made? Are the PHA and/or other community partners included in these reviews and process improvements?

If so, what is their role?

53.  How does the VA case management team support strong networks within the VA and with the PHA and other community partners to ensure that everyone involved in housing homeless Veterans is working together?

54.  What are the key facilitators and barriers to housing homeless Veterans at the VA?

55.  What do you see as the biggest challenge the VA case management team faces in trying to house homeless Veterans?

Wrap-up

56.  Is there anything else you would like to share about the HUD-VASH program?

QUANTITATIVE VARIABLES & ANALYSES

Power Analysis

Using the statistical software program PASS 2008 (Hintze, 2008), the research team determined

the sample size required to obtain 80% power to significantly detect an odds ratio up to 2.0 from a

logistic regression analysis predicting study outcomes, given: (1) at least 30 percent of the sample

were exiters, based on national HUD-VASH data collected during FFY 2008–2011 indicating that

one-third of Veterans exited the program; (2) at least 15 percent of the sample indicated a positive

response on one of the primary predictor variables (e.g., inpatient hospital stays); and (3) an alpha

of 0.05. Expected participation rates were 50 percent for stayers and 40 percent for exiters (Wong,

Hadley, & Culhane, 2006) and did not distinguish between types of exiters (i.e., leased-up vs. non-

leased). Exiters were not over-sampled as there was an insufficient sample pool.

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Appendix C: Methods

Because the initial sample size analyses were based on limited data and educated guesses, the

research team also conducted post-hoc power analyses following the regression and survival

models conducted in this study given: (1) the size of both the HUD-VASH participant sample as

well as the subsample of study respondents only, (2) an alpha of 0.05, (3) the number of

predictor variables included in each model, and (4) either the overall model R2 statistic obtained

from multiple regression analyses or the magnitude of key odds and hazard ratios from logistic

regression and Cox Proportional Hazards survival analyses, respectively. Given these

parameters, power for all models ranged between 95 percent and 99 percent.

Variables

The research team accessed administrative data for the period beginning 12 months prior to a

Veteran’s admission to HUD-VASH and 12 months following discharge from HUD-VASH, if

applicable. Exhibit C.1 provides details on administrative data variables.

Exhibit C.1 Administrative data

Variable

Source

Definition

Values

Type

HUD-VASH Data

Study site

HOMES

VAMC where Veterans  Houston

Nominal

enrolled in HUD-VASH  Los Angeles

Palo Alto

Philadelphia

Study group

HOMES

Veterans who were

Stayers—Obtained a lease with a  Nominal

admitted to the HUD-

HUD-VASH voucher and remained

VASH program and

in the housing unit with the

obtained a HUD-VASH

voucher for 600 days or longer

voucher met specific

and did not exit the program

criteria for one of three  Leased-up exiters—Discharged

study groups

from HUD-VASH after leasing a

housing unit, regardless of reason

for exit

Non-leased exiters—Discharged

from HUD-VASH after obtaining a

voucher but prior to leasing a

housing unit, regardless of reason

for exit

Year of program

HOMES

Most recent year of

2008 or before through 2014

Interval, years

admission

Veterans’ enrollment in

HUD-VASH

Housing First

HOMES

Whether a Veteran

Pre-Housing First—entered HUD- Dichotomous

entered HUD-VASH after  VASH prior to 2013

the policy shift to a

Housing First—entered HUD-

Housing First approach  VASH in 2013 or later

in FY 2013

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Appendix C: Methods

Exhibit C.1 Administrative data

Variable

Source

Definition

Values

Type

Process timeframes

HOMES

Program dates were

Program dates were entered for

Interval, days

entered by VA case

the following HUD-VASH steps:

managers as HUD-VASH  Referral

steps were completed;  Assessment

process timeframes

Admission

were calculated as the

HA referral

number of days between  Receipt of voucher

two program dates

Housing selection

Inspection

Execution of HAP Contract

Move-in

Exit*

*Note: since stayers did not have

an exit date, their length of stay is

calculated using the end of the

study’s observation period,

12/02/2014

VA case

VA Medical Record Number of VA case

VA case management contacts

Interval, number

management

management contacts

were provided for the following

of contacts

contacts

entered by VA case

time periods:

calculated as a

managers

30 days prior to admission

monthly average

Between admission and HA

(i.e., average

referral

number of

Between HA referral and receipt  contacts in a 30

of voucher

days period)

Between receipt of voucher and

move-in

30 days post-move-in

31-60 days post-move-in

61-90 days post-move-in

91-180 days post-move-in

181-360 days post-move-in

361-720 days post-move-in

30 days post-exit

31-60 days post-exit

61-90 days post-exit

Demographics

Gender

VA Medical Record Veteran sex

Male

Dichotomous

Female

Age

Veteran age in years

<35

Ordinal

35-44

categories were

45-54

used in

55-64

descriptive

≥65

findings; interval

age in years was

used in models

Race

VA Medical Record Veteran race

Black or African America

Nominal

White

Other

Ethnicity

VA Medical Record Veteran ethnicity

Hispanic/Latino

Nominal

Non-Hispanic/Non-Latino

Multiple

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Appendix C: Methods

Exhibit C.1 Administrative data

Variable

Source

Definition

Values

Type

Marital status

VA Medical Record Veteran marital status  Married

Nominal

Widowed

Separated

Divorced

Never married

VA enrollment

VA Medical Record Veterans’ priority for

≥50% SC disability

Ordinal

priority group

healthcare identified at  <50% SC disability

categories were

the time of enrollment  No SC disability; Medicaid-eligible  used in

for VHA healthcare,

No SC disability; Not Medicaid-

descriptive

based on Veteran’s level  eligible

findings;

of disability, exposure to  Other

categories were

certain hazards, and

collapsed into a

income

dichotomous

variable in

models to

indicate any

service-

connected

disability versus

no service-

connected

disability

Period of service

VA Medical Record Military era in which the  World War II (12/1941–12/1946)  Nominal

Veteran served

Korean War (7/1950–1/1955)

Vietnam Era (8/1964–4/1975)

Post-Vietnam (5/1975–7/1990)

Persian Gulf War (8/1990–

present)

Other

OEF/OIF

VA Medical Record Whether the Veteran

Deployment in OEF/OIF/OND

Nominal

deployment

was deployed during

No deployment in OEF/OIF/OND

Operation Enduring

Freedom (OEF), Iraqi

Freedom (OIF), or New

Dawn (OND)

Combat exposure

VA Medical Record Whether the Veteran

Combat exposue

Nominal

was exposed to combat  No combat exposure

while serving in the

military

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Appendix C: Methods

Exhibit C.1 Administrative data

Variable

Source

Definition

Values

Type

Medical And Mental/Behavioral Health Conditions and Service Utilization

Medical conditions  VA Medical Record If, during the 12 months  Any medical condition (includes  Dichotomous prior to program

all subcategories)

admission, the Veteran  Hypertension

had either one inpatient  Diabetes, uncomplicated

stay or two outpatient

Chronic pulmonary disease

visits more than 30 days  Obesity

apart and the primary

Traumatic brain injury

diagnosis associated

with these visits were

consistent with the 25

medical conditions

defined by Elixhauser

and colleagues (1998),

as well as TBI based on

ICD-9 codes (National

Center for Health

Statistics, 1980)

(Brenner, Ignacio, &

Blow, 2001)

Mental/behavioral  VA Medical Record If, during the 12 months  Any mental/behavioral health

Dichotomous

health conditions

prior to program

condition (includes all mental

admission, the Veteran  health subcategories)

had either one inpatient

stay or two outpatient

Any substance use condition

visits more than 30 days  (alcohol and/or drug abuse)

apart and the primary

diagnosis associated

Post-traumatic stress disorder

with these visits were

Depression

consistent with the four  Psychoses

mental/behavioral

Schizophrenia

health conditions

defined by Elixhauser

Alcohol abuse

and colleagues (1998),  Drug abuse

as well as schizophrenia,  Suicide and intentional self-

PTSD, and suicide and

inflicted injury

intentional self-inflicted

injury based on ICD-9

codes (National Center

for Health Statistics,

1980) (Kimerling, Gima,

Smith, Street, & Frayne,

2007)

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Appendix C: Methods

Exhibit C.1 Administrative data

Variable

Source

Definition

Values

Type

Medical services

VA Medical

Receipt of outpatient or  Service utilization was examined  Outpatient

Record

inpatient medical

for the following time periods:

service use was

services

90 days prior to entry

measured using

90 days post entry

the interval

90 days post move-in

number of visits;

90 days pre-exit

inpatient service

30 days post-exit

use was

31-90 days post-exit

measured using a

91-180 days post-exit

dichotomous

181-360 days post-exit

variable;

inpatient length

of stay was

measures using

the interval

number of days

Mental/behavioral  VA Medical Record Receipt of outpatient or  Service utilization was examined  Outpatient health services

inpatient

for the following time periods:

service use was

mental/behavioral

90 days prior to entry

measured using

health services

90 days post entry

the interval

90 days post move-in

number of visits;

90 days pre-exit

inpatient service

30 days post-exit

use was

31-90 days post-exit

measured using a

91-180 days post-exit

dichotomous

181-360 days post-exit

variable;

inpatient length

of stay was

measures using

the interval

number of days

Substance use

VA Medical Record Receipt of outpatient or  Service utilization was examined  Outpatient

services

inpatient substance use  for the following time periods:

service use was

services

90 days prior to entry

measured using

90 days post entry

the interval

90 days post move-in

number of visits;

90 days pre-exit

inpatient service

30 days post-exit

use was

31-90 days post-exit

measured using a

91-180 days post-exit

dichotomous

181-360 days post-exit

variable;

inpatient length

of stay was

measured using

the interval

number of days

Emergency care

VA Medical Record Emergency department  Service utilization was examined  Dichotomous

admission

for the following time periods:

90 days prior to entry

90 days post entry

90 days post move-in

90 days pre-exit

30 days post-exit

31-90 days post-exit

91-180 days post-exit

181-360 days post-exit

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Appendix C: Methods

Exhibit C.1 Administrative data

Variable

Source

Definition

Values

Type

Exits

Reason for exit

HOMES

When a Veteran exits

Accomplished goals or obtained

Nominal

HUD-VASH, VA case

access to services and no longer

managers indicate why  needs program

Veterans ended their

Cannot be located

involvement in HUD-

Deceased

VASH case management  Evicted by HA or landlord or other

housing issues

Found/chose other housing

Incarcerated

No longer financially eligible

No longer interested in

participating in HUD-VASH

Noncompliance with HUD-VASH

case management

Too ill to participate in HUD-VASH

Transferred to another HUD-VASH

program site

Unhappy with HUD-VASH housing

Other

Return to VA

HOMES

HUD-VASH participants  VA homeless program use was

Dichotomous

homeless programs

who exited the program  examined for the following time

could utilize VA

periods:

homeless programs

Any (return between exit and end

following their exit

of study’s observation period,

12/02/2014)

Within 30 days

Within 60 days

Within 90 days

Within 180 days

Within 360 days

Interviewers at each study site used an interview protocol to conduct in-person, one-on-one

interviews with a subsample of HUD-VASH participants.  (referred to here as “study

respondents”) either on-site at VAMC facilities or over the telephone. Exhibit C.2 provides

details on survey respondent data variables.

ExhibitC.2 Survey respondent data

Variable

Definition

Values

Type

Study respondent  Sample of Veterans that responded to

Study respondent

Dichotomous

close-ended, quantitative interviews at

Not a study respondent

each study site

Qualitative

Subsample of study respondents that

Qualitative respondent

Dichotomous

respondent

completed an additional semi-structured  Not a qualitative respondent

qualitative interview

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Appendix C: Methods

ExhibitC.2 Survey respondent data

Variable

Definition

Values

Type

Living situation

Veteran living situation at two points in  Emergency shelter

Nominal

during HUD-VASH  HUD-VASH housing process: (1) voucher  Place not meant for human habitation

housing process

receipt and (2) apartment selection

Permanent housing

Transitional housing for homeless

person

Substance abuse treatment facility or

detox center

Family member or friend’s room,

apartment or house

Ease of HUD-VASH  Specific measures:

Scale ranging from 1 (very difficult) to 5  Ordinal

enrollment and

Enrolling in the HUD-VASH program

(very easy)

housing process

Submitting applications to HA

Providing documentation of identity and

income to HA

Finding listings of available apartments

Finding an acceptable apartment option

Getting an apartment inspected by HA

Being selected as a tenant by a landlord

Obtaining money for rent, security

deposit, moving costs

Steps completed in  Specific measures:

Completed

Dichotomous

the housing

Finding listing of available apartments

Not completed

process by non-

Finding an acceptable apartment option

leased exiters

Getting an apartment inspected by HA

before exit

Being selected as a tenant by a landlord

Obtaining money for rent, security

deposit, moving costs

Number of

Veteran provided a count of the number  None

Ordinal

apartments visited  of apartments viewed

One

during housing

Two

search

Three

Four or more

Proportion of

Proportion of apartment that the Veteran

Interval, %

“acceptable”

viewed that were deemed “acceptable” to

apartments

live in

Reason for

Veteran’s primary reason for selecting

Location/neighborhood

Nominal

apartment choice  apartment

Good repair/quality

Particular features of apartment

I didn't have a choice

Comfort during

Veteran’s feeling or comfort or discomfort  Not comfortable

Ordinal

first few nights in  during first nights in apartment

Moderately comfortable

apartment

Very comfortable

Services received  Specific measures:

Received assistance

Dichotomous

during housing

Assistance getting and receiving

Did not receive assistance

process and move- appointment with HA

in

Assistance providing proof of identity or

income

Assistance completing and submitting HA

application

Assistance finding apartment options

Assistance getting essential move-in

items

Assistance moving belongings into the

apartment

Assistance setting up utilities

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Appendix C: Methods

ExhibitC.2 Survey respondent data

Variable

Definition

Values

Type

Housing

Specific measure:

Scale ranging from 1 (very dissatisfied)  Ordinal

satisfaction while  Apartment condition

to 5 (completely satisfied)

in HUD-VASH

Affordability

Building safety and security

Access to shopping*

Access to public transportation**

Neighborhood safety

Opportunities to socialize

Housing

Specific measures:

Scale ranging from 1 (very dissatisfied)  Ordinal

satisfaction after

Apartment condition

to 5 (completely satisfied)

exit

Affordability

Building safety and security

Access to shopping*

Access to public transportation**

Neighborhood safety

Opportunities to socialize

Difference in

Specific measures:

Comparison of mean housing

% change

housing

Apartment condition

satisfaction while in HUD-VASH and

satisfaction of

Affordability

after exit

leased-up exiters  Building safety and security

while in HUD-VASH  Access to shopping

and after

Access to public transportation

Neighborhood safety

Opportunities to socialize

Veteran believes

Whether the Veteran believed HUD-VASH  Yes

Dichotomous

HUD-VASH was a  was a good fit

No

good fit for his/her

needs

Reason Veteran

If Veteran did not believe HUD-VASH was  Did not need as much support as

Nominal

does not believe

a good fit, reason why

offered

HUD-VASH was a

Needed more support than offered

good fit for his/her

Program had more rules than

needs

acceptable

Housing unit did not fit needs

Other

Self-reported

Number of times Veteran indicated that  Do not meet with case manager

Ordinal

number of monthly  they usually met with the VA case

Less than once per month

meetings with VA  manager each month

Once per month

case manager

One to two times per month

More than twice per month

VA case

Specific measures:

Scale ranging from 1 (never) to 5

Ordinal; models

management

My case manager was able to help me

(always)

included a

satisfaction

My case manager and I agreed on goals

dichotomous

My case manager and I had the same

variable

ideas about what my problems were

indicating

My case manager and I trusted each other

whether Veterans

agreed that the

VA case manager

was able to help

usually (4) or

always (5) or not

(1-3)

Self-reported

Veteran’s view of their health while in

Excellent

Ordinal

health status

HUD-VASH

Very good

Good

Fair

Poor

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Appendix C: Methods

ExhibitC.2 Survey respondent data

Variable

Definition

Values

Type

Self-reported

Specific measures:

Yes

Dichotomous

medical problems  Experienced serious medical problems

No

Hospitalized for medical problem

Experienced serious medical problems

AND were hospitalized for medical

problem

Self-reported being  Veteran’s perspective of being “troubled  Not at all

Ordinal

“troubled” by

or bothered” by drugs or alcohol while in  Slightly

drugs/alcohol

HUD-VASH

Moderately

Considerably

Extremely

Self-reported

Veteran’s perceived use of drug or alcohol  Inpatient

Nominal

drug/alcohol

treatment while in HUD-VASH

Outpatient

treatment

Both inpatient and outpatient

No treatment

Factors

Veterans was able to select any of the

Yes

Dichotomous

contributing to exit  following as factors contributing to their  No

exit:

Apartment that was found did not pass

inspection

Conflict with HUD-VASH case manager or

other program staff

Conflict with landlord

Conflict with neighbors

Couldn’t find an available apartment to

rent with voucher

Did not have money to pay for security

deposit or furniture

Difficulty paying the rent

Disagreement with program rules

Dissatisfaction with apartment

Dissatisfaction with available apartments

Dissatisfaction with neighborhood

Evicted from apartment

Improvement in health condition

Improvement in mental health condition

Improvement in substance abuse

condition

Increase in income

Legal trouble such as arrest, jail, warrant,

probation, lawsuit or trial

Offer from family or friend to move into

their housing

Voucher revoked by HA

Worsening in medical condition

Worsening in mental health condition

Worsening in substance abuse condition

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ExhibitC.2 Survey respondent data

Variable

Definition

Values

Type

Main reason for

Of all of the factors contributing to an exit,  Apartment that was found did not pass  Nominal

exit

Veteran was asked to select the main

inspection

reason

Conflict with HUD-VASH case manager

or other program staff

Conflict with landlord

Conflict with neighbors

Couldn’t find an available apartment to

rent with voucher

Did not have money to pay for security

deposit or furniture

Difficulty paying the rent

Disagreement with program rules

Dissatisfaction with apartment

Dissatisfaction with available

apartments

Dissatisfaction with neighborhood

Evicted from apartment

Improvement in health condition

Improvement in mental health

condition

Improvement in substance abuse

condition

Increase in income

Legal trouble such as arrest, jail,

warrant, probation, lawsuit or trial

Offer from family or friend to move into

their housing

Voucher revoked by HA

Worsening in medical condition

Worsening in mental health condition

Worsening in substance abuse

condition

Exit type

Whether the Veteran decided to leave

Voluntary

Dichotomous

HUD-VASH or was asked to leave

Involuntary

Plans for living

If Veteran decided to leave, whether

Plan

Dichotomous

arrangement

he/she had a plan for a place to live after  No plan

following voluntary  exiting

exit

VA case manager  Whether the VA case manager helped

Yes

Dichotomous

assisted in finding  Veteran find a new place to stay after

No

new place to stay  exiting HUD-VASH

following exit

Plan to continue

Whether the Veteran plans to use VA

Yes

Dichotomous

utilizing VA

medical services after exiting HUD-VASH  No

services

Ongoing contact

Whether the Veteran still has contact with  Yes

Dichotomous

with VA case

VA case manager

No

manager

Multiple Regression Analysis Modeling Duration of Housing Process (Exhibit 5.2)

To identify factors related to the speed at which a Veteran proceeded through the HUD-VASH

housing process, the research team conducted a series of five multiple regression analyses that

modeled the impact of selected Veteran and program characteristics on the duration of the

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housing process. The dependent variables for the five models were measured as the continuous

number of days in the following time periods:

(1) Between program admission and referral to the housing authority

(2) Between referral to the housing authority and Veteran’s receipt of the HUD-VASH voucher

(3) Between receipt of the voucher and Veteran moving into housing

(4) Between program admission and receipt of voucher

(5) Between program admission and moving into housing

For models 1, 2, and 4, the sample included all HUD-VASH participants. Models 3 and 5

included only HUD-VASH participants who moved into housing (i.e., stayers or leased-up

exiters).

Each of the initial models included the following independent variables: study site, study group,

age., sex,  race, service-connected disability, whether the Veteran entered HUD-VASH before or

after the transition to a Housing First approach, any medical condition, PTSD, depression,

psychoses, schizophrenia, alcohol abuse, drug abuse, history of suicide and intentional self-

inflicted injury, as well as monthly case management contacts during the time period of interest

and outpatient and inpatient services utilization 90 days prior to and post entry.

Only control variables (study site, sex, age, race, and service-connected disability) and

statistically significant independent variables identified through a backward selection model

were retained in the final models, as indicated in Exhibit 5.2.

Logistic Regressions Modeling Exits from HUD-VASH (Exhibit 8.2)

To determine characteristics that may predict whether a Veteran exits HUD-VASH, the research

team modeled logistic regressions for two dichotomous dependent variables:

(1) Whether a Veteran who moved into HUD-VASH housing later exited the program (leased-up

exiter = 1, stayer = 0)

(2) Whether the Veteran exited the program prior to leasing a housing unit (non-leased exiter =

1, leased-up exiter = 0)

For the first model, the sample included HUD-VASH participants who moved into housing (i.e.,

stayers and leased-up exiters only); the sample for the second model included HUD-VASH

participants who exited the program (i.e., leased-up exiters and non-leased exiters).

Each of the initial models included the following independent variables: study site, sex, age,

race, service-connected disability, whether the Veteran entered HUD-VASH before or after the

transition to a Housing First approach, any medical condition, PTSD, depression, psychoses,

schizophrenia, alcohol abuse, drug abuse, and history of suicide and intentional self-inflicted

injury.

Only control variables (sex, age, race, and service-connected disability) and statistically

significant independent variables were retained in the final models, as indicated in Exhibit 8.2.

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Latent Class Analysis Identifying Profiles of Leased-Up and Non-Leased Exiters

(Exhibits 8.10–8.13)

To identify characteristics of Veterans who exited HUD-VASH, the research team conducted

two latent class analyses (LCA): one for leased-up exiters and another for non-leased exiters.

This analysis identifies unobserved subgroups (latent classes) within a population based on

observed data (McCutcheon, 1987). The use of LCA allowed us to classify and describe

subgroups of Veterans who exited HUD-VASH in an effort to characterize their exits.

The analyses included the following measures as manifest variables:

  Study site

  Sex

  Age

  Race

  VA enrollment priority group

  Medical conditions–dichotomized to indicate any medical condition

  Mental/behavioral health conditions—dichotomized to indicate any mental/behavioral

health condition

  Substance use condition—dichotomized to indicate any substance use condition

  Medical services—dichotomized to indicate whether the Veteran had an inpatient stay for

medical reasons during the 90 days prior to exit

  Reason for exit—collapsed similar categories for a total of seven

Using the poLCA package (Linzer & Lewis, 2011), the research team estimated a series of LCA

models, specifying 1–10 classes. The model for each study group with the lowest Bayesian

Information Criterion (BIC) was selected as the best fitting model.

Cox proportional hazards survival analysis for time to return to homelessness within 360 days

(Exhibit 8.15)

To assess the time between exiting HUD-VASH and returning to homelessness and to identify

characteristics that increase the hazard of a Veteran returning to homelessness after exiting

HUD-VASH, the research team conducted a Cox proportional hazards survival analysis. The

dependent variable was whether HUD-VASH participants who exited the program returned to a

VHA Homeless Program within 360 days of their exit.

The sample included all HUD-VASH participants who exited the program (i.e., leased-up exiters

and non-leased exiters).

The initial model included the following independent variables: study site, sex, age, race,

service-connected disability, any medical condition, PTSD, depression, psychoses,

schizophrenia, alcohol abuse, drug abuse, and history of suicide and intentional self-inflicted

injury.

Only control variables (sex, age, race, and service-connected disability) and statistically

significant independent variables were retained in the final model, as indicated in Exhibit 8.15.

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QUALITATIVE CODING DICTIONARY

Node Name

Description

Barriers Veterans faced while participating in HUD-VASH; includes: barriers to

enrollment in the program, barriers to getting housed, barriers to staying in the

program

Barriers and negative experiences  Examples: program requirements, economic barriers, relationships with family, relationships with program staff, relationships with landlords, drug & alcohol use

history/relapse, etc.  Also includes instances where veterans had to do things for

themselves because of lack of support. Include negative experiences

Difficulties with rules &

regulations

Difficulties with the rules & regulations when accessing the program

Landlord problems

Problems with their landlord/property management office

Need for additional support

Barriers associated with needing additional support

Neighborhood or housing

barriers

Barriers associated with a specific neighborhood or any other housing barriers

Other problems

General barriers or negative experience associated with accessing the HUD-VASH

program

Processing problems

Problems with being processed or any other paperwork related barriers to entering

into the program

Staff or other personnel

difficulties

Difficulties with interacting with staff or other personnel

Experiences with discrimination

Discrimination

Examples: gender and race discrimination

Background issues

Discrimination due to background; could relate to having an arrest record or other

perceived issues such as being a Veteran or being homeless

Disability

Discrimination due to having a disability

Other discrimination

Other types of discrimination

Voucher

Discrimination due to having a HUD-VASH voucher

How Veterans learned about HUD-VASH or the referral source for getting into the

Exposure to program and referral  program

source

Examples: learned from peers/program staff/a brochure, learned from participating

in a program, name of referral source

Doctors or other medical

Physicians or other medical personnel are the source of exposure or referral to

personnel

HUD-VASH

Family or friends

Source of exposure/referral is a family member or friend

Other or cannot recall

Referral/exposure source to HUD-VASH isn't similar enough to others or in which

Veteran cannot recall or isn't clear about how s/he learned about the program

Learned about HUD-VASH through rehab program, shelter or another formal

Other Rehab, shelters, or other  program through which they were receiving some kind of support; may include programs

personnel (such as case managers/social workers) working for those programs—

should not be coded to VA rehab, shelter, or mental health program

Other Veterans

Other Veterans are the source of exposure or referral to the HUD-VASH program

Learned about the HUD-VASH program through another VA program, through

VA

information pamphlets or information sessions provided by VA, or through case

managers/social workers or VA personnel other than physicians or medical

personnel

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Node Name

Description

Anything associated with using program support and receiving social support—

must be a specific instance; includes self-facilitation/self-motivation

Facilitation

Examples: using services such as peer support, employment support, moving

support, paperwork support, linking to other resources, other support such as

training or meetings and education or work related support after leaving the

program

Promoting Veteran

independence

Facilitation that promoted Veteran independence

Reestablishing rental and

Facilitation aspects helped with re-establishing rental, credit history or other means

credit history

of economic assistance

Self sufficiency

Facilitation as it relates to being self-sufficient

Support services

Participating in various programs

Educational programs

Participation in educational programs

Employment assistance

Participation in employment assistance programs

Financial assistance

Participation in financial assistance programs

Food assistance

Participation in food assistance programs

Furniture and household

items support

Participation in furniture and household programs

Other support

Participation in other general support programs

Peer counseling help

Participation in peer counseling programs

Program and meeting

support

Participation in program and meeting support

Self-support

Veteran provided support to themselves

Family and friends influence

References to family or friends as influential during HUD-VASH housing

experience—both positive and negative

Background or context for

Reference family in order to tell a personal story that impacted their housing

Housing

circumstances or their ability to get housing

Difficult relationships with

family or friends

Difficult relationships with family or friends

Family or Friends help with

housing search or move in

Assistance from family or friends during housing search or move-in

General reference to family or

friends

General references about family or friends

Place to stay with family or

friends

Staying with family or friends

Homelessness status and most recent housing situation prior to entering HUD-VASH

Homelessness status

Examples: being required to qualify in the "chronic homelessness" definition in

order to obtain housing, living in a shelter, staying with family or friends

Family member, spouse, ex-

spouse

Respondent living with a family member, spouse, or ex-spouse before HUD-VASH

Friend or acquaintance

Respondent living with a friend or acquaintance before HUD-VASH

Car, RV, trailer, etc.

Respondent living in a car, RV, or other conveyance

Storage unit, camp, bus station  Respondent living in a storage unit, camp, bus station, or unstable/informal housing HUD-VASH Exit Study

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Node Name

Description

Street

Respondent described him/herself as living "on the street" prior to enrollment in

HUD-VASH

Rented room

Respondent staying in a hotel or motel room or other short-term rented room

VA program or shelter

Respondent living in a VA associated shelter or in another VA program that

provided some kind of housing

Other program or shelter

Respondent living in a non-VA associated program or shelter

Post HUD-VASH

Respondent discusses their housing status after leaving the HUD-VASH program

Prison or detention center

Respondent incarcerated prior to applying for HUD-VASH

VA Hospital

Respondent in the hospital for an extended period prior to applying for HUD-VASH

Experience searching for housing—both positive and negative; include the process

steps throughout the experience and housing qualifications

House hunting experience

Examples: whether the HUD-VASH housing list was made available, whether making

appointments to see houses was easy or difficult, whether searching for houses in

different geographic areas was easy or difficult, whether there were challenges with

the move-in requirements, avoiding undesirable neighborhoods

Facilitation

Positive house hunting experiences

Good relationship with

landlord

House hunting facilitation related to their relationship with their landlord

Housing deposit help

House hunting facilitation related to their housing deposit

List of apartments as helpful  House hunting facilitation related to apartment listings

Move in help

House hunting facilitation related to move-in

No problems with rules and

requirements

House hunting facilitation related to the rules and regulation requirements

Other resources for housing

search

Other facilitators to housing search

Quick move in

House hunting facilitation related to a quick move-in experience

Saved up money

House hunting facilitation related to Veteran savings

Supportive or advocative

Code here when respondents discuss house hunting facilitation related to their

case manager

relationship with their case manager

Transportation help

House hunting facilitation related to transportation

Barriers

Negative house hunting experiences

Accessible housing for

disabled

House hunting barriers related to disability access

Bad credit

House hunting barriers related to bad credit

Bad neighborhood - High

crime or drug infested

House hunting barriers related to undesirable neighborhoods

Conflicts with landlord or

apartment management

House hunting barriers related to landlord or property management conflicts

Difficulty navigating listing  House hunting barriers related to the housing list provided by the VA case manager or other HUD-VASH program personnel

Discrimination by

appearance

House hunting barriers related to discrimination due to Veteran appearance

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Node Name

Description

Health history, substance use  House hunting barriers related to health or substance use

High rent

House hunting barriers related to unaffordable rent

Incarceration history

House hunting barriers related to Veteran incarceration history

Inspection issues

House hunting barriers related to getting unit inspected

Lack of resources

House hunting barriers related to having a lack of resources

limited funds for deposit

House hunting barriers related to having limited funds for the security deposit

Limited housing

House hunting barriers related to the limited housing options available to Veteran

Little to no support from

House hunting barriers related to having limited or no support from VA case

VASH case manager

manager

Long time for process

House hunting barriers related to it taking a long time to enroll in program/process

paperwork

Problems with requirements  House hunting barriers related to having difficulty with the program requirements Short time frame for

House hunting barriers related to having a short time frame for the apartment

apartment search

search

Transportation

House hunting barriers related to accessing transportation

Unsuitable housing

House hunting barriers related to unsuitable housing

Other

General house hunting experiences

General commentary on

process or steps

General process steps related to Veteran house hunting experiences

Housing satisfaction

Details related to housing satisfaction

Amenities

Housing satisfaction related to amenities

General satisfaction

General housing satisfaction

Location

Housing satisfaction related to location

Price

Housing satisfaction related to pricing

HUD VASH return to program

Details on whether leased-up and non-leased exiters would return to HUD-VASH

No

Exiter would NOT return to HUD-VASH

Yes, if qualify and or needed

Exiter would return to the HUD-VASH if they qualified or needed the service

Yes, with conditions

Exiter would return to the HUD-VASH program with conditions

Experience with enrolling in the program

Initial enrollment process

Examples: length of enrollment process, satisfaction with the turnaround time

Can't recall the process

Veteran could not recall the enrollment process

Description of enrollment steps  Descriptions of the enrollment process—neither positive or negative

Bringing documentation

Bringing in documentation as part of the enrollment process

Drug testing

Drug tests as part of the enrollment process

Filling out paperwork

Filling out paperwork during enrollment process

Meeting with case manager  One-on-one meeting with VA case manager as part of the enrollment process

Orientation

Orientation as described as part of the enrollment process

Receipt of voucher

Receipt of voucher as final step of enrollment

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Node Name

Description

Screening

Screening interviews as part of enrollment process

TB test, vaccinations, other

preventative medicine

Preventive medicine as part of the enrollment process

Documentation required

Descriptions of the required documentation that participants had to bring to enroll

Enrollment took less time or as  Enrollment (from initial paperwork to voucher) took as long or less time than long as expected

expected

Higher need

Veteran’s homelessness status (multiple instances of homelessness, high risk, etc.)

led to an expediting of their enrollment

Involvement in another program to assist the homeless (e.g., VA domiciliary, HPRP,

Involved in other program

shelter, or rehab program) may have played a role in the speed in which Veteran

enrolled in HUD-VASH

Misinformation

Veteran was led to believe the enrollment process would take longer than it did

Mistaken assumptions

Enrollment process took less time than expected because Veteran simply assumed

that it would take longer due to bureaucracy, assumed waiting lists, etc.

Timeframe didn't matter

Veteran didn't feel the enrollment process took a long time because their situation

didn't require enrollment to happen quickly

VA case manager or social

worker fast tracked the

Enrollment took less time than expected because someone fast-tracked the Veteran

enrolment

Vouchers were available

Enrollment was quick because vouchers were readily available.

Vouchers weren't available  Veteran satisfied with the timeframe or in which the timeframe was shorter than expected because they knew that there weren't enough vouchers to go around

Enrollment took longer than

expected

Enrollment took longer than expected

Enrollment took longer than expected because Veteran couldn't get accurate

Could not get information

information about the process (couldn't reach someone by phone, wasn't provided

the information initially, etc.)

Had to reapply

Enrollment took longer than expected because Veteran had to apply a second time

after being rejected or losing the voucher

Homelessness status or

Shelter or other programs have a time limit and thus make it seem like the voucher

impending homelessness

is taking longer than it should or generally where the individual's homelessness

status makes waiting seem more difficult

Involvement with another

Instances in which involvement with another VA or separate assistance program

program

(CWT, rehab) slows down the process

Misinformation

Process took longer than expected because Veteran given misinformation about the

timeframe

No case manager assigned

VA case manager was not assigned to Veteran, resulting in enrollment taking longer

than expected

VA case worker sat on

paperwork

Enrollment took a long time due to inaction on the part of a VA case worker

Waiting list

Veteran placed on a waiting list to receive a voucher due to a lack of vouchers,

resources, or program closure

Enrollment was difficult

Difficulty enrolling in HUD-VASH

A lot of steps

Difficulty with enrollment was simply a lot of steps to enrollment

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Node Name

Description

Gathering documents

Enrollment was difficult because it was hard to gather documents

Initial Rejection

Veteran initially rejected

Lack of assistance

Lack of assistance or helpful information led to the enrollment process being

difficult

Negotiating between

different parties

Negotiating between all the parties involved made enrollment difficult

Other veterans irritate VASH  HUD-VASH staff described as rude and the respondent attributes it to the behavior staff

of other veterans

Paperwork was lost

Enrollment process was difficult because HUD-VASH lost the Veteran’s paperwork

Personal issues

Personal issues such as family problems, substance abuse, mental illness, etc., made

enrollment difficult

Program qualifications were  Enrollment was difficult due to the program's qualifications, such as involvement in complicated

a drug rehab program or the locations for finding housing were limited and

confusing

Traveling to VASH or PHA

offices was difficult

Enrollment was difficult due to problems with travel

Waiting

Waiting for approval, vouchers, etc., was considered a difficulty to enrollment

Enrollment was easy

Enrollment in HUD-VASH was easy

Facilitation by VA case

Ease of enrollment is attributed to assistance by a VA case manager or other HUD-

manager or staff

VASH staff

Group orientation

Group orientation made enrollment easier

Necessary documents were

readily available

Ease of enrollment is attributed  to necessary documents being readily available

Support from doctors

Enrollment was assisted by a physician, therapist, or other health worker

Support from staff

Staff support (including providing good information about what steps to take) made

enrollment easy

Length of time

Descriptions of how long initial enrollment took

Long-term living arrangement and plans; includes any housing post-exit/current

living situation of exiters—do NOT include if Veteran is homeless

Long-term housing plans and goals  Examples: future plans to stay in the program, plan to own a house after leaving HUD-VASH, plan to change neighborhoods

No housing recovery plan

Veteran did not make a housing recovery plan

Yes had a housing recovery plan  Discussion having a housing recovery plan

Educational goal

Educational goals included in housing recovery plan

Homeownership goal

Home ownership goal in housing recovery plan

Other goals

Other general goals in housing recovery plan

Sobriety goals

Sobriety goal in housing recovery plan

Work goals

Work or occupational goal in housing recovery plan

Unsure or unclear of housing

recovery plan

Veteran unsure/unclear of housing recovery plan

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Appendix C: Methods

Node Name

Description

Program orientation provided by either HUD or VA

Orientation quality

Examples: whether Veteran received orientation, who provided the orientation,

positive or negative responses to orientation quality

Attitudes about orientation

General attitude about orientation

Dissatisfaction with

Dissatisfaction with the amount or quality of information provided in the

information provided

orientation

Information was adequately

explained

Orientation provided the necessary information for participation in HUD-VASH

Information wasn't very

useful

Orientation provided information that was not useful for participation in HUD-VASH

Overall negative feeling about the orientation, but no specifics

Overall negative

Examples: it was not helpful; it was bad; I did not like the orientation

Overall positive feeling about the orientation, but no specifics-

Overall positive

Examples: it was helpful; it was good; I liked the orientation

Personal difficulties

Personal difficulties caused difficulties with the orientation, not the quality of the

orientation itself

Self-efficacy

Veteran’s tendency to ask for additional help or information or to listen well and

take notes contributed to the quality of the information provided in the orientation

Can't recall orientation

Veteran cannot recall having attended an orientation for the program

Filled out paperwork

Paperwork was filled out over the course of the orientation

Host organization

Orientation host

HUD-VASH orientation by

both PHA and VA

Orientation was a joint presentation from both the local housing authority and VA

HUD-VASH orientation

Orientation was presented by VA

Orientation given by VA case

manager

Orientation was provided during a one-on-one meeting with VA case manager

PHA Orientation

Instances in which the orientation is being presented by the local public housing

authority

Informational materials

Descriptions of informational materials (usually the format)

Information presented

Information presented at orientation

Program guidelines explained during orientation

Explained guidelines

Examples: descriptions of the locations Veterans allowed to live, rules and

regulations for apartments under Section 8, rules about drug-free living

Housing tips

Housing tips provided during the orientation

Program overview

Veteran recalls orientation as simply an overview of HUD-VASH, rather than

specifics

Program steps

Specific information about steps to the program going forward

Tips for living

Information about how to budget, get help paying bills, etc.

No orientation

Veteran doesn't remember attending or being provided any orientation to the HUD-

VASH program

Shared experience

Other Veterans with similar experiences at the orientation as a positive experience

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Appendix C: Methods

Node Name

Description

Reason for leaving HUD-VASH

Patterns of exiting program

Examples: financial/income conditions, health issues, drug use concerns, finding

alternative options for housing, being evicted, graduating from the program

Leased exiters

Reasons for leased-up exiters leaving the program

Bought a house or ready to  Exit due to a change in housing situation

find own place

Examples: Veteran bought a house, ready to move on

Evicted due to active

addiction

Exit due to active addiction

Moved to take care of family  Exit to take care of family

Multiple reasons for leaving  Multiple reasons for leaving the program

Other general reasons for leaving the program

Other reason for exiting

Example: legally gave voucher to wife

Unable to pay rent

Exit due to unaffordable rent

Voucher revoked/did not

qualify

Exit due to making too much money or missing the recertification deadline

Non-leased exiters

Reasons for non-leased exiters leaving the program

Chose alternative program

or option

Exit due to choosing alternative programs or housing options

Did not qualify

Exit due to not qualifying

Multiple reasons

Multiple reasons for leaving the program

Exit due to no longer needing housing.

No longer needed housing

Example: inherited property

Not chronically homeless

Veteran not considered chronically homeless. (will likely be combined with did not

qualify)

Other reason

Other reasons for leaving the program.

Unable to afford rent

Exit because Veteran could not afford rent

Exit because Veteran no longer able to live alone

Unable to live alone

Example: entered nursing home

Voucher revoked

Voucher revoked

Examples: unable to find place in time, active addiction, incarceration, searched in

wrong county, lost information necessary for voucher

Stayer with story about exiting

from previous place

Stayer shares story about prior program exit

Veterans personal history

Examples: sharing information on immigration history, family background, reasons

Personal history

for becoming homeless, experiencing illness, disability, or other health related

issues, past physical, psychological, or sexual trauma, military discharge experience

and transition back into society, incarceration experiences

Addiction Relapse Recovery

Personal stories about addiction, relapse or recovery

Arrest Record

Personal stories about arrest record

Family Concerns

Personal stories about family

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Appendix C: Methods

Node Name

Description

Financial Issues

Personal stories about financial difficulties

Health Problems & or Disability  Personal stories about health problems or disability

Other Personal History

Other personal stories

Physical Sexual Trauma

Personal stories about physical or sexual trauma

PTSD or Mental Health

Concerns or Self Harm

Personal stories about PTSD, mental health concerns, or self-harm

Positive experiences

Positive experiences during participation in HUD-VASH

Interactions with staff and

personnel

Positive experiences with staff and personnel

Optimism

Emotional optimism

Overall good experience

General positive experiences

Program help

Positive experiences getting program help

Information on qualifying criteria for program and/or whether Veterans qualified

Program qualifications

Examples: taking a urinalysis as a part of the qualification criteria, receiving

program qualification information

Additional requirements

Miscellaneous or vague requirements that do not fit other categories

Attitudes toward qualifications  Attitudes towards program qualifications

Can't recall requirements

Veteran isn't aware of, or isn't very familiar with, HUD-VASH rules or requirements

Concern about  or problems  Veteran expresses concern about, or specific problems with, following rules or with requirements

keeping up with the requirements of the program

Consequences

Consequences for not meeting HUD-VASH requirements

No problem with rules or

qualifications

Rules or qualifications of the program were not an issue

Background or medical

Program qualifications related to background or medical checks

Disability qualifications or

Veteran told that s/he needed to have a certain percentage service-connected

VA connection

disability

Legal requirements

Rules regarding legal trouble

Medical qualifications

TB tests, vaccinations, etc.

Case management

VA case management requirements

Case management

Rules about keeping up with VA case management, such as having to meet with the

case manager, home visits, etc.

Class or group therapy

Required attendance at group therapy sessions or specific classes (such as on

attendance

budgeting or other life skills) in order to maintain housing

Income requirement

Income requirements, including minimums and maximums

Pre-housing requirements

Pre-housing requirements to qualify for program

Background or credit checks  Specific requirements of landlords such as background checks, credit checks, or application fees

Housing qualifications

Particular qualifications for housing

Rules about border/particular boundaries

Location or region rules

Examples: specific county lines, specific cities

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Appendix C: Methods

Node Name

Description

Orientation attendance

Requirements around attending orientation

Severity of homelessness

Severity of homelessness considered a qualification for the program (or possibly for

determining Veteran priority)

Time to use voucher

Time period given to use the voucher

Renter rules and Inspection

Renter rules and inspection requirements

Continued occupancy

requirement

Rules regarding how long one can be away from the apartment

Financial or renter rules

Qualifications centered on financial issues or keeping up basic lessee contractual

obligations

Inspection and

recertification

Rules for having an apartment inspected or recertified

Requirements have changed

Veteran indicates that HUD-VASH requirements have changed over time

Sobriety

Sobriety requirements for staying in HUD-VASH

Recommendations

Veteran recommendations on how to improve HUD-VASH program

Additional assistance

Recommendations about financial or informational assistance; includes programs

for those with special needs or complex background issues

Additional locations

Recommendations about the availability of additional locations for housing

No recommendations

No recommendations about the HUD VASH housing program

Other recommendations

General recommendations for the HUD-VASH program

Outreach and communication

Improve outreach and communication about the program

Ways to improve the process

Process improvements

Examples: improvements to paperwork, communication about requirements,

options for unique requirements

Qualification changes

Recommendations about qualification requirements

Quality housing

Recommendations about improving neighborhood choices

Recommendations about staffing improvements

Staffing Improvements

Examples: consistency, respect for clients, sensitivity to background issues

References to relationships with VA case manager, other VA staff or staff from

Relationships with case managers  public housing authority—both positive and negative

(housing authority and VA)

Examples: whether VA case manager was accessible, helpful, knowledgeable,

communicative, compassionate

Facilitation

Facilitation related to relationships with case managers

Access to resources

Access to resources as a facilitator to their relationship with case manager

Helped orient to program

(Individualized service)

Program orientation as a facilitator to their relationship with case manager

Highly supportive and

helpful

Supportive and helpful case manager

Importance of accessing

manager

Importance of accessing case manager

Peer support as beneficial

VA peer support as a program facilitator

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Appendix C: Methods

Node Name

Description

Serving as advocates for

veterans

VA case manager as advocate for Veteran

Veteran accountability

Veteran accountability as program facilitator

Barriers

Barriers related to relationship with case managers

High turnover

High staff turnover as a barrier to relationship with case manager

Impersonal or non-

empathetic interactions

Impersonal or non-empathetic case managers

Irregular meetings

Irregular meetings with case manager

Non-responsiveness

Non responsive case manager

Unmet expectations

Barriers related to unmet expectations

Veteran readiness

Veteran describes readiness to access services as barrier to participation

Transportation

References to transportation—both positive and negative

Facilitation

Facilitators related to transportation

Living in area convenient to

transportation

Veteran lives in an area convenient to transportation

Other positive

transportation experiences  Other positive experiences related to transportation

Transportation available for  Transportation is accessible

housing search and moving  Examples: own car, VA case manager/staff's transport to conduct housing search or in

move-in

Barriers

Barriers related to transportation

Housing search and moving

in limiting due to lack of

Transportation as a barrier to housing search or move in process

transportation

In need of a car or

transportation to get around  Lack of vehicle impedes on housing experience

Living in area inconvenient

to public transportation

Lack of public transportation

Other negative

transportation experience

Other negative experiences around transportation

Remain in certain

geographic areas due to lack  Veteran remains in a geographic location due to lack of transportation

of transportation

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APPENDIX D:

STUDY RESPONDENTS

A subsample of 508 HUD-VASH participants responded to in-person or telephone surveys. This

appendix provides information about the subsample of study respondents as well as the

representativeness of the subsample to the larger population of HUD-VASH participants.

STUDY RESPONDENT SUBSAMPLE

Exhibit D.1 summarizes the respondent sample size by study site and group.

Exhibit D.1 Study respondent count

Stayers

Leased-Up

Nonleased

Exiters

Exiters

Total

(N=370)

(N=80)

N=58

N=508

N

%

N

%

N

%

N

%

Houston

92

24.9

8

10.0

5

8.6

105

20.7

Los Angeles

95

25.7

25

31.3

16

27.6

136

26.8

Palo Alto

86

23.2

24

30.0

22

37.9

132

26.0

Philadelphia

97

26.2

23

28.8

15

25.9

135

26.6

Houston

Los Angeles

Palo Alto

Philadelphia

Total

N=105

N=136

N=132

N=135

N=508

N

%

N

%

N

%

N

%

N

%

Stayers

92

87.6

95

69.9

86

65.2

97

71.9

370

72.8

Leased-up exiters

8

7.6

25

18.4

24

18.2

23

17.0

80

15.7

Nonleased exiters

5

4.8

16

11.8

22

16.7

15

11.1

58

11.4

Source: VA Homeless Operations Management and Evaluation System

The program admission year for study respondents is listed in Exhibit D.2.

Exhibit D.2 Year of program admission, study respondents

Stayers

Leased-Up

Nonleased

N=365

Exiters

Exiters

N=80

N=54

N

%

N

%

N

%

2008 or before

21

5.8

1

1.3

0

0.0

2009

80

21.9

11

13.8

0

0.0

2010

133

36.4

15

18.8

0

0.0

2011

106

29.0

27

33.8

3

5.6

2012

22

6.0

9

11.3

21

38.9

2013

3

0.8

8

10.0

26

48.1

2014

0

0.0

9

11.3

4

7.4

Source: VA Homeless Operations Management and Evaluation System

Exhibit D.3 lists study respondents’ mean length of stay in HUD-VASH. On average, stayers

were housed through HUD-VASH for nearly four years (1,455 days); leased-up exiters remained

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Appendix D: Study Respondents

in housing for about two years (734 days) before exiting; and nonleased exiters left the program

after about four months (122 days).

Exhibit D.3 Days in HUD-VASH, by quartile, study respondents

N

25%

50%

75%

Mean

Stayers

Voucher issuance to end of observation period

363

1,309

1,526

1,754

1,535

Move-in to end of observation period

363

1,219

1,448

1,698

1,455

Leased-up exiters

Voucher issuance to exit

66

459

749

1,141

797

Move-in to exit

65

381

688

1,069

734

Nonleased exiters

Voucher issuance to exit

31

81

127

153

122

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Homeless Operations Management and Evaluation System

Exhibit D.4 provides data on the number of study respondents that remained housed through

HUD-VASH for at least one or two years. The majority of all respondents housed through HUD-

VASH remained in housing for two years or more. Among leased-up exiters, over one-half

stayed in housing for at least one year, and one-third remained for at least two years.

Exhibit D.4 Years in HUD-VASH housing, study respondents

All Study

Leased-Up

Respondents

Exiters Only

N=450

N=80

N

%

N

%

1 year or longer

414

92.0

52

65.0

2 years or longer

386

85.8

29

36.3

HUD-VASH = U.S. Department of Housing and Urban Development-U.S. Department of Veterans Affairs Supportive Housing.

Source: VA Homeless Operations Management and Evaluation System

DEMOGRAPHICS

The subsample of participants responding to a survey, labeled here study respondents, was also

overwhelmingly male (86.8 percent of stayers, 91.3 percent of leased-up exiters, and 87.3

percent of nonleased exiters; N=500). As with study participants, nonleased exiter respondents

were younger, on average, than both stayers and leased-up exiters. (See Exhibit D.5.)

Exhibit D.5 Age, study respondents

Stayers

Leased-Up

Nonleased

N=365

Exiters

Exiters

N=80

N=55

N

%

N

%

N

%

<35

16

4.4

0

0.0

10

18.2

35-44

33

9.0

9

11.3

6

10.9

45-54

170

46.6

34

42.5

20

36.4

55-64

122

33.4

32

40.0

16

29.1

≥65

24

6.6

5

6.3

3

5.5

Source: VA Medical Record

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Appendix D: Study Respondents

The majority of study respondents identified as black; however, nonleased exiter respondents

were more likely to identify as white compared with the other study groups. While the majority

of study respondents identified as non-Hispanic, nonleased exiter respondents were more likely

to be Hispanic. (See Exhibit D.6.)

Exhibit D.6 Race and ethnicity, study respondents

Stayers

Leased-Up

Nonleased

N=361

Exiters

Exiters

N=77

N=55

N

%

N

%

N

%

Race

Black or African American

239

66.2

52

67.5

30

54.5

White

104

28.8

22

28.6

24

43.6

Other

18

5.0

3

3.9

1

1.8

Ethnicity

N=363

N=80

N=55

Hispanic/Latino

31

8.5

7

8.8

8

14.5

Non-Hispanic/Non-Latino

326

89.8

72

90.0

46

83.6

Multiple

6

1.7

1

1.3

1

1.8

Source: VA Medical Record

Among study respondents, stayers and leased-up exiters were slightly more likely to have never

been married or be divorced; nonleased exiters were more likely to be married and less likely to

be divorced. (See Exhibit D.7.)

Exhibit D.7 Marital status, study respondents

Stayers

Leased-Up

Nonleased

N=364

Exiters

Exiters

N=79

N=55

N

%

N

%

N

%

Married

35

9.6

8

10.1

12

21.8

Widowed

12

3.3

0

0.0

3

5.5

Separated

33

9.1

6

7.6

7

12.7

Divorced

140

38.5

35

44.3

14

25.5

Never married

144

39.6

30

38.0

19

34.5

Source: VA Medical Record

Stayers were less likely than the other study groups to be receiving compensation for a service-

connected disability (45.7 percent of stayers vs. 57.6 percent of leased-up and 47.3 percent of

nonleased exiters). Leased-up exiter respondents were the most likely to be receiving

compensation for a service-connected disability of 50 percent or more, while stayers and

nonleased exiters were more evenly distributed among the service-connected disability groups.

(See Exhibit D.8.)

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Appendix D: Study Respondents

Exhibit D.8 VA enrollment priority group, study respondents

Stayers

Leased-Up

Nonleased

N=365

Exiters

Exiters

N=80

N=55

N

%

N

%

N

%

≥50% service-connected disability

74

20.3

31

38.8

11

20.0

<50% service-connected disability

92

25.2

15

18.8

15

27.3

No service-connected disability; Medicaid-eligible

185

50.7

27

33.8

27

49.1

No service-connected disability; Not Medicaid-eligible

14

3.8

7

8.8

2

3.6

Other

0

0.0

0

0.0

0

0.0

Source: VA Medical Record

MILITARY HISTORY

The majority of study respondents served during the Vietnam and post-Vietnam eras. Leased-up

exiter respondents were more likely to have served in the post-Vietnam era and less likely to

have served in the Persian Gulf War; nonleased exiters were more likely to have served in more

recent conflicts. (See Exhibit D.9.)

Exhibit D.9 Period of service and combat exposure, study respondents

Stayers

Leased-Up

Nonleased

N=365

Exiters

Exiters

N=80

N=55

N

%

N

%

N

%

Period of service

World War II

0

0.0

0

0.0

0

0.0

Korean War

6

1.6

0

0.0

1

1.8

Vietnam Era

153

41.9

34

42.5

12

21.8

Post-Vietnam

134

36.7

32

40.0

19

34.5

Persian Gulf War

65

17.8

11

13.8

22

40.0

Other

7

1.9

3

3.8

1

1.8

Combat exposure

OEF/OIF deployment

15

4.1

2

2.5

7

12.7

Combat exposure

16

4.4

3

3.8

0

0.0

Source: VA Medical Record

MEDICAL AND MENTAL OR BEHAVIORAL HEALTH CONDITIONS

Roughly 30 percent or more of study respondents had any of the 25 medical conditions assessed

for this study; leased-up exiters had the highest rate and were most likely to have any

mental/behavioral health diagnosis, followed by nonleased exiters. Compared with nonleased

exiters, leased-up exiter respondents had higher rates of depression and alcohol and drug abuse,

while nonleased exiter respondents had higher rates of PTSD, psychoses, schizophrenia, and

suicide and intentional self-inflicted injury. (See Exhibit D.10.)

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Appendix D: Study Respondents

Exhibit D.10 Medical and mental/behavioral health conditions, study respondents

Stayers

Leased-Up

Nonleased

N=365

Exiter

Exiters

N=80s

N=55

N

%

N

%

N

%

Medical conditions

Any medical condition

109

29.9

28

35.0

18

32.7

Most prevalent medical conditions

Hypertension

56

15.3

17

21.3

12

21.8

Diabetes, uncomplicated

30

8.2

9

11.3

5

9.1

Chronic pulmonary disease

15

4.1

5

6.3

2

3.6

Obesity

17

4.7

2

2.5

2

3.6

Traumatic brain injury

0

0.0

1

1.3

0

0.0

Mental/behavioral health conditions

Any mental/behavioral health condition

142

38.9

44

55.0

24

43.6

Post-traumatic stress disorder

21

5.8

13

16.3

11

20.0

Depression

39

10.7

19

23.8

7

12.7

Psychoses

52

14.2

18

22.5

13

23.6

Schizophrenia

27

7.4

14

17.5

10

18.2

Alcohol abuse

81

22.2

27

33.8

13

23.6

Drug abuse

100

27.4

33

41.3

17

30.9

Suicide and intentional self-inflicted injury

25

6.8

3

3.8

6

10.9

Source: VA Medical Record

REPRESENTATIVENESS OF STUDY RESPONDENT SUBSAMPLE

To assess whether the respondent sample was representative of HUD-VASH participants at the

study sites, the research team compared the Veterans who did and did not respond to the primary

interviews on a number of demographic variables as well as medical and mental/behavioral

health conditions. Given the large sample size and the possibility of statistically significant

differences that are not substantively meaningful, the research team applied a Bonferroni

adjustment to determine the level of significance necessary to assess the representativeness of the

respondent sample and applied a conservative alpha level of 0.001.

The study respondents were representative of HUD-VASH participants at the study sites based

on gender; ethnicity; marital status; VA enrollment priority group; period of military service;

experience of combat; the presence of any medical conditions and, specifically, hypertension,

chronic pulmonary disease, obesity, and traumatic brain injury (TBI); any mental/behavioral

health condition and, specifically, post-traumatic stress disorder (PTSD), depression, psychoses,

schizophrenia, and suicide. The study respondents were not representative of the larger sample of

program participants on the following characteristics:

•  Age—Respondents were slightly younger

•  Race—Respondents were more likely to identify as black or African American

•  Diabetes—Respondents had a higher rate of diabetes

•  Substance use disorders—Respondents had higher rates of both alcohol and drug use

•  Year of program entry—Respondents were more likely to have entered the program

earlier, which was expected given recruitment methods

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Appendix D: Study Respondents

Given that primary data collected from study respondents were used largely to provide

subjective, contextual information and that the differences between the two groups were minimal

and not related to the primary findings of this study, we do not think that these differences have

any implications for the interpretation of the analyses presented in this study.

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APPENDIX E:

HOUSTON SITE DESCRIPTION

The Houston HUD-VASH program operates in Harris, Galveston, and Jefferson counties. The

coordinating VA site is the

Michael E. DeBakey

VAMC in Houston, TX.

The HUD-VASH program

has 1,695 vouchers. The

majority of vouchers are

held by the Houston

Housing Authority (HHA,

1,042) and Harris County

Housing Authority (HCHA,

546). HHA can serve

Veterans within the City of

Houston, as well as up to

five miles outside of the city

limits. HCHA can serve

Veterans anywhere within

the county.

HOUSING CONTEXT

The following maps provide context for the housing markets in which Veterans participating in

the Houston HUD-VASH program conducted their housing search.

Map 1 outlines low, very low, and

extremely low income areas based

on median county income. Lower

income areas, which are shaded

darker, are closer to the center of

the City of Houston and there are

very few low income areas in

Harris County. The VAMC, other

Vet Centers, and CBOCs, as well

as HCHA and HHA, are located in

areas that are not low income,

indicating that Veterans in HUD-

VASH likely have to travel to

access VA services and meet with

housing authority staff.

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Appendix E: Houston Site Description

Map 2 depicts median gross rent

by quartile; the darkest areas have

the lowest rent. The areas with the

lowest median rent are often the

same as those with the lowest

incomes and are more densely

located in the center of the City of

Houston. While there are some low

rent areas close to the HHA, the

VAMC, Vet Centers, and CBOCS,

as well as HCHA, are located in

areas where Veterans in HUD-

VASH will be unlikely to afford

housing.

Map 3 provides details on the

rental vacancy rate by quartile;

areas with lower vacancy rates are

shaded darker. This map indicates

that the housing market is

generally tighter in Harris County

than the City of Houston.

Additionally, vacancy rates vary

throughout the city, so it is likely

that housing is available in most

areas.

VA Case Management

The site has 69 VA staff serving Veterans, including three supervisors, 66 case managers, four

peer support specialists, three SUD specialists (each with a case management load), two housing

specialists (one specialist, one coordinator), three physicians, and one nurse. The program also

partners with vocational rehabilitation to provide three employment specialists to assist HUD-

VASH clients. The case load is 1:38. The case management staff comprises 11 teams at seven

locations.

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Appendix E: Houston Site Description

Team

Associated Housing Authority

Service Location

Team

Composition

Blue

Houston VAMC

Silver

Houston VAMC

Houston Housing Authority

Green

Domiciliary

Pearl

Houston Housing Authority

Purple

Houston Housing Authority, Harris

County Housing Authority

Travis Street

ACT Team

Red

Gold

Harris County Housing Authority

Harris County Housing Authority

Aqua

ACT Team

Galveston

Galveston Housing Authority

Galveston CBOC

1 person

Beaumont

Beaumont Housing Authority

Beaumont CBOC

1 person

OUTREACH

Three entities in Houston conduct outreach and screenings for al  local VHA Homeless Programs:

the Homeless Patient Aligned Care Team (HPACT) located at the VAMC, McGovern Drop-In

Center located in the community, and the VA’s Community Resource & Referral Center. A number

of community-based organizations—including Goodwil , Salvation Army, and US Vets—conduct

outreach and recruit Veterans for the program. Outreach also takes place in prisons and jails.

REFERRALS AND ELIGIBILITY

Staff at each of the outreach/drop-in locations conduct an initial intake of 10–15 questions. This

intake verifies the Veteran’s self-reported housing status and collects paperwork and

identification required for the HUD-VASH application. Veterans must be chronically homeless

to be eligible for and referred to HUD-VASH. The housing authority determines eligibility for

the voucher based on the Veteran’s income and criminal background. During this initial referral

period, Veterans are encouraged to provide required eligibility and enrollment documents, such

as proof of identity and income.

TARGETING

The HUD-VASH program targets chronically homeless Veterans.

REFERRAL & ADMISSION

If the 10–15 question screen determines that the Veteran is eligible for HUD-VASH, staff

completing the form forward this information and a standard intake assessment to the VA

housing coordinator. The VA housing coordinator, who is responsible for processing referrals

when there are available vouchers, assigns the Veteran to a housing authority and associated VA

case management team and provides a referral to the VA team lead. The VA team lead then

distributes the referrals among the VA case managers based on case load. The assigned VA case

manager reviews the screening notes to ensure that the Veteran is eligible for HUD-VASH and

then follows up with the Veteran to schedule a meeting to enroll in the program. VA case

managers do not complete a second screening; however, if the Veteran has been housed since the

initial screening since s/he may no longer qualify for the program.

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Appendix E: Houston Site Description

VOUCHER APPLICATION

The VA case management team works with two housing authorities: HHA and HCHA. The

housing authorities have worked together to create a shared HUD-VASH application to

streamline the application process. Despite these efforts, however, each housing authority has a

slightly different application process and required documents.

Both HHA and HCHA receive a list of referrals from the VA housing coordinator that includes

Veterans’ names, Social Security numbers, and dates of birth, allowing the housing authorities to

complete the sex offender check and eligibility verifications in advance of meeting with the

Veteran. Each housing authority has a unique voucher process:

•  HHA—Briefings are scheduled for Tuesdays and Thursdays at 9:00 am. At that time, all

paperwork for both the VA and housing authority is completed and Veterans receive their

vouchers.

•  HCHA—An initial meeting is scheduled with the HCHA case manager on Thursdays.

The VA case manager typically meets with Veterans directly before this meeting to

provide an overview of the program. The voucher briefing is scheduled for the following

Thursday.

A Veteran is not considered to be admitted to HUD-VASH until s/he is assigned to a VA case

management team and the voucher application is submitted to the housing authority.

HOUSING SEARCH

The Houston VA case management team indicates that it does not require VA case management

during the housing process; however, the VA case manager is in regular contact with the Veteran

during this time. Veterans in Houston are issued vouchers for an initial 60-day period, which can

be extended following a VA case manager’s request or by a direct request to the housing

authority by the Veteran. Some Veterans are housed quickly because they have selected a

location or housing unit prior to receiving the voucher. If the Veteran is having difficulties

finding a unit—often related to his/her background—the housing specialist will assist the

Veteran or a VA case manager will accompany the Veteran on housing searches. The peer

support specialist may also assist with the housing search. In general, VA case managers and

other staff provide the level of support that Veterans need to access housing.

Both housing authorities maintain housing lists but the VA case management teams recommend

that Veterans use the internet to search for units. The VA case managers advocate for, support,

and educate the Veteran in selecting a unit of his/her choice.

During group and individual meetings, VA case managers discuss potential barriers to housing

that Veterans may experience and ways to address these concerns. For example, if a Veteran has

a felony charge or a history of broken leases and substance abuse, it may be difficult to locate

housing, particularly in a desirable area. The HUD-VASH case management team has developed

resources to address issues such as eviction, deposits/utilities, income, and criminal backgrounds,

including developing relationships with property owners willing to work with Veterans. Because

lack of income can be a challenge in accessing and maintaining housing, the HCHA allows a

case-by-case hardship waiver for Veterans with no income.

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There are several Veteran-specific buildings in Houston that accept HUD-VASH participants.

However, some of these are known to have rampant drug use, prostitution, and criminal activity.

Veterans are encouraged to look for units that will support their goals of sobriety and not

engaging in criminal behaviors.

INSPECTION

The housing authorities have expedited the inspection process for HUD-VASH applicants.

Reinspections typically have a quick turn-around. In a recent innovation, housing authorities

have begun to allow property owners to photograph repairs and submit them in lieu of an in-

person inspection, which has further expedited this process. In addition, there are a number of

project-based vouchers in Houston, all of which are pre-inspected and ready for move-in.

MOVE-IN

Previously, the means for Veterans to access SSVF for security deposit assistance was a multi-

step process where VA case managers served as intermediaries between Veterans and SSVF; this

required requests for assistance to be made at the level of the VISN Homeless Coordinator. This

process was drawn out, not allowing Veterans to collect deposits in a timely manner and leading

to threats of eviction. Recently, this procedure was changed so that Veterans can now apply to

SSVF directly for assistance with move-in funds.

The Houston VA case management team has a relationship with several organizations that offer

furniture vouchers. However, some require that Veterans receive additional case management

through their agencies. The VA case management team stated that accessing furniture is a

persistent challenge for Veterans.

VA CASE MANAGEMENT

Houston participated in the 14-site Housing First Pilot that was overseen by NCHAV. The entire

HUD-VASH VA case management team transitioned from individual care to a team approach in

July 2013. Each VA case management team meets at least twice a week (“huddles”) and one VA

case manager on each team is assigned an office day to handle paperwork and serve as the main

point of contact for emergencies and calendaring issues; these staff are available Monday

through Friday for walk-in appointments. The teams determine which VA case manager will see

each Veteran based on the location of other meetings scheduled throughout the day. The teams

believe that Veterans know that staff are always available to help them with their issues as each

Veteran has up to six VA case managers. VA case managers described using each team

member’s strengths and areas of expertise to provide a balance to the teams and better serve

Veterans.

During the housing search, Veterans are expected to be in contact with their VA case managers

on a regular basis; a monthly face-to-face meeting with the VA case manager and monthly

contact with a VA housing specialist is the minimum required. A VA case manager may reach

out daily or weekly through phone or in-person meetings, depending on the Veteran’s

preference, to get an update and help address barriers to housing. VA case managers also make a

concerted effort to ensure Veterans understand their leases.

Each Veteran works with a VA case management team to create a psychosocial treatment plan.

Veterans typically utilize the VA as their treatment center, but VA case managers also try to

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Appendix E: Houston Site Description

connect them to community resources. The teams indicated that chronically homeless Veterans

take a longer time to stabilize in housing and often have multiple instances of housing instability;

for this population, the teams make use of all available resources.

After Veterans are housed, VA case managers meet with them as needed—usually monthly—at a

convenient place, ideally a Veteran’s home but also their place of employment, the VA, or other

locations. VA case managers have access to cars, laptops, cellphones, and wireless hot-spots, so

they are able to conduct much of their work in the field and they will drop-in at a Veteran’s

home, hangout spots, and/or hospital appointments if they are having difficulty reaching their

client.

HUD-VASH participants may take part in regular meetings. Thrives, an optional weekly

orientation group, covers topics such as initial enrollment, voucher issuance, the housing search,

and community resources. This group helps Veterans navigate the program and stay connected

with the VA case management team. At the time of voucher issuance, the VA case management

teams hold an optional meet-and-greet at least monthly where Veterans can meet all of the VA

case managers and other HUD-VASH participants who have been through the housing process

and can give advice on issues such as utilities and housing complexes.

Houston VA case management utilizes the following evidence-based practices: Assertive

Community Treatment, Cognitive Behavioral Therapy, Harm Reduction, Motivational

Interviewing, Transtheoretical Model/Stages of Change, Twelve Step Facilitation, Critical Time

Intervention, Intensive Case Management, Peer Support/Mentoring, Supported Employment,

Housing First, and SSI/SSDI Outreach, Access, and Recovery.

PORTS

The VA case management team indicated that Veterans who live locally in areas without an

assigned housing authority can use a Houston voucher in those areas. Otherwise, the Veteran

needs to port to another housing authority to live outside of the Houston VA case management

service boundaries. One concern in dealing with ports is the Veteran’s VA case management

needs and ensuring the Veteran continues to receive needed services and supports. Additionally,

understanding the eligibility criteria, income limits, and payment standards of the receiving

housing authority are important to ensure the Veteran can maintain housing stability.

REASONS FOR EXITS

Leased-Up Exiters

The VA case management team identified a number of reasons why Veterans may exit HUD-

VASH after leasing a housing unit:

•  Increase in income—Often, increases in income are related to Veterans accessing benefits

or obtaining employment, making them ineligible for the program, or the portion of rent

paid by the housing authority becomes so small that the Veteran returns the voucher.

•  Readiness—Veterans may not be ready to live alone. This happens most often among

those who have been chronically homeless.

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•  Nonpayment of rent—Rent payments are particularly difficult for Veterans with limited

incomes who may not be able to repay the housing authority should they fall behind in

payments.

•  Program violations—Program violations may include having additional people living in

the unit who are not listed on the voucher.

•  Noncompliance with VA case management

•  SUD—Veterans with a history of substance abuse may relapse and end up losing their

housing.

•  Incarceration

•  Unit abandonment

•  Eviction

Nonleased Exiters

The VA case management team identified a number of reasons why Veterans may leave the

HUD-VASH program after they have received a voucher but prior to obtaining a housing unit:

•  Mass briefings—During the 100,000 Homes Campaign, the VA and housing authorities

conducted mass voucher briefings with up to 50 Veterans at one time to quickly house

them. The VA case management teams described a possible relationship between these

mass briefings and Veterans exiting HUD-VASH prior to leasing a unit, due in part to

VA case managers’ inability to establish rapport. The team described losing contact with

these Veterans more easily, especially those who did not have phones. Additionally, they

believed that Veterans who enrolled in HUD-VASH during the mass briefings did not

have a clear understanding of VA case management requirements and when they learned

about the expectations of the program, they decided not to participate.

•  Voucher as safety net—VA case managers have found that some Veterans are living with

family or friends and view the HUD-VASH voucher as a safety net in case their current

housing situation becomes unstable rather than as a mechanism for getting into housing.

If Veterans do not need an alternative living situation, they do not use the voucher after it

is issued.

•  Isolation—VA case managers felt that some Veterans exited HUD-VASH before finding

housing because they preferred living with other people or a roommate, which is not

usually permitted for HUD-VASH participants due to voucher restrictions. Veterans

living in encampments express a fear of loneliness when they move into their own

apartment.

•  Motivation—A lack of motivation, often paired with an unwillingness to meet with a VA

case manager in-person, contributes to Veteran exits during the housing search process.

•  Challenging process—Veterans may find the process, from program admission to

accessing housing, to be too difficult.

•  Loss of contact—VA case managers lose contact with the Veteran during the housing

search process

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VETERANS IN CRISIS

Veterans in crisis are identified by self-report, observation, or referral. If they are having a

financial crisis, the VA case manager will coordinate a referral to an outside agency. If they are

having a medical or mental health crisis they are referred to trained clinicians (licensed social

workers) and have access to medical care at the VA hospital.

GRADUATION

The goal is for Veterans enrolled in HUD-VASH to graduate from the program, give up VA case

management but retain the voucher if needed. To be eligible for graduation, the Veteran must be

stably housed and able to pay his/her bills, maintain a steady income, attend all medical

appointments, manage mental health issues, if applicable, and be compliant with medications or

other doctor’s orders. In addition, the Veteran must be able to manage his/her own housing,

interact with the housing authority, and handle the voucher recertification process without VA

case management.

VA case managers have an open door policy for graduated Veterans; Veterans know that if an

issue arises, they can still receive support. Even if a Veteran is eligible for a traditional HCV,

s/he will continue to receive HUD-VASH VA case management for at least one year following

graduation.

COMMUNICATION BETWEEN AGENCIES

Both housing authorities have staff dedicated to HUD-VASH. A VA housing coordinator meets

with each housing authority and VA case management team weekly, acting as a liaison between

the two parties.

Since VA case management is collocated with HCHA, direct contact between VA case managers

and the housing authority is possible, making communication easy and efficient, with responses

“in real time.” Communication processes with HHA are undergoing some changes to become

more efficient; VA case managers stated that it would be ideal to collocate with the HHA as

well.

FACILITATORS OF HOUSING SUSTAINABILITY

The Houston VA case management team identified a number of facilitators of housing

sustainability for Veterans in the HUD-VASH program:

•  Relationship with VA case manager—Establishing rapport with Veterans facilitates

housing sustainability. HUD-VASH participants often have limited social support and the

VA case management team becomes an objective, supportive force that is available at

any time to help them move forward. Veterans look forward to meeting with the VA case

managers, which helps them sustain stable housing because they want to maintain contact

and communication with the team. VA case managers also believe that they can empower

Veterans to advocate for themselves.

•  Advocacy—VA case managers advocate for Veterans with property owners, who may be

less rigid with Veterans than the general population. Property owners are more likely to

rent a unit to Veterans who have a VA case manager to call if there is a housing concern.

The housing specialist, in particular, can assist Veterans with the housing search.

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•  Employment—The employment specialist helps Veterans find stable income to maintain

their housing. Integrating VA and non-VA resources and educating Veterans about

resources is also important.

BARRIERS FOR HOUSING SUSTAINABILITY

Veterans in Houston face a number of challenges in accessing and sustaining housing, including

the following:

•  Lack of communication—The lack of communication about HUD-VASH that occurred

during the mass voucher briefings was notable. Veterans who entered HUD-VASH

during a mass briefing often did not fully understand the program. During these briefings,

staff were dealing with a large volume of applicants and were unable to spend sufficient

time providing a thorough explanation of the program and its expectations, and the large

group environment prevented Veterans from asking questions. Another challenge to

housing stability is the VA case manager’s inability to communicate with Veterans unless

they present at a designated service location for VA case management as many do not

have a phone.

•  Personal history—Common barriers to housing are past eviction, prior broken leases,

poor credit, and criminal backgrounds, including felonies and arson. Veterans in recovery

may have federal charges and the only property owners willing to rent to them are in

locations that compromise their recovery.

•  Unethical property owners—Unscrupulous property owners may offer quick leases

without inspection or having the HAP contract signed. Veterans have also been told that

all utilities are covered under the voucher and then asked by the property owner to sign a

lease that does not include utilities, leaving the Veteran with utility arrearages. Some

Veterans with rent arrearages have been told by property owners that they can leave and

the property owner will not follow-up on the missing rent when, in actuality, the property

owner subsequently evicted the Veteran, making him/her ineligible for a HCV in the

future.

•  Financial issues—Veterans with no or low income may have difficulty paying the rent

due to money mismanagement, sometimes related to literacy issues and learning

disabilities. While SSVF may provide funds at the beginning of the HUD-VASH housing

process, there are few resources to assist Veterans with rent arrearages and there are

limits on how long a community group can help with rent.

•  Untreated cognitive/mental/behavioral health conditions—Veterans with PTSD, TBI, or

SUD may have difficulty accessing and maintaining housing.

•  Transition from homelessness—The transition from living on the streets to renting a

housing unit is easier for some Veterans than others. HUD-VASH may require that

Veterans learn a new way of interacting in the world that is too stressful or challenging

for some.

•  Lack of furniture—A lack of resources for Veterans to set up their housing units makes

the HUD-VASH unit not seem like home. Often, to qualify for a furniture voucher, the

Veteran must be physically homeless. If a Veteran receives a voucher and signs the lease

before receiving furniture, s/he is ineligible for this assistance.

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PROCESS IMPROVEMENTS / RECOMMENDATIONS

The VA case management team recommends meeting with Veterans individually at the start of

the program. The team indicated that mass briefings make it difficult to assist Veterans and

ensure they sustain housing.

The VA case management team would like to incorporate additional housing specialists into

their staff. Housing specialists can be particularly helpful with Veterans who have special needs

or felony records In addition to assisting with the housing search, the housing specialists can

speak to property owners on the Veterans’ behalf.

Houston Housing Authority

HHA has two housing specialists dedicated to HUD-VASH. Veterans are served by HHA staff at

the housing authority. Details on HHA’s voucher issuance and payment standards are shown in

the table below:

Payment Standard

97% FMR or 102% FMR depending on zip code, 110% FMR in opportunity

areas

Portion of Rent that is Veteran’s

Responsibility

30–40%

Initial Voucher Issuance Period  60 days

HHA and HCHA use the same application for HUD-VASH, though both require different

accompanying documents.

VOUCHER APPLICATION

Veterans are informed of the documents needed to enroll in HUD-VASH at their initial point of

entry into the program, whether it be the VAMC, the drop-in center, or through community

outreach. VA case managers then request specific information from Veterans during the initial

HUD-VASH intake, which includes completing a release allowing the VA to share their

information with the housing authority. During a second intake with VA case managers,

Veterans are given details on the application process, told again what documents are needed, and

informed of the date, time, and location of the next meeting with HHA. Regular meetings are

held weekly on Tuesdays and Thursdays at the housing authority, though additional meetings

may take place in the community when there are a large number of voucher issuances occurring

at once.

Following the intake process, the VA housing coordinator gives the HHA a referral list that

includes Veterans’ names, Social Security numbers, and dates of birth. This allows the HHA to

complete the sex offender check and eligibility verifications in advance of meeting with the

Veteran. This list of names is provided on Monday for the Veterans scheduled to attend a regular

meeting on Tuesday or Thursday of that week.

The application is completed during the meeting with the housing authority.

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VOUCHER BRIEFING

Veterans generally meet with HHA only one time to complete the HUD-VASH application and

participate in a voucher briefing. Regular meetings are held at the HHA on Tuesdays and

Thursdays. The VA case management team provides transportation from the VA to the housing

authority on Tuesdays, while Veterans are responsible for their own transportation on Thursdays.

Additional meetings may be held in the community.

HOUSING SEARCH

HHA refers Veterans to online resources for use during their housing search, including the HCV

website and social services on the Harris County Resource Center website. The housing authority

has space available in its offices for clients to access housing sites and do online housing

searches, and the city has a call center that Veterans can use in their housing search.

HHA also operates 150 project-based vouchers at two Veteran-specific sites downtown: Travis

Street Plaza Apartments and Midtown Terrace. There are also several other locations with a large

concentration of Veterans, including The DeGeorge.

INSPECTION, HAP CONTRACT, AND LEASE

Once the Veteran identifies a unit, the RFTA must be submitted to HHA. An inspection can then

be scheduled. Veterans are given priority during the scheduling of inspections across all groups

served by HHA. Before an inspection is set up, the rental offer is determined by looking at rent

comparables in the area of the selected unit. This allows the inspector to negotiate rent during the

inspection. Rent negotiations are more likely to be an issue for Veterans living with family

members. For singles, most property owners accept the initial rent offer.

Most units in Houston fail the first inspection, so move-in is delayed while property owners

make repairs and schedule a second inspection. It takes an average of three weeks between

submission of the RFTA and the unit passing inspection. Once the unit does pass inspection and

the property owner accepts the rent offer, the Veteran can move in immediately.

The lease is executed between the property owner and the Veteran. By law, the VA case manager

cannot be involved in this process but can provide education to the Veteran about signing a

contract/lease. The HAP contract is executed between the property owner and the housing

authority.

PORTS

HHA described a port as a transfer of a Veteran from one jurisdiction to another. To port a

voucher, the Veteran alerts his/her VA case manager and housing authority that s/he would like

to port. The accepting location can either accept or decline the request. The port must be

coordinated to ensure that the voucher is released in the first location before the Veteran moves;

a Veteran cannot have two vouchers open at the same time.

REEXAMINATIONS

HHA processes decreases in income immediately, with changes in rent going into effect during

the following month. Increases in income are only processed during the annual recertification.

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ANNUAL RECERTIFICATION

HHA sends Veterans a letter and recertification packet with a 90-day notice to begin the

recertification process. VA case managers are also notified of these timelines, and they will

contact Veterans to remind them about the recertification. Once a Veteran completes the

recertification packet, the VA case manager scans the documents to store in the Veteran’s record.

REASONS FOR EXITS

As HHA houses an increasing number of Veterans through HUD-VASH, they feel that the

process is getting more difficult, even as procedures are becoming more streamlined and

efficient. The housing authority indicated that Veterans who were most able to engage with the

VA case manager and housing process have already been housed, leaving the most difficult to

serve still on the street.

Leased-Up Exiters

HHA identified a number of reasons why Veterans may exit HUD-VASH after leasing a housing

unit:

•  Lease violations—Lease violations range from behavioral issues that are causing

problems with neighbors or the property owner to nonpayment of rent.

•  Noncompliance with recertification

•  Noncompliance with VA case management

•  Loss of contact– If the housing authority is unable to contact the Veteran with regard to

compliance issues, the Veteran may be terminated from the program.

•  Graduation—Veterans who graduate from VA case management can be moved to a

regular HCV.

•  Unit abandonment

•  Voluntary withdrawal from the program

Nonleased Exiters

HHA identified a number of reasons why Veterans may leave the HUD-VASH program after

they have received a voucher but prior to obtaining a housing unit:

•  Personal history—Veterans with a criminal background, poor credit history, or histories

of eviction have more difficulty finding a unit that will accept them.

•  Motivation—Some Veterans lack the motivation needed to be successful in completing

the steps necessary to find housing through the HUD-VASH program.

•  Transition from homelessness—Veterans who have a long history of homelessness are

connected to street life and find the transition to looking for and getting housing

overwhelming.

•  Mental illness

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VETERANS IN CRISIS

When HHA learns that Veterans are facing housing issues, they typically attempt to contact the

Veteran via mail. HHA staff may also contact the VA case manager to get the issue resolved.

COMMUNICATION BETWEEN AGENCIES

HHA has regular meetings with supervisory staff in an effort to improve the program. Recently,

HUD-VASH program staff from the housing authority and VA case managers met to allow staff

to get to know each other and improve collaboration between the agencies.

FACILITATORS OF HOUSING SUSTAINABILITY

HHA identified a number of facilitators of housing sustainability for Veterans in the HUD-

VASH program:

•  HUD-VASH Boot Camps—During these events, agencies throughout the community

reviewed the current housing process and collaborated on how to improve it.

•  Opportunity areas—HHA has a waiver to pay up to 110% FMR in opportunity areas.

This allows clients to move into nicer areas, usually with better schools and more

community resources.

•  Collaboration with VA and local partners—Working together to achieve a common goal

enables all providers to reach their objective of ending Veteran homelessness. Projects

like the 100,000 Homes Campaign and Houston’s Heros have enabled the housing

authority to work with partners to reach what some might consider unattainable goals.

BARRIERS TO HOUSING SUSTAINABILITY

Veterans in Houston face a number of challenges in accessing and sustaining housing, including

the following:

•  Mass briefings—During the 100,000 Homes Campaign, the HHA took part in multiple

mass voucher briefings. Though the housing authority was able to meet its enrollment

goals through these events, these mass briefings had inefficiencies that led to lower

success rates than those achieved through individual intakes and briefings with fewer

Veterans. Mass briefings are no longer conducted.

•  Challenging process—HHA has worked hard to deal with inefficiencies within the HUD-

VASH application and housing process. At one time, HHA enumerated the steps

involved in housing Veterans and determined that the Veteran had to move through 57

steps. HHA has since worked with the VA to make the process more lean and reduce

barriers for Veterans entering the program. Given that HUD-VASH requires so many

points of contact with Veterans, there is a high likelihood of mistakes. As the number of

steps in the process are decreased so, too, are the number of errors that occur.

PROCESS IMPROVEMENTS / RECOMMENDATIONS

HHA has a number of recommendations that they believe could make HUD-VASH more

efficient and better serve Veterans. One suggestion was improving coordinated access to and use

of the Vulnerability Index to determine the appropriate level of housing for individual Veterans.

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For example, it may be that some Veterans would do better in transitional housing than living

independently through the HUD-VASH program. It would be helpful if the coordinated access

intake could better determine the services that Veterans receive so that a Veteran who is not

ready for independent housing is not using a voucher unsuccessfully, while another Veteran who

could use the voucher effectively must wait.

Similarly, it would be helpful if the VA and HHA systems could work in tandem so that both

agencies had access to the same information. At times, information in HOMES would be useful

to HHA staff who are not permitted access to that system, which includes consent forms. Having

one system would make HUD-VASH operate much more effectively.

HUD-VASH participants at HHA would also benefit from more flexibility in program

requirements. The housing authority understands that, ideally, the Veteran would be involved in

a minimal number of interactions; however, additional interactions are often necessary to fulfill

program requirements. For example, it can be difficult for Veterans to provide income

verifications, which can delay the housing process. If HHA can confirm that the Veteran is

eligible and will be paying a standard amount, it would be beneficial if they could waive the

income verification requirement.

HHA has found that inspections and reinspections often delay the housing and recertification

processes. The housing authority would like to certify property owners who consistently meet

inspection guidelines. Additionally, having less frequent inspections would be helpful for

completing recertifications in a more timely way.

Finally, the HHA is aware that some area property owners exploit HUD-VASH Veterans, often

because Veterans participating in the program have few housing options. The housing authority

would like to be able to debar property owners who engage in unethical practices so that they are

held accountable for their actions and understand that they will not be able to continue to rent to

tenants receiving housing assistance if they continue this behavior.

Harris County Housing Authority

HCHA has two staff who work on HUD-VASH, including a supervisor (Director of the HCV

Program) and one case manager. Veterans are served by HCHA staff at the housing authority.

Details on HCHA’s voucher issuance and payment standards are shown in the table below:

Payment Standard

100% FMR, 110% FMR in opportunity areas

Portion of Rent that is Veteran’s

Responsibility

30%

Initial Voucher Issuance Period  60 days

HHA and HCHA use the same application for HUD-VASH, though both require different

accompanying documents.

VOUCHER APPLICATION

The HUD-VASH HCHA case manager meets with the VA housing coordinator on Tuesdays to

discuss the availability of vouchers and schedule voucher meetings. The VA housing coordinator

provides the housing authority with a list of Veterans who will be referred to the HCHA. This

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allows the housing authority to complete the sex offender check and eligibility verifications in

advance. The housing authority schedules a voucher application meeting, which is conducted on

Thursdays at HCHA, typically with a group of Veterans rather than individually. VA case

managers meet with Veterans first to complete their part of the assessment before introducing the

Veterans to the HCHA case manager. The HCHA case manager shows the Veterans a film about

HUD-VASH, reviews the application packet and the rules and regulations of the program, and

answers any questions Veterans have about the program or materials.

VOUCHER BRIEFING

Prior to the scheduled voucher briefing, The HCHA case manager reviews the completed

application packet provided by the VA case manager. If any required documents are missing or

out of date (as is often the case since Veterans submit documents during the initial referral

phase), the HCHA case manager contacts Veterans regarding additional documents to process

the application.

The voucher briefing typically takes place one week after the initial HCHA meeting, also on a

Thursday. During the voucher briefing, Veterans are provided with a housing packet that

includes a Housing Estimator to help them determine which units they will qualify for and the

rent they will be expected to pay. Recently, the housing authority has started to include

community providers in these meetings, allowing Veterans to learn about additional community

resources, such as move-in assistance. A list of additional community providers is also available.

HOUSING SEARCH

The HCHA case manager assists Veterans in their housing search, particularly those who have

criminal histories or other background characteristics that may make it more difficult to find a

unit. HCHA has relationships with property owners and has identified several who will accept

Veterans with a criminal history. There are also two specific properties where the housing

authority will refer Veterans who have exhausted all other options. While these properties are not

ideal, because of criminal activity in the area, they do provide housing for Veterans who have

been unable to find other options.

Once the Veteran identifies a unit, the RFTA is completed and submitted to the VA case

manager. The VA case manager then passes the RFTA to the HCHA inspection department.

INSPECTION, HAP CONTRACT, AND LEASE

The housing authority negotiates rent prior to the inspection by reviewing rent comparables in

the area of the selected unit. The majority of property owners in Harris County accept the initial

rent offer; however, all units must pass inspection prior to the Veteran moving in.

HCHA prioritizes inspections for HUD-VASH Veterans and schedules them as soon as possible

after RFTAs are submitted. Other HCHA clients must submit the packet by the 15th of the

month but Veterans are able to submit the RFTA at any time. Inspections typically take place

within a day or two unless there is a tenant in the unit. Units usually pass the first inspection.

Once a unit passes inspection, the HCHA case manager contacts the property owner to discuss

the HAP contract and Veteran move-in. It is possible for the inspection and contract to be

completed on the same day that the RFTA is submitted but it usually occurs up to four days later.

The property owner and the Veteran plan for the Veteran to move in.

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PORTS

The Houston VA case management teams are currently not accepting any incoming ports from

other HUD-VASH programs. However, Veterans are allowed to port to another HUD-VASH

program. To port from HCHA to another housing authority, a Veteran must first be accepted into

VA case management at the receiving VA HUD-VASH program. If the receiving program has

available vouchers, the Veteran will receive a voucher directly from the accepting housing

authority. If the receiving location does not have any available vouchers, the receiving housing

authority can bill HCHA for the Veteran’s voucher.

REEXAMINATIONS

Both increases and decreases in income are processed immediately at the HCHA, with changes

to rent going into effect the following month.

ANNUAL RECERTIFICATION

HCHA conducts annual recertification with Veterans in HUD-VASH. The housing authority

informs VA case managers about upcoming recertifications so they can assist Veterans in

completing this process. The HCHA case managers provide VA case managers with the dates

and times of recertification appointments so they can plan to attend them.

REASONS FOR EXITS

Leased-Up Exiters

HCHA identified a number of reasons why Veterans may exit HUD-VASH after leasing a

housing unit:

•  Increase in income—Veterans who are found to be over-income are able to remain in the

HUD-VASH program for six months. If their income does not decrease during that time,

they are terminated after this six month period. If, however, they experience a decrease in

income, they can remain in the program and continue to receive rental assistance.

•  Noncompliance with recertification

•  Noncompliance with VA case management

•  Unit abandonment

•  SUD

•  Mental illness

Nonleased Exiters

HCHA identified a number of reasons why Veterans may leave the HUD-VASH program after

they have received a voucher but prior to obtaining a housing unit:

•  Personal history—HCHA indicated that Veterans with a criminal history have a difficult

time finding housing where they will be accepted as tenants. This is a major concern in

the Houston area.

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Appendix E: Houston Site Description

•  Financial issues—The HUD-VASH program requires Veterans to pay a portion of the

rent, with a minimum responsibility of $50. Veterans without income cannot afford to

rent a unit with the voucher. HCHA has started to offer zero-income Veterans a hardship

waiver so that they will not have an obligation to pay any portion of the rent; this has

helped reduce this type of exit.

•  Loss of contact

•  Mental illness

•  Incarceration

VETERANS IN CRISIS

The HCHA case manager is very involved with the Veterans served through HUD-VASH and

ensures that Veterans understand that the lease signed with the property owner is a legally

binding contract. The housing authority mediates housing issues so that Veterans’ future ability

to receive assistance is not negatively impacted. One option HCHA often uses is a mutual

agreement between the Veteran and the property owner that releases the Veteran from the lease

obligation, particularly for Veterans who are entering long-term treatment programs (Veterans

entering programs less than 30 days long may remain in their units). Having a mutual agreement

in place allows Veterans to return to HUD-VASH with fewer issues following treatment.

If the housing authority learns about a housing issue once an eviction is already in process, the

HCHA case manager will try to stop the eviction and get a mutual agreement in place. The

Veteran can then be issued a new voucher for a new unit. On occasion, the VA case management

team asks the housing authority for flexibility due to Veteran crises. There are times, however,

when the HCHA is unable to accommodate VA requests because they are against their

regulations.

COMMUNICATION BETWEEN AGENCIES

Since HCHA and VA case managers are collocated at the housing authority, the teams are in

constant communication. The HCHA case manager and the VA housing coordinator meet

weekly. The housing authority has provided the VA case managers with frequently used

documents so they can assist Veterans with housing questions or concerns. This has also allowed

the VA case managers to become more familiar with the housing authority’s procedures and

processes, improving their understanding and ability to communicate with Veterans.

FACILITATORS OF HOUSING SUSTAINABILITY

HCHA identified a number of facilitators of housing sustainability for Veterans in the HUD-

VASH program:

•  Collocation of HCHA and VA—The co-location of the HCHA and VA has made the

program more efficient and productive. Both teams share the same vision and collaborate

to determine how best to serve Veterans. The shared work space also allows the HCHA

case manager to refer Veterans directly to the VA case managers on-site.

•  Veteran relationships with HUD-VASH staff—The HCHA case manager is very

involved with the Veterans served through the housing authority. To keep Veterans in

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Appendix E: Houston Site Description

HUD-VASH, HCHA staff work to understand the story behind Veterans’ issues rather

than accepting termination. In addition, Veterans often trust the HCHA case manager

with their problems, allowing the housing authority to follow-up with Veterans’ VA case

managers to ensure that they receive the support and assistance they need.

•  Veteran pride—HCHA described the pride Veterans feel when they receive their housing

packets during the voucher briefing, which translates into taking responsibility for their

own progress and housing situation.

•  Small size of HUD-VASH program—HCHA is able to be flexible and respond to

changing demands because of the program’s small size. The HCHA case manager knows

all of the HUD-VASH Veterans by name and is able to personally assist them through

their housing search and annual recertifications.

BARRIERS TO HOUSING SUSTAINABILITY

Veterans in Houston face a number of challenges in accessing and sustaining housing, including

the following:

•  Chronically homeless Veterans—When Houston began to focus on the chronically

homeless Veteran population, the length of time to lease-up increased and attrition rates

rose.

•  Move-in assistance—Many property owners will not let Veterans move in without a letter

from a service provider that is offering financial assistance. Many providers require

specific documents, such as proof of a passed inspection, which can delay a Veteran’s

move into the unit.

•  Criminal background and credit histories

•  Application fees

PROCESS IMPROVEMENTS / RECOMMENDATIONS

Given the high attrition rate in HUD-VASH, the biggest challenge for HCHA is receiving

enough referrals from the VA to keep all of their vouchers in use. The HCHA reports that they

have requested additional referrals but do not receive them. They have also asked for an

explanation of how the VA referral process works so that this issue could be addressed. HCHA

expressed interest in obtaining a larger voucher allocation so that they can better meet the

housing needs of Houston’s large vulnerable Veteran population.

Step-by-Step Processes

The following chart summarizes the steps in the process of housing Veterans in HUD-VASH—

from initial referral to the program to moving into the housing unit—as well as the roles of the

VA case managers and housing authorities.

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Appendix E: Houston Site Description

VA Case Management

Houston Housing Authority (HHA)

Harris County Housing Authority

(HCHA)

Referral & Admission

Initial Intake / Referral Screening

 Staff at each referral location

complete initial intake and verify

Veterans’ self-reported housing

status and paperwork required for

voucher application. (Most

paperwork is scanned and kept at

the VA.  If a Veteran turns in a HUD-

VASH application and does not

return within 30 days, it is then

destroyed.)

 Referral staff send VA case

management team completed

referral form and HOMES

assessment.

 Veteran must sign a release form.

Referral Processing

Prioritization on Interest List

 Initial intake / referral screening

determines Veteran eligibility and

priority on interest list.

 If Veteran is eligible s/he is referred

to a housing authority. If not, s/he is

referred to a community-based

organization.

VA Case Manager Assignment

 When a voucher is available, VA

housing coordinator assigns Veteran

to a housing authority and

associated VA case management

team and provides a referral to the

VA team lead.

 VA team lead assigns VA case

manager based on case load.

Enrollment Meeting Scheduled

 VA case manager reviews screening

notes to confirm Veteran eligibility.

 VA case manager schedules

enrollment meeting.

Voucher Application & Briefing

Enrollment Meeting

 For Veterans working with HHA,

enrollment meeting takes place in

advance of meeting with HHA.

 For Veterans working with HCHA,

enrollment meeting takes place

immediately before the initial

meeting with HCHA.

Veteran Enrollment in VA Case

Management

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Appendix E: Houston Site Description

VA Case Management

Houston Housing Authority (HHA)

Harris County Housing Authority

(HCHA)

Housing Authority Referral

 VA housing coordinator provides list

of referrals with Veteran's name,

Social Security number, and date of

birth to housing authorities.

Eligibility Verification

Eligibility Verification

 HHA completes sex offender check

 HCHA completes sex offender check

and confirms Veteran eligibility in

and confirms Veteran eligibility in

advance of meeting with Veteran.

advance of meeting with Veteran.

Voucher Application Completed &

Initial Meeting with Veteran

Submitted during Voucher Briefing   HCHA case manager meets with

 Veteran completes voucher

Veteran to provide program

application and participates in

overview and review application

voucher briefing during one meeting

materials.

held Tuesdays and Thursdays at

 Initial meeting held Thursdays at

HHA.

HCHA.

 HHA case manager contacts Veteran

by telephone or letter to schedule a

meeting.

Voucher Application Completed

 Veteran completes voucher

application.

Voucher Application Submitted

during Voucher Briefing

 HCHA reviews completed voucher

application and conducts voucher

briefing.

 Community providers inform

Veteran about additional resources.

 Voucher briefing held Thursdays at

HCHA one week after initial voucher

briefing.

Housing Search

RFTA Submission

RFTA Processing

RFTA Processing

 VA case manager submits RFTA to

HCHA inspection department.

Inspection & Rent Negotiation

Rent Negotiation & Inspection

Rent Negotiation & Inspection

Scheduled

Scheduled

 HHA determines rent offer and

 HCHA determines rent offer and

contacts property owner to

contacts property owner to

negotiate rent.

negotiate rent.

 HHA schedules an inspection.

 HCHA schedules an inspection.

Inspection

Inspection

 Veterans prioritized for inspections.

 Veterans prioritized for inspections.

Reinspection

Reinspection

 Most units fail during the first

 Units typically pass during the first

inspection and must be reinspected.

inspection.

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Appendix E: Houston Site Description

VA Case Management

Houston Housing Authority (HHA)

Harris County Housing Authority

(HCHA)

HAP Contract & Lease

Execution of Lease

HAP Contract Review

 Lease details arranged between

 HCHA case manager contacts

property owner and Veteran.

property owner to discuss HAP

contract and Veteran move-in.

Execution of HAP Contract

Execution of Lease

 Lease details arranged between

property owner and Veteran.

Execution of HAP Contract

Move-In

Move-In Assistance

Move-In

 Veterans apply to SSVF for

 Move-in typically takes place

assistance with move-in funds. The

between 24 hours and 4 days after

VA case management team has a

inspection.

relationship with organizations that

offer Veterans furniture vouchers.

Accessing furniture is a persistent

chal enge.

VA Case Management

Houston Housing Authority (HHA)

Harris County Housing Authority

(HCHA)

Referral & Admission

Initial Intake / Referral Screening

Staff at each referral location complete

initial intake and verify Veterans’ self-

reported housing status and

paperwork required for voucher

application. (Most paperwork is

scanned and kept at the VA. If a

Veteran turns in a HUD-VASH

application and does not return within

30 days, it is then destroyed.)

Referral staff send VA case

management team completed referral

form and HOMES assessment.

Veteran must sign a release form.

Referral Processing

Prioritization on Interest List

Initial intake / referral screening

determines Veteran eligibility and

priority on interest list.

If Veteran is eligible s/he is referred to

a housing authority. If not, s/he is

referred to a community-based

organization.

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Appendix E: Houston Site Description

VA Case Management

Houston Housing Authority (HHA)

Harris County Housing Authority

(HCHA)

VA Case Manager Assignment

When a voucher is available, VA

housing coordinator assigns Veteran

to a housing authority and associated

VA case management team and

provides a referral to the VA team

lead.

VA team lead assigns VA case manager

based on case load.

Enrollment Meeting Scheduled

VA case manager reviews screening

notes to confirm Veteran eligibility.

VA case manager schedules

enrollment meeting.

Voucher Application & Briefing

Enrollment Meeting

For Veterans working with HHA,

enrollment meeting takes place in

advance of meeting with HHA.

For Veterans working with HCHA,

enrollment meeting takes place

immediately before the initial meeting

with HCHA.

Veteran Enrollment in VA Case

Management

Housing Authority Referral

VA housing coordinator provides list

of referrals with Veteran's name,

Social Security number, and date of

birth to housing authorities.

Eligibility Verification

Eligibility Verification

HHA completes sex offender check

HCHA completes sex offender check

and confirms Veteran eligibility in

and confirms Veteran eligibility in

advance of meeting with Veteran.

advance of meeting with Veteran.

Voucher Application Completed &

Initial Meeting with Veteran

Submitted during Voucher Briefing

HCHA case manager meets with

Veteran completes voucher

Veteran to provide program overview

application and participates in

and review application materials.

voucher briefing during one meeting

Initial meeting held Thursdays at

held Tuesdays and Thursdays at HHA.   HCHA.

HHA case manager contacts Veteran

by telephone or letter to schedule a

meeting.

Voucher Application Completed

Veteran completes voucher

application.

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Appendix E: Houston Site Description

VA Case Management

Houston Housing Authority (HHA)

Harris County Housing Authority

(HCHA)

Voucher Application Submitted during

Voucher Briefing

HCHA reviews completed voucher

application and conducts voucher

briefing.

Community providers inform Veteran

about additional resources.

Voucher briefing held Thursdays at

HCHA one week after initial voucher

briefing.

Housing Search

RFTA Submission

RFTA Processing

RFTA Processing

VA case manager submits RFTA to

HCHA inspection department.

Inspection & Rent Negotiation

Rent Negotiation & Inspection

Rent Negotiation & Inspection

Scheduled

Scheduled

HHA determines rent offer and

HCHA determines rent offer and

contacts property owner to negotiate

contacts property owner to negotiate

rent.

rent.

HHA schedules an inspection.

HCHA schedules an inspection.

Inspection

Inspection

Veterans prioritized for inspections.

Veterans prioritized for inspections.

Reinspection

Reinspection

Most units fail during the first

Units typically pass during the first

inspection and must be reinspected.

inspection.

HAP Contract & Lease

Execution of Lease

HAP Contract Review

Lease details arranged between

HCHA case manager contacts property

property owner and Veteran.

owner to discuss HAP contract and

Veteran move-in.

Execution of HAP Contract

Execution of Lease

Lease details arranged between

property owner and Veteran.

Execution of HAP Contract

Move-In

Move-In Assistance

Move-In

Veterans apply to SSVF for assistance

Move-in typically takes place between

with move-in funds. The VA case

24 hours and 4 days after inspection.

management team has a relationship

with organizations that offer Veterans

furniture vouchers. Accessing

furniture is a persistent chal enge.

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APPENDIX F:

LOS ANGELES SITE DESCRIPTION

The Los Angeles HUD-VASH program’s service area includes Greater Los Angeles County as

well as the counties of Ventura, Kern, Santa Barbara, and San Luis Obispo. For the HUD-VASH

Program in Los Angeles, areas are

divided by Service Planning Areas

(SPAs) due to the large geography of

the county. The coordinating VA site

is the VA Greater Los Angeles

Healthcare System in Los Angeles,

CA. The HUD-VASH program has

5,069 vouchers. The majority of

vouchers are held by the Housing

Authority of the City of Los Angeles

(HACLA, 3,179) and the Housing

Authority of the County of Los

Angeles (HACoLA, 1,293). HACLA

can serve Veterans within the City of

Los Angeles. HACoLA can serve

Veterans anywhere in the county.

Housing Context

The following maps provide context for the housing markets in which Veterans participating in

the Los Angeles HUD-VASH program conduct their housing search.

Map 1 outlines low, very low, and

extremely low income areas based

on median county income. Lower

income areas—shaded in dark

blue—are located throughout the

County of Los Angeles, though

low income areas near the coast are

rare. Most low income areas are

toward the city center, northwest of

the city limits, or farther north,

closer to the county boarder. While

the VAMC is not located in a low

income area, there are other Vet

Centers and CBOCs throughout the

city that are in closer proximity to

lower income areas. Additionally,

both HACLA and HACoLA are fairly centrally located for a low income Veteran who is going

through the HUD-VASH housing process and annual recertification.

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Appendix F: Los Angeles Site Description

Map 3 provides details about the

rental vacancy rate by quartile.

Darker areas have lower vacancy

rates. It is clear from this map that

the city has a tight housing market,

with few vacancies. Areas that are

not low income and have high

median rents along the coast have

higher vacancy rates but these are

unlikely to be areas that Veterans

in HUD-VASH can afford. Areas

closer to the city center have

slightly lower vacancy rates.

VA Case Management

The site has 138 VA staff serving

Veterans, including two HUD-

VASH screeners, six supervisors,

107 social workers, 84 of whom

are HUD-VASH case managers,

one psychiatrist, three SUD

specialists, six vocational

rehabilitation specialists, two

housing specialists, six peer

support specialists, and five nurses.

The case load is approximately

1:35. HUD-VASH staff in Los

Angeles are organized into five

teams at eight locations, five of

which are project-based. Teams are

organized by SPA, with each team

serving a specific part of the service area.

Team

Associated Housing Authorities

Service Location

Team Composition

SPA 1

HACoLA

Antelope Valley

SPA 2

HACLA/HACoLA

San Fernando Valley

SPA 3

HACLA/HACoLA

San Gabriel Valley

SPA 4

HACLA/HACoLA

Metro LA

SPA 5

HACLA/HACoLA

West

SPA 6

HACLA/HACoLA

South

SPA 7

HACLA/HACoLA

East

SPA 8

HACLA/HACoLA

South Bay

ACT 1

ACT Team

ACT 2

ACT Team

ACT 3

ACT Team

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Appendix F: Los Angeles Site Description

OUTREACH

The Los Angeles VA case management team receives referrals to HUD-VASH from a number of

sources, including other VA programs—GPD, domiciliaries, and the VA screening clinic—as

well as community-based organizations. Veterans also learn about HUD-VASH from other

Veterans via word of mouth; Veterans housed through HUD-VASH often reach out to homeless

Veterans and encourage them to apply to the program. Outreach events, like Stand Downs, and

peer support are also significant sources of referrals.

REFERRALS AND ELIGIBILITY

All referral sources, including those within the VA, complete a referral form. Two HUD-VASH

screeners process referrals daily and ensure that Veterans meet the program’s eligibility criteria.

The HUD-VASH screeners confirm homelessness in both CPRS and HOMES, which must

indicate that the Veteran is “literally homeless.” If the Veteran is not in CPRS, intake workers

rely on self-reports. Walk-in applicants are screened directly by a HUD-VASH screener and do

not require a referral form. Los Angeles does not currently maintain an interest list as the VA

case management program is adequately staffed and has received additional vouchers, enabling

the program to accept Veterans very quickly.

TARGETING

The HUD-VASH program in Los Angeles originally targeted only chronically homeless

Veterans, which led to many unused vouchers as this is the hardest population to reach and the

least likely to accept VA case management. The program has since expanded its targeting criteria

to include women, families, OEF/OIF/OND, elderly, very low to no income, and Veterans with a

serious mental illness or SUD. By targeting other priority groups in addition to those

experiencing chronic homelessness, the program is accepting more at-risk Veterans, most

pointedly those from current wars with PTSD or TBI. Additionally, the program in Los Angeles

has refined its definition of chronic homelessness to include Veterans who have had shorter, day-

long homeless episodes, whereas previously Veterans had to experience homeless episodes of

two weeks or more.

ADMISSION

During the referral process, Veterans indicate which SPA they would like to live in. However,

Veterans are able to select housing across any of Los Angeles County SPAs regardless of what

they first indicated. After consulting with the supervisor in that SPA, the VA screeners assign the

Veteran to a VA case manager based on availability. The VA case manager receives an email

indicating that a Veteran has been added to his/her case load. If a HOMES assessment has not

already been completed for the Veteran, the VA case manager will collect this information,

which includes details about the Veteran’s homeless background, income, employment,

education, substance use, medical diagnoses, and family contacts. The VA case manager will

also conduct a chart review and request a release of information from the Veteran allowing the

VA case manager to speak with the housing authority and property owners throughout the

housing process.

At this point, the Veteran is also informed about the program’s mandatory VA case management

component. If a Veteran is not interested in VA case management, s/he may opt out of the

program and be directed to other housing alternatives. If the Veteran is interested in and eligible

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for the program, the VA case manager admits the Veteran without any further review. If there are

eligibility questions, the VA case manager consults the supervisors; all program denials must be

processed through the supervisor.

VOUCHER APPLICATION

Once a Veteran is accepted into the program, the VA case manager instructs him/her to collect

the necessary paperwork for the voucher application and assists the Veteran in completing it. The

Veteran is not referred to the housing authority until the entire application packet is complete;

completed materials are submitted to the housing authority by HUD-VASH staff or the HUD-

VASH case manager.

HACLA has two meetings scheduled each week for voucher briefings. HACoLA offers one

meeting per week, though the time often changes. Not having a set voucher briefing time may

cause difficulties in scheduling Veterans to meet with the housing authority, particularly those

without phones or an easy means of contact. The VA peer support specialist attends these

meetings and transports Veterans from the VA to the housing authorities.

HOUSING SEARCH

Locally, the goal is for a Veteran to move into a housing unit within 90 days of admission to

HUD-VASH, though Veterans have 120 days to locate a unit. Veterans are not encouraged to

look for a unit until after they have received a voucher as they will not know the estimated

amount of their voucher until they meet with the housing authority. VA case managers noted that

there is a quick turnover for rental units in Los Angeles; if a unit is available, the Veteran must

be ready to rent immediately. Most property owners will not meet with a Veteran unless the

Veteran has a voucher and RFTA in-hand.

During the first few weeks following the voucher briefing, Veterans often search for—and

find—units to rent. If several weeks have passed and a Veteran has not identified a unit, the VA

case manager will become more actively involved, assisting the Veteran by pulling a list of

available units and helping him/her review and eliminate units using online resources, such as

Google Maps, to assess neighborhoods and potential housing options. The VA case manager will

help the Veteran narrow down where to live based on his/her individual needs; however, the

team indicated that using a HCV is more difficult in some areas than others. Veterans may find

units in more desirable areas but this typically requires a lot of effort on the Veteran’s part. A

VA housing specialist also cultivates relationships with local property owners and investigates

housing options for Veterans.

If the Veteran continues to have difficulty finding a unit, the VA peer support specialist will

become more involved with the housing search. The VA peer support specialist maintains a list

of housing websites and relationships with property owners who will inform him/her about open

units. In addition, the VA peer support specialist hosts a weekly Housing Readiness Group where

Veterans are instructed on what their vouchers cover, how to present themselves to property

owners, what to bring to meetings with property owners, and how to answer property owners’

questions. Finally, the VA peer support specialist is particularly concerned with neighborhood

red flags—such as areas where drugs are sold and used—and tries to help Veterans avoid

triggers that may compromise their housing stability.

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INSPECTION

The Los Angeles VA case management team indicated that after the Veteran submits the RFTA,

the housing authorities schedule the inspection rather quickly, usually within 15 days. The

housing authorities do not communicate with VA case managers directly about the results of the

inspection; VA case managers hear through word of mouth when a unit passes. The inspection

department sends paperwork to housing authority advisors for rent negotiations. Execution of the

final lease agreement may be delayed due to reinspections and rent negotiations, which can be

frustrating for property owners. In at least a few instances, though, the inspection, lease signing,

and move-in have all been accomplished on the same day.

MOVE-IN

From the time that Veterans are first assigned a VA case manager, they are encouraged to save

money for a security deposit and move-in costs. Veterans with higher levels of income may not

need assistance. Those who do need assistance may be referred to SSVF if funds are available or

to other community agencies. AmVets assists with furniture and offers free delivery as well as

vouchers for their thrift store and food, but requires 30 days or more for processing.

VA CASE MANAGEMENT

The following table describes VA case management requirements:

During housing

process

Weekly phone calls; one monthly face-to-face visit

Year 1

Monthly face-to-face visit

Year 2

Quarterly face-to-face visit

Year 3+

Two face-to-face visits annually

Once a Veteran is accepted into HUD-VASH, the VA case manager becomes the first point of

contact at the VA for all case management services.

Notes

If Veteran is unreachable, VA case manager will leave a note in the Veteran’s medical record

asking providers to notify social work when they meet with the Veteran. VA case managers will

also try to locate Veterans at other VA appointments.

Once a Veteran is accepted into HUD-VASH, the VA case manager becomes his/her first point

of contact at the VA. The Veteran can no longer go to the screening clinic to access emergency

shelter; instead, the VA case manager will refer the Veteran to services. The VA case

management team feels this is an important engagement strategy and helps to build trust with the

Veteran and address individual needs and barriers.

VA case managers strive to balance completing required paperwork with building rapport with

Veterans, which they say is especially important when referring them to other services. This

rapport is usually strengthened when the VA case manager goes through each step in the housing

process with the Veteran, from completing the voucher application through move-in. The VA

team indicated that they have greater difficulty working with Veterans who are transferred to

their case load. Working with the Veteran through the entire process also allows VA case

managers to assess how much support the Veteran will need once s/he is housed and if s/he may

benefit from more wraparound services.

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There are three VA SUD specialists across all of the VA case management teams in Los

Angeles, each covering three SPAs. SUD specialists lead group meetings and conduct crisis

counseling in addition to carrying a full case load. VA case management teams in Los Angeles

also have two or more VA peer support specialists for each SPA; they provide a variety of

services including transportation, some case management, housing search assistance, wellness

checks, and help with paperwork, and have recently begun to facilitate groups. All SPAs also

have a registered nurse to consult on health issues and provide some home health services.

The Los Angeles HUD-VASH program received funding for three ACT teams beginning in FFY

2014, which will enable the program to provide more wraparound services. The final VA staffing

array has not been finalized but may include nurses, social workers, and/or psychiatrists.

Veterans who do not have phones are asked to check in with their VA case manager at a set time

each week, at least during the initial housing process. Other Veterans are expected to have one

face-to-face monthly VA case management contact and weekly phone calls during this time.

After that, VA case managers typically meet with Veterans monthly for one year, quarterly the

second year, and then semi-annually the third year. If VA case managers have difficulty

contacting Veterans, they leave a note in the Veteran’s VA medical record asking providers to

notify social work if they meet with the client. They also view Veterans’ other VA appointments

and locate the Veteran at those times.

Los Angeles utilizes the following evidence-based practices: ACT, Cognitive Behavioral

Therapy, Harm Reduction, Motivational Interviewing, Twelve Step Facilitation, Intensive Case

Management, Peer Support/Mentoring, Supported Employment, Housing First, and SSI/SSDI

Outreach, Access, and Recovery.

PORTS

If Veterans want to move out of the central urban area of Los Angeles and into one of the

valleys, the VA case management team will usually refer them to Kern County Housing

Authority.

REASONS FOR EXITS

Leased-Up Exiters

The VA case management team identified a number of reasons why Veterans may exit HUD-

VASH after leasing a housing unit:

•  Withdrawal—Veterans may no longer need VA case management following a long

period of housing stability.

•  Lease violations—VA case managers try to mediate issues between the Veteran and the

property owner to avoid an eviction. If the property owner agrees to release the housing

authority from responsibility, the Veteran can be re-vouchered and look for alternative

housing.

•  Incarceration

•  Loss of contact

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Nonleased Exiters

The VA case management team identified a number of reasons why Veterans may leave the

HUD-VASH program after they have received a voucher but prior to obtaining a housing unit:

•  Increase in income—Veterans may attain employment or receive additional benefits that

make them ineligible for the program.

•  Housing preference—Veterans may not like the available housing, would prefer to live in

an area that has few options for those using a HCV, or relocate before finding a unit with

their voucher.

•  Withdrawal—Veterans may get married or enter another phase of their lives and no

longer need or are interested in the program.

•  Substance abuse relapse

•  Mental illness

•  Loss of contact

VETERANS IN CRISIS

The VA case manager is typically the first person to learn that a Veteran is having a housing

issue, either from the Veteran him/herself, the property owner or other tenants. The VA case

management team generally learns about issues before the housing authority and they can often

mediate. Eviction-level lease violations have occurred with Veterans in HUD-VASH but

extenuating circumstances have prohibited the VA case managers from mediating the issue, such

as an inability to contact the Veteran or property owner. There have been instances when

property owners do not inform the housing authority that a Veteran is no longer staying in the

unit or is going through the eviction process and continues to receive the housing authority’s

portion of the rent; in these cases, it is essential that the Veteran inform the VA case manager to

receive assistance.

GRADUATION

A Veteran may graduate from HUD-VASH after a significant time of successful independent

living and a mutual agreement between the Veteran and HUD-VASH case manager that the

Veteran has successfully met or made sufficient progress with treatment plan goals and obtained

maximum benefit from program participation. Veterans can retain the HCV as long as housing

authority requirements continue to be met. After discharge, a Veteran’s HUD-VASH voucher is

converted into a regular HCV when one is available. While Veterans are using HUD-VASH

HCVs after discharge they will be contacted several times a year by an aftercare case manager to

ensure continued success. Veterans can also retain the right, as HUD-VASH “alumni,” to contact

the program for any follow-up assistance at any time, even after the voucher is converted.

COMMUNICATION BETWEEN AGENCIES

Dedicated HUD-VASH staff serve as liaisons with the housing authorities throughout the HUD-

VASH process. HACLA staff contact the VA peer support specialist about upcoming meetings

scheduled with Veterans. The peer support specialists, in turn, communicate this information to

the VA case managers. A HUD-VASH peer support specialist and supervisor serve as liaisons to

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HACoLA and attend weekly meetings to discuss individual case issues as well as address any

programmatic concerns.

FACILITATORS OF HOUSING SUSTAINABILITY

The Los Angeles VA case management team identified a number of facilitators of housing

sustainability among Veterans in HUD-VASH:

•  Motivation—VA case managers use Motivational Interviewing to address the underlying

issues that may prevent a Veteran from being successfully housed. Case managers and

peer support specialists rely on personal stories to combat the “fear of success” and offer

reassurance that the Veteran is capable of succeeding.

•  Supportive relationships—By participating in VA case management, the Veteran is

surrounded by the team. The VA case management team also works to support the

Veteran in reestablishing family relationships.

•  Connection to resources—The availability of a nurse on the team is helpful for Veterans

with ongoing medical issues; some nursing services are provided directly in the home.

VA case managers also facilitate connections to VA providers and community programs,

including adult day care and senior centers.

BARRIERS TO HOUSING SUSTAINABILITY

The Los Angeles VA case management team identified a number of challenges to housing

sustainability among Veterans in HUD-VASH:

•  Housing process—The lag between inspection and lease signature can be a barrier to

accessing housing; Veterans are told that “the clock stops” on their voucher when the

RFTA is submitted, but many still feel anxious and may change their minds at that point

or the property owner may turn down the housing authority’s rent offer.

•  Vulnerability—The VA case management team described the difficulty of providing case

management to this hard-to-serve population, many of whom do not engage well with

VA case managers and the community. A Veteran described the challenge of overcoming

the “homeless mentality.”

•  Mental illness and SUD—The VA case management team has an insufficient number of

VA SUD specialists; they primarily focus on crisis management rather than supporting

Veterans before they fall into crisis. In addition, VA case managers do not have sufficient

access to Veterans’ psychiatrists; additional psychiatrists are needed to adequately

address the Veterans’ needs.

•  Chronic medical conditions and chronic pain—Extensive medical challenges can be

daunting at an emotional level (e.g., threat of future paralysis) as well as the physical

level (e.g., not being physically able to complete paperwork).

•  Financial issues—Accessing move-in and other assistance is difficult for Veterans in Los

Angeles.

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PROCESS IMPROVEMENTS / RECOMMENDATIONS

The HUD-VASH program in Los Angeles is adding a second VA case management team for

each SPA as well as staff to support an ACT team. A VA incentive specialist would be helpful in

assisting Veterans to obtain benefits. VA case managers also indicated that an occupational

therapist would be useful for Veterans in West Los Angeles.

Members of the VA case management team participated in the Cognitive Behavioral Therapy

(CBT) training sponsored by NCHAV, which allows staff to provide therapy for Veterans in

their homes. Additional funding to educate staff on other evidence-based treatments would be

useful moving forward.

Housing Authority of the City of Los Angeles

HACLA has 17.5 staff dedicated to HUD-VASH. This includes a half-time manager and two

assistant managers, who supervise the teams; eight eligibility interviewers, who conduct the

initial interviews, determine eligibility, issue vouchers, process RFTAs, and contract housing;

four advisors, who conduct annual, special, and interim recertifications and requests to move;

one administrative assistant whose sole duty is to assess every file for quality control before

voucher issuance and prior to signature of the HAP contract; and two clerks. The case load is 450

Veterans per advisor. HACLA staff serve Veterans at the housing authority and other locations,

as needed, to accommodate disabled Veterans. Details on HACLA’s voucher issuance and

payment standards are shown in the table below:

Payment Standard

100-110%FMR

Portion of Rent that is Veteran’s

Responsibility

30-40%

Initial Voucher Issuance Period  120 days

HACLA is clear about its role in the HUD-VASH program: the housing authority provides

housing, not counseling. They reported that they handle the HUD-VASH program much more

expediently than the regular HCV program; referrals to HUD-VASH are processed on the day

the Veteran is interviewed and the voucher is issued the following Friday.

VOUCHER APPLICATION

HACLA provides the VA case management team with application materials. The VA case

managers assist Veterans in completing the application and collecting required documents.

HACLA staff conduct eligibility interviews at the housing authority on Thursdays, at which time

the Veteran submits the application and documents. HACLA eligibility interviewers conduct a

full interview, verify application details, and ensure all required forms are completed and signed.

The Veteran is invited to a voucher briefing at the housing authority the following Friday.

After the interview, HACLA processes the file, completes a sex offender check, and confirms

eligibility and income. The sex offender check can be done online immediately through the HUD

website, which avoids delays. The number of attendees during the Thursday eligibility interviews

varies, and the housing authority may or may not know how many Veterans to expect. As much

as possible, the housing authority tries to assign the Veteran to the staff member who completed

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the initial interview. HACLA holds voucher briefings at the housing authority on Fridays

outlining all program processes and forms, including the RFTA, inspection, and housing

requirements. HACLA staff give Veterans an estimate of the maximum rent for which they will

be approved and the expected portion for which they will be responsible. Veterans receive a

voucher following the information sessions.

HOUSING SEARCH

Veterans and the VA case management team conduct the housing search. The housing authority

refers Veterans to online resources but does not actively connect them with particular property

owners or properties. Once a Veteran identifies a unit, the RFTA is completed and submitted to

the housing authority. The Veteran may submit the RFTA to the housing authority during walk-

in hours (Monday–Thursday, 8–11 am and 1–3 pm) or the VA case manager can fax the RFTA

to HACLA.

INSPECTION

The HACLA eligibility interviewer contacts the property owner to set up an inspection within

two days of RFTA submission. Inspections are usually scheduled for three days from the date of

contact. Prior to the inspection, the HACLA eligibility interviewer updates the Veteran file,

establishes a new property owner in HACLA’s system, if necessary, and reviews internal rent

comparables to ensure the requested rent is within the voucher payment standards. The HACLA

inspector inspects the unit and runs a comparable rent report through the AREA system. The

inspection results and comparables are made available to the eligibility interviewer within three

days of the inspection; once verified, the eligibility interviewer forwards the results to the

contractor.

HAP CONTRACT AND LEASE

Following the inspection, the HACLA eligibility interviewer contacts the property owner to

make a rent offer. If the offer is accepted, the property owner meets with the Veteran to have the

lease signed and sends it to the housing authority for review. The HACLA contractor eligibility

interviewer contacts the Veteran and determines a move-in date. The Veteran can move in

immediately unless s/he needs time to secure funds for the security deposit. The housing

authority provides a rent breakdown that outlines the security deposit and describes the Veteran’s

rent responsibility. Some local funding sources require this documentation as a condition for

providing move-in assistance.

Once the owner and tenant sign a lease agreement HACLA generates the HAP contract, which is

executed by both the owner and housing authority within 60 days of the of the lease start date.

HACLA generally pays owners within days of the contract execution.

PORTS

HACLA and HACoLA have an inter-jurisdictional agreement that allows both agencies to

contract within each other’s jurisdiction to eliminate the portability processing time from one

housing authority to another. However, if a HACLA voucher holder finds a unit in distant areas

in HACoLA’s jurisdiction (e.g., Lancaster, Palmdale), HACLA will process the portability to

HACoLA as it would pose a burden on HACLA staff to inspect and to conduct home visits. The

portability process for applicants and participants is as follows:

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•  VA case manager informs HACLA of the Veteran’s request to port and that VA will

continue to provide case management in the new location or that they have coordinated

with the agency that will provide the case management.

•  The Veteran specifies which housing authority s/he want to port to and signs and dates

the request.

•  The eligibility interviewer prepares the file for the voucher holder and submits it to the

Outgoing Portability Unit, which notifies the receiving housing authority of the port they

will be receiving and that it is a HUD-VASH applicant/participant. HACLA has no

control over the receiving housing authority’s process.

•  Veterans who graduate from VA case management are typically converted to a regular

HCV.

REEXAMINATIONS

HACLA learns about changes to Veteran income from the VA case manager or the Veteran. The

VA case manager will usually submit documents needed to process the change. A decrease in

income is processed immediately as a Special Review, with the change of rent going into effect

the first day of the following month. The participant is required to inform HACLA of any

increases after the Special Review, which will be processed immediately with a 30-day notice of

the increase to the tenant. Increases in income are only processed during a Special Review if they

were preceded by a decrease in income; otherwise, these increases are not processed until the

annual review period.

ANNUAL RECERTIFICATION

During the annual review, the HACLA advisor reviews the Veteran’s income, processes

changes, and inspects the unit. The HACLA advisor also assists Veterans with their requests to

move.

Veterans are informed of the recertification three months in advance when HACLA sends the

Veteran an appointment letter with the application for recertification. If Veterans do not attend

the appointment or they reschedule, they may be scheduled for a second or third appointment. If

the Veteran does not comply with his/her appointment, HACLA sends a 14-day notice stating

that if the Veteran does not comply by a given date, s/he may be terminated from the program.

HACLA will send the Veteran a 30-day intent-to-terminate notice before removing the Veteran

from the program.

HACLA notifies the VA case management teams of all recertification correspondence. They are

encouraged to assist the Veteran when the 14-day notice is issued, and more aggressively when

the 30-day notice is issued, to help the Veteran retain the HCV. HACLA will stop the

termination process if the Veteran complies with the requirements prior to the termination date.

REASONS FOR EXITS

Leased-Up Exiters

HACLA identified a number of reasons why Veterans may exit HUD-VASH after leasing a

housing unit:

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•  Increase in income—Veterans whose income increases may no longer be eligible for

assistance.

•  Withdrawal—Veterans who feel that they no longer need assistance may voluntarily

relinquish their vouchers, often stating that they would like to pass the voucher on to

another Veteran who needs it more.

•  Entry into a different program—Veterans may find that another housing assistance

program is a better fit for them.

•  Eviction—The main reason Veterans are evicted from their unit is for nonpayment of

rent.

•  Noncompliance with recertification—Veterans will be terminated from the program if

they do not complete their annual recertification.

•  Noncompliance with VA case management—If Veterans do not comply with mandatory

VA case management, VA can terminate them from the program.

•  Program violations—Veterans can be terminated from the program for violating program

rules, including subletting the unit or having unauthorized people living in the household.

•  Absence of 30 or more days—Veterans cannot be absent from a unit for more than 30

days without informing the housing authority. If Veterans are to be hospitalized for more

than 30 days, or they enter a treatment program, they may request an allowance from the

housing authority. If the housing authority is aware of the absence, they can allow

Veterans to be absent from the unit for no more than 90 days. 13

•  Voucher expiration—Veterans may ask to move during the annual recertification process.

If Veterans make this request, they are issued a new voucher and given 120 days to

complete the housing search again. If these Veterans do not lease new units and they have

moved out of the assisted unit, they can be terminated from the program. 14

•  Graduation—Veterans who graduate from HUD-VASH are converted to regular HCVs.

•  Fraud and criminal activity—Veterans who knowingly provide inaccurate information

related to their eligibility or income commit fraud and are terminated from the program.

•  Unit abandonment—Some Veterans leave the unit without notice and cannot be located

by the housing authority or VA.

•  Incarceration

•  Death

13 HACLA policy allows participants who are terminated for being out of the unit for more than 90 days to be reinstated if they return within one year of the termination and provide verification that the absence was due to participation in SUD or medical treatment. The Veteran must provide evidence and a statement from the VA case manager that they are continuing to receive case management.

14 HACLA policy allows 30-day hardship extensions to the voucher and also allows for extensions due to a medical condition up to 240 days in total.

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Nonleased Exiters

HACLA identified a number of reasons why Veterans may leave the HUD-VASH program after

they have received a voucher but prior to obtaining a housing unit:

•  Withdrawal—Some Veterans decide that they are not interested in participating in HUD-

VASH once they learn more about it.

•  Readiness—The VA case manager may recommend that Veterans are not ready for

independent housing and that they withdraw from the program.

•  Entry into a different program—Veterans may find that another housing assistance

program is a better fit for them.

•  Inability to locate a unit—Veterans may not find a unit within the allotted 120 days.

•  Increase in income—Veterans who have an increase in income may no longer be eligible

for assistance.

•  Death

VETERANS IN CRISIS

HACLA staff believe it is important that they be made aware of any housing issues with

Veterans. Property owners are required to inform HACLA if a Veteran is not paying his/her rent

so that the housing authority can begin the notification process with the Veteran. If HACLA

finds that the Veteran is in danger of losing his/her housing, HACLA staff will engage the VA

case manager. Likewise, the contract between HACLA and the property owner requires that the

property owner report any actions being taken against a Veteran, such as a three-day notice to

comply or an eviction.

COMMUNICATION BETWEEN AGENCIES

HACLA and VA staff conduct a weekly teleconference (Wednesday at 11:00 am) to deal with

application problems, participant issues, changes to procedures, and any other challenges that

arise. A monthly meeting between HACLA and VA directors provides an opportunity to address

lease-up goals. HACLA generates a weekly summary report on the status of all referrals from the

VA, allowing the VA the opportunity to reconcile their records and ensure that all referrals are

legitimate. In addition, both HACLA and VA hold periodic training for staff.

HACLA staff indicated that they work with the VA to address any issues while drawing clear

distinctions between the two agencies’ areas of responsibility. Though each has different duties,

they have learned to work together to improve and streamline processes and have engaged

community partners interested in playing an active role in assisting Veterans. HACLA has a

point of contact for VA case management teams and copies them on all correspondence to

Veterans. Sometimes the housing authority is aware of an individual Veteran’s VA case manager

and other times they are not, as the assignment of VA case managers often changes.

FACILITATORS OF HOUSING SUSTAINABILITY

HACLA identified a number of facilitators of housing sustainability for Veterans in the HUD-

VASH program:

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•  Streamlined application—VA case management teams complete the application, which

streamlines the process for the Veteran and the housing authority. HACLA has

coordinated with HACoLA to generate one core application for the program across the

entire Los Angeles service area. Though additional revisions need to be made, the core

application has simplified the process as VA case managers no longer have to use two

separate applications.

•  Streamlined voucher issuance—HACLA has prioritized Veterans in HUD-VASH,

streamlining processes and making them more efficient. Veterans can move from the

eligibility interview to obtaining a voucher in one week, which the housing authority

believes increases the Veterans’ motivation. The regular eligibility interview and voucher

briefing times have made the process more convenient.

•  HUD-VASH Interjursidictional Agreement between HACLA and HACoLA—Both

agencies can contract within the other’s jurisdiction, eliminating the portability

processing time that can add 30–60 days to the process.

BARRIERS TO HOUSING SUSTAINABILITY

Veterans in Los Angeles face a number of challenges to accessing and sustaining permanent

housing, including the following:

•  Transition from homelessness—HACLA acknowledged the difficulty some Veterans

have transitioning from chronic homelessness to economic stability. Obtaining security

deposit assistance has also been a barrier to housing for some Veterans.

•  Multiple points of contact—HUD-VASH participants in LA work with many individuals,

including the VA case manager, the HACLA eligibility interviewer/contractor, HACLA

advisor, and potentially the HACLA clerk, which can complicate things and create

confusion.

•  Misunderstanding—HACLA staff mentioned that often Veterans state that they

understand program requirements when it seems clear that they do not.

•  VA case management advocacy—HACLA has programmatic rules and calculations that

apply to all clients. They are unable to be flexible on many of these rules. At times,

however, a VA case manager may try to advocate for a client rather than assisting the

client in complying with the program.

•  Different requirements between local housing authorities—The Los Angeles housing

authorities operate independently with agency-specific procedures and forms, which can

make the process more complex for VA case managers who may be assisting Veterans at

both housing authorities.

•  Provision of ongoing supportive services from the VA—Veterans may lose their housing

when direct, ongoing case management supportive services could have assisted them in

maintaining their housing.

PROCESS IMPROVEMENTS / RECOMMENDATIONS

HACLA is constantly evaluating HUD-VASH and looking for areas for improvement. The

housing authority tries to copy a VA case management point of contact on all correspondence

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that is sent to Veterans. However, HACLA staff recognize that this may be overwhelming and

not useful. Additional dialogue may be necessary to determine what information will make the

biggest impact for the Veterans. HACLA is in the process of purchasing a program that will

allow their system to automatically generate third-party notices so that they can include

individual VA case managers as well as general VA contacts on notices.

HACLA has been granted a waiver from HUD that has streamlined the recertification process.

Rather than providing all of the verifications for bank accounts, Veterans may self-certify

accounts under $5,000.

Housing Authority of the County of Los Angeles

HACoLA has four case managers serving all homeless programs, including HUD-VASH. The

case load is approximately 257 per case manager. Veterans are served by HACoLA staff at the

housing authority as well as the VAMC. Details on HACoLA’s voucher issuance and payment

standards are shown in the table below:

Payment Standard

90% FMR

Portion of Rent that is Veteran’s  Up to 40% of monthly adjusted income at time of contract execution. Portion of rent Responsibility

may increase at time of annual recertification based on Veteran’s income and/or

approval of owner’s rent increase request.

Initial Voucher Issuance Period  120 days

VOUCHER APPLICATION

The VA case managers assist Veterans in preparing their voucher application and required

documentation. HACoLA staff review application materials at the VAMC at a regular meeting

time on Thursdays and inform Veterans immediately if anything is missing from the application.

HACoLA staff submit the completed applications to the housing authority and run the sex

offender check and necessary verifications. Veterans may also submit applications to HACoLA

via email or fax.

VOUCHER BRIEFING

After Veterans have submitted their application and the housing authority has confirmed

eligibility, Veterans attend a voucher briefing session at the VAMC, typically within two weeks

following application submission. Voucher briefings take place at a regular meeting time on

Thursdays, usually in a group setting. If a Veteran is unable to attend the Thursday meeting,

HACoLA can arrange an individual meeting.

HOUSING SEARCH

During the voucher briefing, HACoLA provides Veterans with a resource card to use during the

housing search and points Veterans to www.socialserve.com, which is administered by LA

County Housing Resource and provides information on available housing units specific to

Veterans and the HUD-VASH program. It also allows users to map the location of a unit and the

distance to public transportation, shopping, and medical centers and links to other services

provided throughout the county.

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The voucher issuance period can be extended up to 180 days or longer, depending on

circumstances (e.g., medical issues, reasonable accommodations, disabilities). However, if a

Veteran is approaching 180 days, HACoLA staff will reach out to the VA to get the Veteran

housed immediately.

INSPECTION, HAP CONTRACT, AND LEASE

Once the Veteran locates a unit, the Veteran or case manager submits the RFTA to HACoLA.

HACoLA staff contact the property owner to negotiate the rent. If the property owner accepts the

rent offer and the unit is affordable for the Veteran, the housing authority schedules an

inspection, typically within 10 days. If the unit fails inspection, the inspector schedules a follow-

up appointment while at the property; however, this can be changed by the property owner.

The contract process begins once the unit passes inspection. The housing authority requests that

the Veteran and property owner sign a lease with a move-in date. Staff confirm the affordability

of the unit, the utility allowance, and inspection results and establish terms of tenancy before

reviewing and approving the lease. When information is verified and data entry is completed, the

housing authority sends the HAP contract based on the established terms of tenancy via email or

regular mail; the property owner may also sign the contract at the housing authority. Once

contracts are returned, staff will release the rent payment to the owner.

PORTS

Should a Veteran ask to port to anther housing authority, the Veteran must first request approval

from his/her VA case manager. If approved, the VA case manager will submit a letter to the

housing authority approving the port, and the Veteran will complete and submit a Request to

Transfer form. If needed, staff will provide additional time on the voucher to allow the Veteran

to locate a unit in the new jurisdiction. HACoLA staff forward a copy of the Veteran’s file to the

receiving housing authority.

If a Veteran ports from another housing authority to HACoLA, HACoLA’s portability staff will

issue a voucher to the Veteran within 10 days of receiving the file. Once the voucher is issued,

staff will monitor the file and process the new HAP contract if the Veteran locates a suitable

housing unit. The Veteran’s voucher time is subject to the number of days remaining on the

voucher the Veteran received from the originating housing authority.

REEXAMINATIONS

HACoLA processes decreases in income as soon as they are reported and verified, with changes

to rent going into effect the following month. Increases in income are acknowledged as they are

reported but changes to the rent do not go into effect until the annual recertification.

ANNUAL RECERTIFICATION

Recertifications are completed annually. If a Veteran does not initially comply with the

recertification, the HACoLA staff will reach out to the VA case manager and request that the

Veteran receive assistance filling out the packet and providing the required verifications.

HACoLA has found that some Veterans are no longer eligible for rental assistance during

recertification. When this is the case, the housing authority still completes the recertification and

terminates payments to the property owner. However, Veterans are able to stay on the program

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for six months; if they experience changes to income or eligibility during that period, they may

to report it and the housing authority can recommence payments. If not, the Veteran no longer

qualifies for the program.

REASONS FOR EXITS

Leased-Up Exiters

HACoLA identified a number of reasons why Veterans may leave the HUD-VASH program

after they have obtained a housing unit:

•  Increases in income—Veterans who are over-income can remain on the program for six

months; if they remain over-income, they are no longer eligible for assistance.

•  Lease violations—Some Veterans do not comply with the lease agreement or program

rules. In these cases, HACoLA staff will contact the Veterans via letter and inform them

that they are in violation of the obligations and outline the specific violations. The

Veteran has 15 days to respond; HACoLA will schedule a meeting with the Veteran to

resolve the violations.

•  Evictions—Veterans who are evicted from their unit may stay in HUD-VASH; they can

be issued a new voucher and complete the housing search again.

•  Noncompliance with annual recertification—Veterans will often complete the first annual

recertification but then fail to complete the packet or comply with mandatory

verifications during subsequent recertifications.

•  Withdrawal—Veterans may be no longer interested in remaining in the program.

•  Nonpayment of rent

•  Unit abandonment

•  Death

Nonleased Exiters

HACoLA identified a number of reasons why Veterans may leave the HUD-VASH program

after they have received a voucher but prior to obtaining a housing unit:

•  Privacy concerns—Veterans do not want to provide all of the detailed information

required for the HUD-VASH application.

•  Personal history—Veterans with histories of eviction may not be able to find units that

will accept them.

•  Challenging process—Veterans lose interest in the program because they get frustrated

with the paperwork and housing search; they may feel that HUD-VASH is too much

work.

•  Difficulty finding acceptable housing—It can be hard for Veterans to locate affordable

units. There are also times when Veterans find a unit within the rental guidelines but the

rent comparables do not support the rent. If the property owner is not willing to negotiate

on the rent, Veterans must find another housing unit.

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•  Transitions from homelessness—Some Veterans, particularly those with a history of

chronic homelessness, have a difficult time transitioning from the “homeless way of life”

and experience fear of the responsibility of obtaining housing andthen readjusting to

homelessness if they lose the housing.

•  Transportation—Many Veterans lack transportation for the housing search.

•  Health issues—It can be difficult to search for housing if the Veteran is ill or

hospitalized.

VETERANS IN CRISIS

When Veterans experience housing issues, HACoLA staff will engage VA case managers but are

more likely to work with Veterans and property owners directly.

COMMUNICATION BETWEEN AGENCIES

HACoLA and the VA have weekly conference calls and HACoLA staff may have more frequent

contact with individual VA case managers if issues arise for particular Veterans. HACoLA also

holds Task Force meetings on an as-needed basis to address specific processes. These meetings

may take place once or on a monthly basis, depending on the concern, allowing the housing

authority and VA to reevaluate and streamline processes and reduce the administrative burden of

the program on a continuous basis. Community work groups are also commonplace, providing

an opportunity for HACoLA to collaborate with VA and other community providers.

FACILITATORS OF HOUSING SUSTAINABILITY

HACoLA identified a number of facilitators of housing sustainability for Veterans in the HUD-

VASH program:

•  Decreasing time to housing—Preparing Veterans for the housing search and decreasing

process timelines has made it easier to get Veterans housed.

•  Program flexibility—HACoLA is flexible on some of the regulatory requirements for

HUD-VASH participants; eliminating or cutting back on processes makes the program

easier to navigate and leads to greater success in housing Veterans.

•  Streamlining application materials—HACoLA has worked with HACLA to create a

uniform HUD-VASH application. Additional revisions are being completed. While

supplemental forms may never be uniform due to individual requirements at each housing

authority, streamlining the process has made it easier for VA case managers to complete

applications.

BARRIERS FOR HOUSING SUSTAINABILITY

Veterans in Los Angeles face a number of challenges to accessing and sustaining permanent

housing, including the following:

•  Housing affordability—Many property owners have higher rents than the market

generally supports. Since the housing authority takes rent comparables into consideration

for rent negotiations, the rent must be reflective of the market, but some property owners

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refuse to negotiate. HACoLA is committed to creating more project-based vouchers to

increase the city’s affordable housing stock.

•  Location of affordable units—Many Veterans simply do not want to live in the areas that

are affordable with the HUD-VASH vouchers. Additionally, Veterans who use the VA

for medical services prefer to be located near the VAMC where there is a lack of

affordable housing; this is problematic, particularly for those who use public

transportation.

•  SUD—Veterans with SUD are more likely to abandon their units. They may also face

losing their housing while in treatment. Veterans can stay out of their homes for 30 days

for treatment but they often return to treatment soon after being discharged.

•  Multiple points of contact—The housing authority believes some Veterans may feel that

they do not have a consistent case manager because the HUD-VASH program has so

many points of contact.

PROCESS IMPROVEMENTS / RECOMMENDATIONS

HACoLA owes its success to being open-minded and fluid. The housing authority strives to

learn about the latest policies and regulations and work with federal and local partners to

improve its programs, whether by addressing specific Veteran needs or involving the

community.

HACoLA believes that offering additional wrap-around services for Veterans is important and

suggests completing more frequent assessments and reassessments as Veterans’ needs change.

The housing authority indicated that more frequent check-ins with Veterans and assistance

helping them communicate with property owners would be useful for those with housing issues.

In addition, HACoLA would like the VA to hire more housing locators; if the housing success

rate of Veterans can be increased, the housing authority will be able to maximize lease-ups.

Currently, the housing authority has a 70% success rate with lease-up. Veterans would also

benefit if additional funds were available for move-in. Accessing funds for security deposits and

move-in costs can be difficult.

The housing authority would like to improve various aspects of the housing process. HACoLA

indicated that the definition of “chronically homeless” has made it difficult to serve the large

homeless population in Los Angeles. In effect, Veterans may be told that they are not “homeless

enough” to meet program eligibility requirements. However, particularly for Veterans with

children, meeting the federal definition may not be in the best interest of their family. If Veterans

stay in a shelter they may be separated from their children, depending on the children’s age.

Similarly, families cannot stay in parks or cars as the Department of Children and Family

Services will remove the children.

Some HUD guidelines can also make the housing process more difficult. For example, HUD

requires that income verification documents must have been issued within 60 days of the voucher

release date. Veterans may provide current documents when they initially enroll in HUD-VASH,

but by the time a voucher is issued, they are no longer up to date. It would be useful if the

guidelines could be adjusted to record the date that the income verification documents are

received independent of the time of voucher issuance.

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Appendix F: Los Angeles Site Description

The housing authority is in the process of organizing a property owner service fair. HACoLA

anticipates inviting all property owners currently involved with the housing authority to set up a

booth at either the housing authority or VAMC to advertise their housing to voucher holders.

Depending on the success of the initial fair, the housing authority would consider hosting this

event bimonthly.

Step-By-Step Processes

The following chart summarizes the steps in the process of housing Veterans in HUD-VASH—

from initial referral to the program to moving into the housing unit—as well as the roles of the

VA case managers and housing authorities.

VA Case Management

Housing Authority of the City of Los

Housing Authority of the County

Angeles (HACLA)

of Los Angeles (HACoLA)

Referral & Admission

Referral

  Referral source completes referral form,

including Veteran's neighborhood

preference.

  Referrals can be submitted by fax

through a secure line from the

community or by encrypted email from

other VA providers (e.g., GPD Liaisons).

Referral Processing

  Two VA intake workers process referral

forms daily, check Veteran's homeless

status in CPRS and HOMES, and ensure

Veteran meets eligibility requirements.

VA Case Manager Assignment

  VA intake worker assigns Veteran to a

SPA and consults with VA SPA supervisor

on VA case manager assignment.

  VA intake worker assigns VA case

manager and notifies him/her of

assigned Veteran by email.

Screening Assessment

  VA case manager contacts Veteran to

schedule an in-person screening

appointment to review eligibility and

discuss program requirements. VA case

manager reviews medical record and

HOMES assessment, completes missing

data, and discusses mandatory case

management with Veteran.

Veteran Enrollment In Va Case

Management

  If eligible, Veteran is admitted to HUD-

VASH case management. VA case

manager assists with compiling all

necessary identification and income

documentation to submit with voucher

application. Veteran is assigned to a

HUD-VASH application appointment for

assistance completing voucher

application.

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Appendix F: Los Angeles Site Description

VA Case Management

Housing Authority of the City of Los

Housing Authority of the County

Angeles (HACLA)

of Los Angeles (HACoLA)

Voucher Application & Briefing

Voucher Application Completed

  HUD-VASH staff assist Veteran in

completing voucher application.

Voucher Application Submitted

  HUD-VASH staff submit completed

voucher application and required

documents to housing authority at time

of eligibility interview.

Eligibility Interview

Eligibility Interview

  HACLA reviews application and interviews

  HACoLA reviews application and

Veteran on Thursdays at HACLA office; if

interviews Veteran on Thursdays at

all information and signatures are in order,

VAMC.

HACLA interviewer invites Veteran to

  Applications can be emailed or faxed to

voucher briefing the fol owing Friday.

HACoLA and reviewed prior to meeting

with Veteran at voucher briefing.

  Veteran invited to attend voucher

briefing 1–2 weeks after submitting

application. HACoLA informs HUD-

VASH case managers via email when

Veteran is assigned to a voucher

issuance session.

Eligibility Verification

Eligibility Verification

  HACLA completes sex offender check and

  HACoLA completes sex offender check

confirms Veteran eligibility.

and confirms Veteran eligibility.

Voucher Briefing

Voucher Briefing

  Voucher briefings held Fridays at HACLA

  Voucher briefings held Thursdays at

office.

VAMC.

Housing Search

Weekly Meetings

  VA peer support specialist offers optional

weekly Housing Readiness Group to

assist Veterans with housing search.

RFTA Submission

RFTA Processing

RFTA Processing

  Veteran or VA case manager submits

  HACLA offers walk-in hours daily (8–11

  Veterans or HUD-VASH staff can submit

RFTA to housing authority.

am, 1–3 pm) where RFTA can be

RFTA to HACoLA offices in-person

submitted or it can be faxed or e-mailed.

Monday–Friday.

Inspection & Rent Negotiation

Inspection Scheduled

Rent Negotiation & Inspection

  HACLA eligibility interviewer contacts

Scheduled

property owner to schedule inspection

  HACoLA determines rent offer.

within 2 days of RFTA submission;

  HACoLA contacts property owner to

inspection scheduled for 3 days from date

negotiate rent.

of contact.

  HACoLA schedules inspection, typically

within 10 days.

File Updated

Inspection

  HACLA eligibility interviewer updates file,

including property ownership and internal

rent comparables.

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Appendix F: Los Angeles Site Description

VA Case Management

Housing Authority of the City of Los

Housing Authority of the County

Angeles (HACLA)

of Los Angeles (HACoLA)

Inspection

Reinspection

  HACLA inspector completes inspection and    If unit fails inspection, HACoLA

uploads results into HACLA system.

inspector schedules reinspection while

  Inspection clerk uploads comparables  into

at the property

system.

  Inspection results and comparables are

available to the eligibility interviewer

within 3 days of inspection. Once obtained,

the eligibility interviewer forwards file to

contractor.

Reinspection

  If unit fails inspection, HACLA inspection

department contacts property owner to

schedule reinspection, allowing for any

repairs/deficiencies to be address by

owner.

  When failed results are viewed, the

eligibility interviewer calls owner and

schedules reinspection. Owner will dictate

when the reinspection can take place.

Rent Offers

  HACLA eligibility interviewer contractor

determines rent offer and contacts

property owner to negotiate rent and start

date of the lease.

  HACLA elibility interviewer contractor

contacts Veteran to inform that  s/he

should meet with owner to sign lease.

HAP Contract & Lease

Lease Review

Execution of Lease

  Property owner sends HACLA eligiblity

  HACoLA asks Veteran and property

interviewer lease for review.

owner to sign lease with move-in date.

  HACLA eligibility interviewer approves

lease.

Execution of HAP Contract & Lease

Lease Review

  Veteran signs lease with property owner

  HACoLA reviews lease and drafts HAP

and submits a copy of the lease to HACLA.

contract.

  HACLA draws up HAP contact once lease is

received from property owner.

  Contracting  elibility interviewer generates

HAP contract and mails it to the owner for

signatures.

  HACLA receives signed HAP contract and

processes it for payment.

Execution of HAP Contact

  HACoLA schedules inspection once HAP

contract is completed. If inspection

passes, Veteran is able to sign lease that

day and a copy is sent to Housing

Authority.

Move-In

Move-In Assistance

  Veterans may be referred to SSVF, if

funds are available, or to other

community agencies. AmVets assists

with furniture, and offers free delivery,

as well as vouchers for their thrift store

and food, but requires 30 days or more

for processing.

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APPENDIX G:

PALO ALTO SITE DESCRIPTION

The Palo Alto HUD-VASH

program operates in the following

counties: Alameda, Monterey, San

Mateo, San Joaquin, Santa Clara,

Santa Cruz, and Stanislaus. The

coordinating VA site is the VA

Palo Alto Health Care System in

Palo Alto, CA. The HUD-VASH

program has 1,478 vouchers. The

majority of vouchers are held by

the Housing Authority of the

County of Santa Clara (HACSC,

740) and the Housing Authority of

Monterey County (HACM, 199).

HACSC serves Santa Clara

County, including the urban area

around Santa Jose. HACM serves Monterey County, the southernmost part of the Palo Alto

catchment area, including Salinas and many coastal and rural areas.

Housing Context

The following maps provide context for the housing markets in which Veterans participating in

the Palo Alto HUD-VASH program conduct their housing search.

Map 1 outlines low, very low, and

extremely low income areas based

on median county income. There

are few extremely low income

areas in Palo Alto. Those that exist

are near San Jose (near the

intersection of Alameda and Santa

Clara Counties), north of

Sacramento (San Joaquin county),

and the eastern section of

Stanislaus County. Monterey

County also has some lower

income areas in the southern and

eastern parts of the county. There

is little overlap between VAMCs,

other Vet Centers, and CBOCs or

housing authorities and low

income areas.

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Appendix G: Palo Alto Site Description

Map 2 depicts median gross rent by

quartile; the darkest areas have the

lowest rent. The areas with the lowest

median rent are typically in more rural

areas, away from city centers. It is clear

from this map that Alameda County and

most areas in Santa Clara County have

higher median rents.

Map 3 provides details on the rental

vacancy rate by quartile. Darker areas

have lower vacancy rates. The darkest

shade in Palo Alto indicates a vacancy

rate of zero, meaning there is essentially

no available housing in these areas.

Further, urban areas have low vacancy

rates, while rural areas have more

vacancies.

VA Case Management

The Palo Alto HUD-VASH staff includes supervisors, social workers, VA case managers, SUD

specialists, housing specialists, peer support specialists, program support specialists, and a

recreational therapist. The case load is 1:28. VA staff are divided among five teams at eight

locations.

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Appendix G: Palo Alto Site Description

Team

Associated Housing

Authority

Service Location

Team Composition

Community and

1 supervisor

Alameda

Housing Authority of the County

of Alameda (HACA)

VAMC Fremont

6 VA case managers

CBOC

1 housing specialist

Central

Community and

1 peer support specialist

Valley

San Joaquin

Housing Authority of the County  VAMC Stockton

1 SUD specialist

of San Joaquin (HACSJ)

CBOC

Community and

Stanislaus

Housing Authority of the County

of Stanislaus (HACSTAN)

VAMC Modesto

CBOC

1 supervisor

8 VA case managers

1 housing specialist (shared with

San Jose)

Community and

Menlo Park

Housing Authority of the County

1 peer support specialist

of San Mateo (HACSM)

VAMC Menlo Park

Campus

2 program support specialists

1 SUD specialist (shared with San

Jose)

1 recreational therapist (shared

with San Jose)

1 supervisor

7 VA case managers

1 housing specialist (shared with

Community and

Menlo Park)

San Jose

Housing Authority of the County

1 peer support (shared with Menlo

of Santa Clara (HACSC)

VAMC San Jose

CBOC

Park)

1 SUD specialist (shared with

Menlo Park)

1 recreational therapist (shared

with Menlo Park)

1 supervisor

5 VA case managers

1 housing specialist (shared with

Santa Cruz

Housing Authority of the County  Community and

of Santa Cruz (HACSCUZ)

VAMC Capitola Clinic  Monterey)

1 peer support specialist

1 SUD specialist (shared with

Monterey)

1 supervisor

5 VA case managers

Community and

1 housing specialist (shared with

Monterey

Housing Authority of the County

of Monterey (HACM)

VAMC Monterey

Santa Cruz)

CBOC

1 peer support specialist

1 SUD specialist (shared with Santa

Cruz)

OUTREACH

Urban Region (Menlo Park & San Jose Teams)

In the urban areas around the Palo Alto VAMC, Veterans are referred to HUD-VASH by other

facilities, including medical centers, the residential programs in Menlo Park, and the Homeless

Veterans Rehabilitation Program (HVRP). Staff at the VA mental health clinics, emergency

rooms, and other social workers refer Veterans to the program, including chronically homeless

Veterans. Veterans may also receive referrals from homeless shelters, Health Care for Homeless

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Appendix G: Palo Alto Site Description

Veterans (HCHV) and Grant and Per Diem (GPD) programs in five sites around San Jose as well

as other community-based organizations. Chronically homeless Veterans often self-refer to the

program.

Veterans also learn about the HUD-VASH program through word of mouth. Additionally, they

may attend a weekly housing resource group in Menlo Park and San Jose, which is designed to

help any Veteran with a housing issue to access resources. Veterans learn about this group from

the National Call Center for Homeless Veterans and from widely distributed flyers. Veterans

who attend this group may request a referral to HUD-VASH.

Central Valley (Alameda, San Joaquin & Stanislaus Teams)

In the Central Valley, the HUD-VASH program receives referrals through weekly drop-in hours

offered at HACSJ where staff screen individuals for eligibility for HUD-VASH. They also

receive referrals through GPD and local homeless shelters. The local Salvation Army also refers

Veterans to HUD-VASH.

Coastal Region (Santa Cruz & Monterey Teams)

In the coastal areas south of Palo Alto, the VA case management team receives referrals from

VA providers and social workers as well as community partners. Veterans in this area can also

attend Housing Resource Groups: one group is offered weekly in Santa Cruz at the Veterans

Center, and two are offered once a week in Monterey.

Doctors and HCHV programs in Santa Cruz often refer Veterans to HUD-VASH during drop-in

harm reduction groups. Weekly events are also held in Santa Cruz at the Veterans Memorial

Building. During these events Veterans access medical care through a VA medical mobile

outreach unit, get food and supplies such as tents, and see a Veteran advocate and Veteran

Service Officers. HUD-VASH staff are also on hand for outreach. Further outreach includes

visits to areas with high rates of homelessness at least monthly.

REFERRALS AND ELIGIBILITY

Though each VA case management team may follow a different day-to-day agenda based on the

vast variety of people, services, and locations included in the service area, there is a general

procedure for referrals. A standard form is used to refer all Veterans within the Palo Alto service

area to HUD-VASH, regardless of whether they are referred through social workers, a VA

treatment program, residential program, or other community programs. The referral is designed

to capture the Veteran’s current housing status, homeless history, vulnerability, and income.

TARGETING

Because the demand for vouchers exceeds their supply, the VA teams maintain an interest list,

with priority given to chronically homeless Veterans and those with the greatest number of case

management needs. The VA teams also target vulnerable Veterans, including Veterans with low

income and significant medical, mental health, and/or substance use issues, putting them at

greatest risk for death on the street. The VA team uses a standard matrix, similar to the Arizona

Self-Sufficiency Matrix, which assesses risk level in the following domains: housing, basic

needs, physical health, family/social issues, substance abuse, mental health, and finances.

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Appendix G: Palo Alto Site Description

Additionally, the VA teams pay special attention to female, elderly, disabled, OIF, OEF, OND

Veterans as well as families.

Palo Alto defines chronic homelessness in accordance with the HEARTH Act definition; the

criterion for a homeless occasion is at least 7 days.

REFERRAL AND ADMISSION

VA support staff add referral details to a spreadsheet, including Veterans’ living area preference.

All VA case managers can access this spreadsheet. Individual VA case management teams are

responsible for screening Veterans who fall within their area of purview to determine each

Veteran’s level of homelessness and need. Each of the teams uses a standard screening template

to verify the information contained in the referral form and prioritize their interest list. A

standard matrix is used to determine which Veterans are most in need of VA case management.

Urban Region (Menlo Park & San Jose Teams)

The Menlo Park and San Jose teams offer rolling screenings and admissions to HUD-VASH. VA

case managers rotate weekly to conduct screenings. If demand for vouchers among chronically

homeless Veterans exceeds supply, the VA case management team consults the matrix to

determine which Veterans should be invited to participate in HUD-VASH. VA case managers

inform prioritized Veterans of the documents necessary to complete the voucher application and

schedule an intake meeting to complete the initial HUD-VASH paperwork.

Central Valley (Alameda, San Joaquin & Stanislaus Teams)

In the Central Valley the VA case management teams conduct screenings in person. The

screenings may be with an individual VA case manager or the entire VA team and are conducted

during a weekly drop-in time, which is communicated to the community, housing authorities,

and homeless Veterans. The steps involved after this screening differs depending on where the

Veteran is interested in living and the housing authority affiliated with that area.

Coastal Region (Santa Cruz & Monterey Teams)

In Monterey, one VA case manager is responsible for all screenings, while in Santa Cruz,

screenings are assigned among individual VA case managers. After the Veteran verifies the

information on the referral form and is deemed eligible, s/he is either invited to attend an

admission group where initial HUD-VASH paperwork is completed or is added to the interest

list and contacted by a VA case manager when a voucher is available. If a Veteran is unable to

join the admission group, individual processing can be completed.

VOUCHER APPLICATION

Urban Region (Menlo Park & San Jose Teams)

Veterans in Menlo Park and San Jose must attend a group or individual orientation that lasts one

to two hours. The orientation covers the HUD-VASH program basics, FAQs, and support

services that are available, such as transportation. Veterans sign a program agreement and are

assisted with completing the voucher application. Voucher applications vary by housing

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Appendix G: Palo Alto Site Description

authority. A VA case manager or other HUD-VASH staff submits the application directly to the

housing authority, usually through fax or email.

When the application is accepted, the housing authority schedules a voucher briefing with the

Veteran. Originally, HACSM scheduled two meetings with Veterans—one to complete the

application materials and one for the voucher briefing—but VA staff are working with the

housing authority to limit this contact to one meeting. HACSC holds one meeting with Veterans

for the voucher briefing.

Central Valley (Alameda, San Joaquin & Stanislaus Teams)

Once a Veteran is admitted to HUD-VASH in the Central Valley, the application process varies

for each housing authority.

Alameda

The VA case management team gives Veterans a list of required documents during the in-person

screening and schedules them for a HUD-VASH orientation. During the orientation the VA case

manager provides an overview of the program and assists the Veteran with completing the voucher

application. The VA case manager delivers the application in-person to HACA. The housing

authority contacts the VA case manager about any missing paperwork or, once the application is

processed, to set up a voucher briefing one to three weeks after the application is submitted. The

voucher briefing includes an orientation, which the VA case manager usually attends with the

Veteran. HACA does not expedite the application process for HUD-VASH applicants but they are

flexible in assisting Veterans (e.g., allowing them to sign letters attesting to their identity in lieu of obtaining certain identifying documents).

San Joaquin

During the in-person screening, VA case managers provide Veterans with the voucher application

and schedule a meeting for the following week to review the completed packet. The VA case

manager ensures that the Veteran understands the program rules and has completed all application

materials. The Veteran submits the application to HACSJ; VA case managers often walk over to

the housing authority with the Veteran or follow-up to ensure the application has been submitted.

The housing authority processes the application in one to three weeks; if they find any

discrepancies, they will contact the Veteran and/or the VA case manager. HACSJ can be flexible

and will not delay the voucher issuance if the Veteran is missing one piece of documentation.

Instead, the housing authority will ask that the Veteran bring any missing documentation to the

voucher briefing. Following the housing authority’s review of the application, the Veteran attends

a voucher briefing at HACSJ. HUD-VASH applicants are typically processed alongside other

HCV applicants.

Stanislaus

The Veteran sets up an appointment with the HACSTAN; the VA case manager does not attend

this meeting but the housing authority has a staff member dedicated to HUD-VASH. The housing

authority informs the Veteran of the documentation necessary to bring to the meeting. During this

meeting the housing authority offers an orientation to the program and assists the Veteran in

completing the voucher application. If all the paperwork is in place, the Veteran may receive

his/her voucher at that time, but it typically takes a week or less to receive the voucher. HACTSAN

expedites HUD-VASH vouchers.

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Coastal Region (Santa Cruz & Monterey Teams)

Both VA case management teams in the coastal region work with Veterans to complete the

voucher application but processes differ across the VA case management teams and housing

authorities.

Santa Cruz

VA case managers assist Veterans in completing the voucher application during a second meeting

after an initial orientation. Since the voucher application used by HACSCRUZ is very extensive,

the VA case manager provides the Veteran with one-on-one attention. When the application is

complete, it is submitted to the housing authority and the Veteran schedules an initial appointment

to review and verify the paperwork. Following this initial appointment, the Veteran schedules a

voucher briefing with HACSCRUZ that includes an orientation about the housing authority’s rules.

The housing authority meetings are scheduled individually with a HACSCRUZ specialist, who is

not specific to HUD-VASH. The assigned VA case manager assists the Veteran by arranging

transportation and offering support.

Monterey

Veterans who work with the Monterey VA team are informed in advance of the group admission

meeting what documentation is required for the voucher application. If the Veteran brings the

required documents to this meeting, the VA case manager completes a pre-application for HUD-

VASH and submits it to HACM. A VA case manager attends every HACM meeting with the

Veterans; since VA case managers are assigned to attend this meeting on a rotating basis, this VA

case manager may not be the Veteran’s long-term VA case manager. This strategy ensures that

Veterans are introduced to a number of VA case managers, though if a particular Veteran needs

additional help, the assigned VA case manager will also attend. The housing authority meetings are

held weekly at a set time with a HACM staff member specific to HUD-VASH.

HOUSING SEARCH

Urban Region (Menlo Park & San Jose Teams)

Both VA case management teams in the urban region share a VA housing specialist who is

responsible for identifying properties and troubleshooting housing issues. A VA peer support

specialist offers weekly start-up groups that cover housing issues such as credit and interview

strategies. The curriculum rotates, and Veterans are required to attend at least four sessions to

become well-versed in different areas. Both teams also offer ride-alongs three times per week,

during which they visit units from the housing authority lists; online searches; cold phone calls;

or information on units that the teams have learned about through word of mouth. The VA case

managers also organize ride-alongs with a more narrow focus, such as senior housing or a certain

number of rooms, to save Veterans time.

The Menlo Park and San Jose VA case management teams have relationships with property

owners and property management companies that inform them in advance about open units.

Some waive Veterans’ application fees and are also flexible with credit and background checks,

which the VA case managers particularly value. Although these units are often not the most

desirable, these residences can serve as a last resort for Veterans who have had an eviction, credit

issues, or felonies.

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VA case managers describe the biggest housing issues for Veterans in the urban region as the

tight housing market and amount of rent that the voucher will cover. The market is inhibiting

lease-ups because there has been an increase in technological jobs in the area but not an increase

in housing stock. Therefore, property owners often want more than the payment standard offered

by the housing authorities. The housing authorities determine if the unit is worth more than the

standard, but the Veteran is then expected to pay the additional portion on his/her own, which

may not be possible. HACSM allows Veterans to pay up to 50% of their income, while HACSC

allows Veterans to pay up to 40%.

Central Valley (Alameda, San Joaquin & Stanislaus Teams)

One VA housing specialist works across the Central Valley. The VA housing specialist finds

units through online searches, relationships with property owners who notify the VA when units

that can accept a voucher are open, and by talking to anyone with “Apartments for Lease” signs.

The VA peer support specialist conducts weekly group ride-alongs to housing located by the VA

housing specialist. The VA housing specialist also meets with Veterans weekly in San Joaquin

County and calls to touch base with the Veterans in Alameda and Stanislaus Counties to share

new listings. For the first 30 days following voucher issuance, Veterans are encouraged to take

the initiative to determine what type of housing they want and where, and meet with property

owners. After 30 days the VA case manager provides additional assistance.

The ability to secure affordable housing varies by area: it is easy to find housing in Modesto in

Stanislaus County, a bit more difficult in San Joaquin County, and very difficult in Alameda

County as the voucher is about $550 per month less than the lowest rents. The cost of living has

also increased there recently, but the voucher value has not changed. There is additional

difficulty housing Veterans through the HACSJ because the VA case managers are unaware of

how the voucher dollar amount is determined and there are large variations in the amounts

generated for Veterans at the same income level. Other housing authorities offer standard

amounts based on income level so Veterans can begin their housing search as soon as they have

been accepted into the program, while Veterans housed through HACSJ must wait until the

voucher amount is confirmed.

Coastal Region (Santa Cruz & Monterey Teams)

Monterey and Santa Cruz share a VA housing specialist who offers weekly startup groups

designed to help Veterans prepare for their housing search by filling out a sample application,

obtaining their credit reports, and identifying the type of unit they want. The VA housing

specialist assigns homework to help Veterans begin their housing search. The VA housing

specialist and VA peer support specialist offer weekly housing searches tailored to Veterans’

preferences. They visit property owners familiar with the program, units on the housing authority

lists, Craigslist units, and units they hear about from individuals they have worked with in the

past. These trips have been successful in getting Veterans housed, and particularly in helping

Veterans to consider a wider range of locations and options. Individualized housing searches can

be arranged for rural areas, Veterans who cannot handle groups, and other special circumstances.

In this region, although Veterans are given an initial 120-day timeframe to find housing, they are

encouraged to find housing within the first 60 days.

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INSPECTION

Urban Region (Menlo Park & San Jose Teams)

As soon as the Veteran submits the RFTA the housing authority schedules an inspection, which

occurs one to four weeks later. Units that take longer typically have not yet been vacated by a

previous tenant, and inspections cannot be scheduled until the unit is empty. If the unit is

available immediately the property owner can request that the housing authority prioritize the

inspection and schedule it within a week. If a unit fails inspection, another week is usually added

to the process. VA case managers request that the Veteran attend the inspection so that s/he can

sign the lease immediately afterwards.

Central Valley (Alameda, San Joaquin & Stanislaus Teams)

The Central Valley VA case management teams have discussed deputizing the VA housing

specialist in San Joaquin County to complete inspections. Currently, only the housing authorities

are completing the inspections, which can take from one day to a week with HACSTAN, one to

two weeks with HACA, and up to four weeks with HACSJ. Housing authority staffing issues can

hinder the completion of inspections in a timely manner. Specifically, housing authorities with

few staff do not have coverage if an inspector is out; at housing authorities with multiple

inspectors, the inspector completing a reinspection may notice an issue the first inspector did not.

These problems complicate the inspection process and can prolong the housing process.

Coastal Region (Santa Cruz & Monterey Teams)

Preinspections are rare, although they sometimes occur at senior housing complexes where an

inspector can evaluate multiple units at once. The standard procedure is for the unit to be

inspected following the submission of the RFTA, typically within seven to 10 days and can be

expedited if necessary. Property owners who would like to expedite the inspection contact the

housing authorities directly. If a unit requires a reinspection, it is usually completed within one

or two days of the property owner confirming the repairs have been made. Inspectors at the

HACM usually give the unit a passing grade unless it is dangerous or unlivable. However, the

inspectors recommend repairs to units that have passed inspection, which the property owners

must complete. Veterans can move in the day their units pass inspection.

MOVE-IN

All VA case management teams rely on local SSVF programs and other community

organizations and government agencies for move-in assistance. Some Veterans can afford to pay

the deposits on their own, usually because of back pay on benefits or Social Security.

Each of the VA teams described the difficulty of finding a consistent source for furniture,

especially beds, as well as transportation to deliver furniture. The Coastal Region VA teams

obtain beds from the Veteran Resource Center, which purchases them in bulk, and household

items from the local GPD program. Additionally, a local facility has a large warehouse and

invites graduates from Veterans Transitional Center in Monterey to take any items that they may

need. The Veterans Transitional Center is a community-based agency that provides Veterans

with transitional housing, emergency services, and case management. VA case managers have

also been known to fill their cars with donations from the local community.

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VA CASE MANAGEMENT

The following table describes VA case management requirements:

During housing

process

Weekly face-to-face meeting

Year 1

Minimum monthly home visits, more as needed based on acuity

Year 2+

Minimum monthly home visits, more as needed based on acuity

Urban Region (Menlo Park & San Jose Teams)

Veterans are assigned a VA case manager when they enroll in HUD-VASH, usually the case

manager who completed the Veteran’s admission. Veterans who enroll through a group

admission are quickly assigned individual case managers. During the housing process, case

managers check in with Veterans at least weekly, preferably in person, and by telephone if

necessary. The teams also conduct monthly in-person check-ins with unhoused Veterans. The

VA case management teams provide a group where Veterans can discuss and address their

housing barriers with case managers and other Veterans, renew motivation for the housing

search, and be reminded that they have a finite amount of time to find a unit. After Veterans are

housed, most meetings take place in the Veterans’ homes, typically on a monthly basis, unless

more frequent visits are needed.

Central Valley (Alameda, San Joaquin & Stanislaus Teams)

Veterans must meet with their VA case managers face-to-face once a week during the housing

process. Veterans may attend a weekly Housing Resource Group meeting—in lieu of a VA case

management meeting—with a VA housing specialist, VA SUD specialists, and the VA case

management team. Veterans who have been housed typically meet with their VA case managers

monthly in their homes but they may also meet at the case manager’s office or attend community

meetings led by one of the VA SUD specialists. All VA case management teams also assist

Veterans during the annual recertification process.

In San Joaquin, attendance at weekly advanced group meetings is required for Veterans who are

not yet housed. These meetings, led by VA case managers with assistance from VA peer support

specialists, address topics such as anger management, budgeting, goal setting, and other basic

life skills. After Veterans are housed their attendance is no longer required, but many Veterans

continue to participate to learn new skills and socialize with other Veterans.

In Stanislaus, VA SUD specialists also build rapport with GPD participants, as those Veterans

often transition to the HUD-VASH program.

Coastal Region (Santa Cruz & Monterey Teams)

The Santa Cruz VA case management team has office space but is based primarily in the field

and tends to meet with Veterans in the community, typically at the Veterans Memorial Building.

The Monterey VA case management team operates out of the VA clinic in Monterey, which

serves as the center of the HUD-VASH program.

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VA case managers hold weekly VA case management meetings when a Veteran is in the early

stages of the program; however, the frequency of meetings decreases over time. Before a Veteran

is housed, s/he must meet with his/her VA case manager a minimum of once a month, but VA

case managers will maintain the frequency at once a week if needed. VA case managers connect

Veterans to appropriate healthcare services and other necessities. Sobriety is not a program

requirement, but Santa Cruz VA case managers inform Veterans of harm reduction groups in the

community and the Monterey VA case management team offers SUD groups. The Santa Cruz

VA case managers also hold a monthly group meeting for all Veterans where they provide

snacks and coffee, discuss resources, and socialize. Attendance is encouraged, especially for new

members of the program who have the opportunity to speak to peers who have successfully

found and maintained housing.

The Palo Alto teams utilize the following evidence-based practices: Assertive Community

Treatment, Cognitive Behavioral Therapy, Harm Reduction, Motivational Interviewing, Twelve

Step Facilitation, Peer Support/Mentoring, Supported Employment, and Housing First.

PORTS

Porting within the housing authorities in the Palo Alto service area is much easier than porting to

an outside location covered by a different VA case management team. However, porting is rare

given the large catchment areas covered by the housing authorities.

REASONS FOR EXITS

Leased-Up Exiters

The VA case management teams identified a number of reasons why Veterans may exit HUD-

VASH after leasing a housing unit:

•  Incarceration—If the incarceration is short-term, the VA case management teams will

work with the Veteran, but if the Veteran is incarcerated for a longer period of time, the

program must discharge the Veteran.

•  Readiness—Successful housing is related to a Veteran’s motivation and comfort living

alone in an unstructured environment. After leasing housing, Veterans may realize that

they want or need a higher level of support, particularly those with medical or mental

health issues or active SUD. Not being able to maintain housing is not always considered

a failure because each Veteran needs to be in the right place at the right time. Though

atypical across housing authorities in the service area, HACSJ is very flexible with

Veterans who are away from their housing for mental health treatment, allowing Veterans

to seek treatment for up to six months, at which point they may be ready to live

independently.

•  Withdrawal—Veterans may move, opt out of the program, seek a residential assistance

program or rehabilitation, or are no longer interested in participating in HUD-VASH.

•  Loss of contact

•  Increases in income

•  Death

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Nonleased Exiters

The VA case management teams identified a number of reasons why Veterans may leave the

HUD-VASH program after they have received a voucher but prior to obtaining a housing unit:

•  Increases in income—If a Veteran becomes over-income, s/he is no longer eligible for

rental assistance.

•  Challenging process—Veterans may be overwhelmed by the paperwork and bureaucracy

involved in enrolling in the program and finding housing. Chronically homeless

Veterans, some of whom have been living on the streets for 10 to 20 years, can become

easily overwhelmed by the program requirements.

•  Loss of contact—Veterans’ vouchers often expire if the VA case managers cannot locate

the Veterans.

•  Personal history—Veterans may encounter multiple housing application rejections based

on bad credit or other background characteristics and become discouraged.

•  Serious mental illness and SUD—Veterans with mental and behavioral health issues are

often difficult to track and maintain in the program.

•  Motivation—Veterans may not be motivated to do what it takes to get housing but do not

want to sacrifice the voucher.

•  Incarceration

VETERANS IN CRISIS

VA case managers attempt to get a signed release of information with everyone in close contact

with Veterans, including property owners, the housing authority, family members, and clinicians.

This allows VA case managers to learn about crises from these individuals and assist Veterans.

Other HUD-VASH Veterans may also indicate that a fellow Veteran is having issues, but

Veterans and VA case managers must handle these admissions with care because of

confidentiality rules.

VA case managers described many of the housing authorities as being flexible for Veterans with

housing issues, often granting them additional time to address problems. Housing authorities

avoid evictions if at all possible, and most have never had to deal with evictions among Veterans

in HUD-VASH. For example, HACSJ tries to avoid eviction by working with the property owner

and discussing with the Veteran the availability of additional services or a representative payee.

GRADUATION

A Veteran may graduate from HUD-VASH case management after one year of successful

independent living, agreement between the Veteran and the case manager that the Veteran has

met his/her goals, and the Veteran no longer requires HUD-VASH case management services to

maintain independent housing. Veterans who graduate retain their HUD-VASH voucher and are

not transferred to the regular HCV Program. Though regular VA case management contact ends

at graduation, VA case management is still available if needed.

VA case managers throughout the Palo Alto service area stated that many Veterans are in need of

long-term VA case management. The Central Valley teams pointed out that graduation is not

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Appendix G: Palo Alto Site Description

necessarily their goal for most Veterans, because they understand that many Veterans in HUD-

VASH may need VA case management to stay housed. This team admits that most of the

chronically homeless Veterans need much more intensive VA case management, so they often do

not graduate in a year, if at all. Serious mental health issues also make the VA case managers

reluctant to stop VA case management. Finally, even those who appear ready for graduation may

opt to retain VA case management.

COMMUNICATION BETWEEN AGENCIES

Urban Region (Menlo Park & San Jose Teams)

The VA case management teams working with HACSM and HACSC describe communication

with the housing authorities as challenging. The VA case managers believe this stems directly

from staff cuts at the housing authorities—they are trying to do more with fewer people. The

housing authorities no longer update the VA case managers as routinely because they seem

administratively overwhelmed.

San Mateo

HACSM prefers that VA case managers attend pre-voucher meetings with Veterans. However, the

scheduled meeting time is often unclear or during a time that the VA case manager is unavailable.

The gaps in communication about scheduling have made it difficult for VA case managers to assist

Veterans.

Santa Clara

VA case managers have a phone meeting with HACSC every Wednesday morning to review

issues and answer questions. They also have quarterly in-person meetings. VA case managers feel

that it is still difficult for the housing authority to keep up with communications regarding all of

their cases due to the large size of the program.

Central Valley (Alameda, San Joaquin & Stanislaus Teams)

The supervisor meets with each of the housing authorities quarterly, but they usually

communicate more frequently. The increase in frequency is especially true recently, because the

housing authorities are applying for project-based allocations.

Alameda

The VA case management team does not have scheduled appointments with HACA but VA case

managers have one point of contact at the housing authority and can reach out for assistance if

needed; the housing authority is very responsive. Likewise, the housing authority can always get in

touch with VA case managers.

San Joaquin

VA case managers collocate at HACSJ every Tuesday from 9 am to11 am and hold meetings with

Veterans in their building. This has created a very supportive relationship with HACSJ staff, and

VA case managers have access to them any day of the week.

Stanislaus

VA case managers meet with HACSTAN several times per week. Communication is less frequent

when all Veterans are housed. Overall, the VA case managers described having a very good

relationship with the housing authority.

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Coastal Region (Santa Cruz & Monterey Teams)

Santa Cruz

The VA case managers communicate with the HACSCUZ on a biweekly basis.

Monterey

The Monterey VA case management team and HACM hold quarterly meetings. VA case managers

indicate that these meetings have improved efficiency and communication, even if they have not

sped up the housing process. One challenge cited by the VA case managers is a lack of

communication following a Veteran’s RFTA submission. Though the housing authority usually

responds to the request within two weeks, the VA case managers do not hear from the housing

authority until the inspection, which can be frustrating for the Veteran and property owner.

FACILITATORS OF HOUSING SUSTAINABILITY

The Palo Alto VA case management team identified a number of facilitators of housing

sustainability for Veterans in the HUD-VASH program:

•  Organization—The Daily Management System, a Lean Management organizational

model recently implemented at the Palo Alto VA, has helped them better organize their

program and increase teamwork. Daily huddles allow the team to share resources.

•  Specialized staff—The increase in support for VA case managers through specialized

roles, such as VA peer support, VA SUD specialist, and VA housing specialists, has

allowed VA case managers to better serve the Veterans on their large case loads. It has

also enabled the program to access more resources and build better relationships in the

community.

•  Housing sustainability focus—The teams also credit their success to their focus on

housing sustainability. They work with each Veteran individually to better target each

person’s needs. Motivational Interviewing has been effective in helping Veterans believe

that they can be housed. Additionally, Veterans who have been discharged from the

program and have lost their vouchers are placed back on the interest list so they can

return to the program when they are ready. The VA case managers understand that some

Veterans may need multiple chances.

•  Groups—Many of the activities that the VA case management teams offer help Veterans

get and stay housed. Through group housing searches VA case managers and Veterans

are able to meet each other and share stories and advice. Likewise, housing groups allow

unhoused Veterans to discuss their barriers and learn from each other.

•  Connection to resources—Community resources are key to the Palo Alto HUD-VASH

program. Community-based organizations are integral to every step of HUD-VASH,

from identifying homeless Veterans through outreach efforts, to providing medical and

transportation services and financial move-in assistance.

BARRIERS TO HOUSING SUSTAINABILITY

Veterans in the Palo Alto region face a number of challenges to accessing and sustaining

permanent housing, including the following:

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•  Lack of affordable housing—There is a shortage of available housing across the region

served by the Palo Alto VAMC, as well as a lack of property owners willing to accept

HCVs, given that the housing authority payment standards do not reflect the market value

of area rentals. The technology industry continues to create jobs in the area but there is

insufficient housing to meet the demand, and the demand for housing has effectively

priced low income earners out of the market. While rent continues to rise, there is no plan

to increase the already low level of the housing authority payment standards. In practice,

this translates to VA case managers encouraging Veterans to accept any unit they can

find and get on a waiting list for a complex that accepts HCVs so they can move into a

better unit in the future. Those who are unable to find a unit in the tight housing market

may give up.

•  Financial issues—Lack of funding for move-in assistance is a challenge in Palo Alto.

While a Veteran with no income can be approved for HUD-VASH, community partners,

including SSVF, are not required to provide move-in assistance. Since a Veteran with

zero income cannot prove that s/he can sustain payments, many organizations do not

want to provide move-in assistance.

•  Motivation—Ambivalence on the part of the Veteran is a significant hurdle to overcome.

VA case managers stated that Veterans express disbelief that they will be able to access

housing and are therefore only willing to make a minimal commitment to the program.

•  Readiness—Some Veterans may not be ready for independent housing or may not be able

to afford it. VA case managers indicated that, given their Housing First approach, they

are not working on housing readiness issues. As they enroll more chronically homeless

Veterans, this becomes an increasing challenge.

•  Personal history—Veterans with poor credit scores often have difficulty finding a

property owner who will rent to them. Veterans who are frequently denied housing due to

their background may become discouraged by the process.

•  VA program regulations—The VA case management teams said that HUD-VASH can

seem mechanized given all of the paperwork and data entry VA case managers are

expected to complete. It can become difficult to balance the clinical side of the VA case

management with the rules, regulations, and expectations of the program.

•  Staffing concerns—Finding qualified staff can be an issue, particularly because the cost

of living in the service area is so high; as a result, teams are often understaffed.

•  Mental illness

•  SUD

PROCESS IMPROVEMENTS / RECOMMENDATIONS

The Palo Alto VA case management teams had many concerns related to funding. First, the VA

teams would like to see SSVF expand to all counties in the service area. Additionally, the VA

teams would like the allocations to be larger for SSVF so these agencies do not run the risk of

expending all of the assistance available for Veterans in HUD-VASH. It would also be helpful if

SSVF funds could be used for application fees, particularly for Veterans with zero income or no

savings.

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The teams also recommended a cost of living allowance for expensive housing markets, such as

Alameda, as they are struggling to house Veterans in these expensive areas. Furthermore, they

suggested having each voucher allocation come with a set amount of funds to be used for move-

in expenses, ideally an amount equal to the area’s median rent.

In areas where it can take a long time to schedule inspections, such as San Joaquin County, it

would be helpful if VA housing specialists could conduct inspections. In some areas, it is

estimated that this could cut three to four weeks off of the lease-up time.

VA case management teams reiterated the benefit of Motivational Interviewing. They said it has

been useful for important issues ranging from substance abuse to housing to Veteran

ambivalence. VA teams suggested further training to enable VA case managers to become more

proficient with this technique.

Housing Authority of the County of Santa Clara

HACSC has four staff who work with HUD-VASH Veterans: a housing programs manager, two

intake specialists, and two housing specialists. Details on HACSC’s voucher issuance and

payment standards are shown in the table below:

Payment Standard

None specified

Portion of Rent that is Veteran’s

Responsibility

35%

Initial Voucher Issuance Period  120 days

Veterans are served by HACSC staff at the housing authority. HACSC prioritizes HUD-VASH

and codes the applicant files so that so that all workers, from clerks to inspectors, are aware of

their priority status. HACSC has been designated by Congress as a HUD Moving to Work

(MTW) Agency, which provides them with flexibility to modify certain HUD regulations to

streamline their programs.

VOUCHER APPLICATION

HACSC has a designated email/fax inbox for HUD-VASH referrals. VA case management

teams submit applications through this mechanism and the HACSC housing programs manager

forwards them to the assigned specialist within the housing authority. After reviewing the file

and ensuring that the Veteran meets program eligibility criteria, the specialist contacts the

applicant and VA case manager to schedule an intake and inform them whether additional

documents are needed. During the intake meeting, the HACSC specialist reviews the materials

with the Veteran and VA case manager.

HACSC offers VA case managers trainings so that they can complete most of the voucher

application in advance of the intake meeting. During the trainings, the housing authority guides

VA case managers through the HACSC process, including filling out the application, reviewing

the materials, determining eligibility, and explaining income limits, criminal and other

background information, and qualifying and disqualifying criteria. Thanks to these efforts, the

application packet is usually complete when it reaches the housing authority.

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VOUCHER BRIEFING

The Veteran is scheduled for a voucher briefing after the intake meeting. Although the briefing is

a separate appointment from the intake meeting, it is usually scheduled for the same day.

Typically, the VA case manager attends this meeting with the Veteran. During the briefing,

HACSC staff provide the Veteran with additional housing information, the voucher, and RFTA

materials. Voucher briefings usually take place with a group of Veterans.

HOUSING SEARCH

The housing search is generally the responsibility of the Veteran and the VA case management

team. However, HACSC provides HCV listings and online resources to the Veteran and shares

information about available properties with the VA housing specialist. Once the Veteran finds a

property s/he is interested in renting, the property owner completes the RFTA. Usually, the VA

case manager or Veteran, or sometimes the property owner, submits the completed documents to

the HACSC leasing team. An HACSC inspector reviews the documents to determine the

affordability of the rent, review the property ownership, and evaluate rent comparables. Once

this review is complete, a HACSC clerk contacts the property owner to schedule an inspection.

Since HACSC is a MTW site, they have modified the amount of rent for which clients are

responsible; HUD-VASH participants must cover 35% of the rent.

INSPECTION

It generally takes about three days from submission of the RFTA to the inspection. A HACSC

clerk emails the VA case manager regarding the scheduled inspection time. If a unit passed

inspection within the last 30 days but was not rented, HACSC will accept the prior inspection;

however, if it has been more than 30 days, the unit has to be reinspected.

HAP CONTRACT AND LEASE

All contract negotiations occur at the time of inspection. It is preferred that the VA case manager

and Veteran attend the inspection because the HAP contract and lease can be executed as soon as

the unit passes inspection and the Veteran can arrange for immediate move-in.

PORTS

The VA case manager coordinates ports with the receiving VA and housing authority to ensure

that there is a HUD-VASH program through which the Veteran can receive case management.

REEXAMINATIONS

The housing authority has streamlined the reexamination process using their status as a MTW

agency. If a Veteran receives an increase in income between regularly scheduled recertifications,

the increase is not processed until the next recertification. Decreases are processed immediately,

with changes going into effect the following month.

ANNUAL RECERTIFICATION

Due to the housing authority’s MTW designation, the HACSC has opted not to conduct

recertifications on an annual basis but on a bi-annual or tri-annual basis. If a Veteran household

has wages or income that are not fixed, HACSC will re-examine the household every two years.

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If a Veteran household has a fixed income, the reexamination will only take place every three

years as these households are unlikely to have an income change.

REASONS FOR EXITS

Leased-Up Exiters

HACSC identified a number of reasons why Veterans may exit HUD-VASH after leasing a

housing unit:

•  Transition from homelessness—Veterans who enter housing directly from the streets may

find it difficult to set up their home: they do not have pots or pans or furniture and are not

accustomed to paying rent, buying groceries, cooking, or interacting with neighbors.

•  Zero income—All Veterans in HUD-VASH are responsible for paying a portion of their

rent. When utilities are not included with the rent, Veterans who do not have an income

often have difficulty making these payments.

•  Substance abuse—Veterans with active drug or alcohol problems may spend much of

their income on these substances rather than paying their rent, jeopardizing their housing.

•  Noncompliance with VA case management—HACSC learns from VA case managers

that Veterans are not compliant with VA case management and will terminate them from

the program to open the voucher for another Veteran.

•  Lease violations—Some Veterans have difficulty following the lease agreement and

abiding by rules. Often, these Veterans invite unauthorized people into the household,

which is grounds for termination.

•  Unit abandonment—Sometimes Veterans leave their HUD-VASH units without

informing their VA case manager or the housing authority.

•  Death

Nonleased Exiters

HACSC identified a number of reasons why Veterans may leave the HUD-VASH program after

they have received a voucher but prior to obtaining a housing unit:

•  Lack of affordable housing—The vacancy rate in the area is very low, making it difficult

to find affordable units. HACSC tries to recruit more property owners to identify

available and affordable units for program participants.

•  Personal history—Veterans who have poor credit, a criminal background, or a history of

homelessness frequently find it more difficult to locate a unit. Property owners often have

choice in who they rent to, in part because of the low vacancy rate in the area, and they

will select other applicants over these Veterans.

•  Challenging process—Veterans can find the HUD-VASH process overwhelming due to

the paperwork and steps involved.

•  Loss of contact

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•  Incarceration

•  Substance abuse

VETERANS IN CRISIS

HACSC usually learns from property owners that Veterans are experiencing housing issues.

When the housing authority follows-up with VA case managers, they often find out that VA case

managers are aware of the issues as well and have been working with the Veterans to resolve

them. HACSC and VA case managers frequently work in tandem to assist Veterans in this area.

If a Veteran is not complying with housing rules, the housing authority usually counsels the

Veteran with the VA case manager present. Because the Veteran is actively receiving VA case

management, the housing authority generally does not terminate him/her. If the Veteran is not

paying his/her portion of the rent and is evicted, HACSC will give the Veteran another voucher

and an official warning indicating why the previous voucher was terminated and stating that if it

happens again, the Veteran could lose the voucher indefinitely. The VA case manager works

with the Veteran to prevent the situation from happening again (e.g., creating a budget with the

Veteran or working with a payee to manage the Veteran’s money). For Veterans with multiple

violations, HACSC has created second and third levels of review before allowing them to

continue in the program.

COMMUNICATION BETWEEN AGENCIES

HACSC operations staff and VA case managers meet weekly to discuss any scheduling, voucher

extensions, noncompliance, terminations, or other challenges. VA case managers contact

HACSC staff daily if an issue requires immediate attention. HACSC and the VA share updated

rosters so that each team knows the correct point of contact for specific areas or clients. Larger

team meetings that include management are also held quarterly to discuss broader policy issues.

Additionally, monthly meetings that involve both the housing authority and VA as well as

community stake holders have been held since May 2013 following a rapid results acceleration

boot camp. These meetings help to keep everyone engaged and ensure that the program is

reaching prioritized Veterans and meeting target performance measures.

FACILITATORS OF HOUSING SUSTAINABILITY

•  HACSC described facilitators that have made housing sustainability easier for Veterans:

•  VA case management—Property owners are more understanding of Veterans in HUD-

VASH and appreciate the VA case managers’ involvement in mitigating problems.

•  Communication with between VA and the housing authority

•  HUD-VASH Boot Camp

BARRIERS TO HOUSING SUSTAINABILITY

HACSC indicated several challenges for housing sustainability:

•  Staffing issues—HACSC finds it difficult to make sure HUD-VASH applicants are

processed as quickly as possible because there is insufficient staff dedicated to this

population.

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•  Mental health issues—HACSC staff indicated that Veterans with mental health issues,

such as PTSD, often have difficulty communicating and may become easily agitated.

Although these Veterans are receiving services through VA, they may not be compliant

with their treatment or refuse to follow-up with providers.

PROCESS IMPROVEMENTS / RECOMMENDATIONS

HACSC stressed the importance of having an open dialogue with VA and community providers.

In an effort to streamline procedures, the housing authority and VA staff mapped out the HUD-

VASH processes and highlighted the barriers for both teams. They discussed ways to make the

process more efficient, such as including a documents checklist to assist VA case managers with

completing the voucher application. Both teams have also worked with homeless service

providers to continue the discussion with a broader scope. One idea that came out of these

meetings was setting aside money for flexible funds to be used for furniture or other move-in

necessities not normally covered by housing rental assistance.

HACSC is working with the VA on a request for 25 project-based vouchers for HUD-VASH and

has identified three potential sites if these vouchers are awarded.

Housing Authority of Monterey County

HACM has four staff dedicated to HUD-VASH, including two eligibility specialists who

complete intake for all Veterans, and two senior housing program specialists with ongoing

Veteran caseloads. Veterans are served by HACM staff at the housing authority. Details on

HACM’s voucher issuance and payment standards are shown in the table below:

General

South Countya

Peninsulab

SRO - $653 (100% FMR)

SRO - $588 (90% FMR)

SRO - $679 (104%FMR)

0BR - $864 (99.25% FMR)  0BR - $784 (90% FMR)

0BR - $899 (103.25%

1BR - $990 (101% FMR)

1BR - $882 (90% FMR)

FMR)

Payment Standard

2BR - $1,162 (94.2% FMR)  2BR - $1,111 (90% FMR)

1BR - $1,020 (104.1%

3BR - $1,623 (90.15%

3BR - $1,620 (90% FMR)  FMR)

FMR)

4BR - $1,811 (90% FMR)

2BR - $1,186 (96.1%FMR))

4BR - $1,811 (90% FMR)

5BR - $2,083 (90% FMR)  3BR - $1695 (94.15% FMR)

5BR - $2,083 (90% FMR)

4BR - $1,891 (94% FMR)

5BR - $2,175 (94% FMR)

Portion of Rent that is Veteran’s

Responsibility

30%, up to 40% including utilities

Initial Voucher Issuance Period  120 days

a Chualar, Gonzales, Soledad, Greenfield, King City, San Lucas, San Ardo, and Lockwood.

b Big Sur, Carmel, Carmel Valley, Marina, Monterey, Pacific Grove, Sand City, and Seaside

VOUCHER APPLICATION

VA case managers assist Veterans with completing the voucher application, which is submitted

to the HACM intake/eligibility specialist. The housing authority has trained VA case managers

on how to complete the application and what supporting documents are needed; VA case

managers will reach out to the housing authority with questions, ensuring that the applications

are complete in advance of the eligibility interview. Eligibility interviews take place one to two

weeks after the application is submitted and are held every Wednesday at the housing authority.

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A VA case manager is present at this meeting, though it may not be the VA case manager

assigned to the specific Veterans who are being interviewed.

VOUCHER BRIEFING

After HACM completes the sex offender check and income verification to confirm the Veteran’s

eligibility, the Veteran is scheduled for a group voucher briefing. The Veteran is informed of the

meeting details via letter. At the briefing, Veterans watch a video that reviews the rules and

regulations of the program. This is followed by a question and answer period and then Veterans

receive their vouchers.

HOUSING SEARCH

The housing authority provides a list of units that accept HCVs to the VA housing specialist,

who is the main point of contact for the housing search. Since this position was filled, HACM

has seen an increase in the lease rate among Veterans. Previously, Veterans’ vouchers would

often expire or Veterans would struggle with high deposits that they could not afford. HACM

sees the VA housing specialist as instrumental in getting Veterans leased-up.

The housing authority indicates that affordable housing is available within their service area.

However, most of the affordable housing is in areas where Veterans do not want to live. The

housing search is also impacted by seasonal workers who come to the area during the growing

season. Veterans have an easier time finding a unit that they can afford in the fall than in the

spring or summer.

INSPECTION

After the RFTA is submitted, an HACM inspector reviews the file. Based on the utilities

specified by the property owner and the requested rent, the HACM inspector determines if the

Veteran can afford the unit and whether s/he qualifies for it. HACM will deny a RFTA if the rent

is too high and the property owner is not willing to negotiate or if the cost of utilities makes the

Veteran’s monthly payment over the approved amount, which is particularly an issue for

Veterans with zero income. Additionally, property owners are less likely to negotiate on rent

during the spring and summer months when the number of seasonal workers and potential

tenants increases.

An inspection is generally scheduled within three to five days. However, it can take more time to

get it completed due to the housing authority’s large, rural service area. If repairs are needed, the

housing authority assesses the property owner’s willingness to do the work. If the property

owner is unwilling to make the repairs, the Veteran is informed via letter and is given a new

RFTA to continue the search. This rarely happens because the VA housing specialist advocates

for the Veteran and encourages the property owner to make the repairs.

HAP CONTRACT AND LEASE

When the unit passes inspection the HAP contract between HACM and the property owner is

signed onsite. The lease agreement between the owner and tenant is signed at a time decided by

both parties.

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PORTABILITY

For a Veteran to port his/her HUD-VASH voucher, the receiving housing authority can accept

the Veteran into its HUD-VASH program, convert the Veteran’s voucher into a HCV, or bill the

original housing authority. If the housing authority is billed, the Veteran is still considered to be

a part of the original HUD-VASH program.

REEXAMINATIONS

Decreases in income are processed immediately so that changes in rent responsibility go into

effect during the following month. Increases in income are also processed immediately, though,

due to the required documentation, the adjustment may take more than one month to go into

effect.

ANNUAL RECERTIFICATION

An annual recertification is conducted for all Veterans in HUD-VASH. The recertification

process consists of an annual inspection and an office visit to update the Veteran’s information.

In most cases, the Veteran attends this appointment on his/her own. However, the VA case

manager will attend this meeting if necessary. The paperwork needed for this appointment is

similar to that required for the intake process; an appointment letter with a list of documents

needed is mailed to the Veteran two to three weeks in advance.

REASONS FOR EXITS

Leased-Up Exiters

HACM identified a number of reasons why Veterans may exit HUD-VASH after leasing a

housing unit:

•  Graduation—Veterans who graduate from HUD-VASH may transfer to the regular HCV

program and continue to receive housing assistance but no longer participate in VA case

management.

•  Withdrawal—A Veteran may decide that s/he no longer needs housing assistance and VA

case management will discharge the Veteran from the program.

•  Increase in income—Veterans who receive additional benefits or begin working or

earning more money may receive too much income to be eligible for HUD-VASH.

•  Eviction

•  Death

Nonleased Exiters

HACM identified a number of reasons why Veterans may leave the HUD-VASH program after

they have received a voucher but prior to obtaining a housing unit:

•  Loss of contact—If the program cannot communicate with a Veteran, the Veteran will be

terminated from the program.

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•  Willingness—The Veteran has to be willing to complete the paperwork and attend

appointments. Some Veterans are uncomfortable sharing the personal information

required by the program.

VETERANS IN CRISIS

HACM learns that Veterans are experiencing housing issues from both property owners and VA

case managers. If the property owner contacts HACM, the housing authority will inform the VA

case manager and request increased home visits or support to the Veteran to remedy the issue.

If a Veteran continues to violate his/her lease, the housing authority may schedule the Veteran

for a Council Meeting, in which they describe how the Veteran is violating the lease and inform

her/him that s/he is at risk of losing the voucher. The housing authority tries to remind the

Veteran of the hard work that s/he has put into the program so as to encourage changes in

behavior necessary to remain in the unit.

COMMUNICATION BETWEEN AGENCIES

Staff who work with HUD-VASH at HACM meet with VA case managers and the VA housing

specialist quarterly. They discuss how the program is working and if there are any issues that

need to be addressed to improve it. Staff will also review individual cases during these meetings.

Topics of discussion include changes to public programs and available assistance. Recently,

increases to housing allowances through the GI Bill impacted Veterans in the program; housing

authority and VA staff used the quarterly meeting as a time to discuss how this type of income

would be handled moving forward to ensure that both agencies agreed and gave Veterans correct

information. HACM and VA staff also have an open dialogue to deal with issues as they arise.

FACILITATORS OF HOUSING SUSTAINABILITY

HACM described a number of facilitators that have made housing sustainability easier for

Veterans:

•  VA staff complete the voucher application—Having the VA assist Veterans in

completing the voucher application streamlines the entire process by making the turn-

around time shorter and allowing HACM to assist more people in less time.

•  VA staff attendance at eligibility interview

•  VA housing specialist

•  Communication with VA

BARRIERS TO HOUSING SUSTAINABILITY

HACM indicated the following challenges for housing sustainability:

•  Security deposits

•  Personal history—Veteran rental and credit histories can be a barrier for accessing

housing, being accepted by property owners, and accessing funds for the security deposit.

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PROCESS IMPROVEMENTS / RECOMMENDATIONS

Previously, HACM submitted the same background checks for HUD-VASH applicants as they

did for all of their clients. However, the criminal background check does not apply to Veterans

and the housing authority has been able to decrease costs and time to housing by only requesting

the sex offender check.

Because the housing search in the area served by HACM can be difficult, the housing authority

and VA housing specialist encourage Veterans to find a unit that is acceptable in the short-term,

even if only for a six month lease, and then continue their housing search once they have moved

in. This allows Veterans to have a unit and then look for a place that meets their long-term

housing criteria. Often, Veterans find that they are happy with their unit and opt not to move.

The VA referral process can be difficult for HACM. To meet their targets, the housing authority

needs the VA to over-refer, because not all Veterans who are referred to HUD-VASH will sign a

lease and move into a unit. However, the VA is concerned that if they over-refer, HACM may

not have a sufficient number of available vouchers. Additionally, since the VA has to screen

every Veteran, it can be costly and time-consuming for them to over-refer, especially as the

program is often understaffed.

Step-By-Step Processes

The following chart summarizes the steps in the process of housing Veterans in HUD-VASH—

from initial referral to the program to moving into the housing unit—as well as the roles fo the

VA case managers and housing authorities.

Housing

Monterey

VA Case

San Jose

Authority of

Housing Authority of

Management

VA Case Management

the County of

VA Case

the County of

(All Teams)

Team

Santa Clara

Management

Monterey (HACM)

(HACSC)

Team

Referral & Admission

Referral

  All referral sources

throughout the

service area use a

shared referral

form.

  Form is faxed or

delivered to the VA

Palo Alto HUD-

VASH office.

Referral

Processing

  VA support staff

input referral

information to

spreadsheet

accessible to all

Palo Alto VA case

management

teams.

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Housing

Monterey

VA Case

San Jose

Authority of

Housing Authority of

Management

VA Case Management

the County of

VA Case

the County of

(All Teams)

Team

Santa Clara

Management

Monterey (HACM)

(HACSC)

Team

Screening

Screening

Screening

  Each VA case

  VA case managers rotate

  One VA case manager

management team

regularly to conduct

completes al

uses standard

referral, chart and

screenings by

screening template

telephone screenings.

reviewing referral,

to verify referral

chart and telephoning

form information.

Veterans.

Prioritization on

Interest List

  Referral form and

screening

determine Veteran

eligibility and

priority on interest

list.

VA Case Manager

Assignment

  Case managers are

assigned to work

with Veterans

based on individual

voucher openings

as wel  as areas of

expertise.

Admission Meeting

Admission Group

Scheduled

Meeting Invitation

  VA case manager invites

  Veteran is contacted by

prioritized Veteran to

a case manager and

program; informs Veteran

invited to attend an

of required documentation

admission group.

  Veteran is told to bring

for voucher application, and

required application

schedules intake meeting to

documents to this

complete initial paperwork.

meeting.

Veteran Enrolled

in VA case

management

  Veteran is assigned

a VA case manager

upon attendance at

admission meeting.

Voucher Application & Briefing

Voucher Application

Admission Group

Completed

Meeting

  Veteran must attend 1-2

  Veteran must attend

hour individual or group

admission group

orientation, sign program

meeting.

agreement and complete

  VA case manager

PHA voucher application

completes pre-

packet with VA case

application with

manager.

Veteran during this

meeting.

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Housing

Monterey

VA Case

San Jose

Authority of

Housing Authority of

Management

VA Case Management

the County of

VA Case

the County of

(All Teams)

Team

Santa Clara

Management

Monterey (HACM)

(HACSC)

Team

Voucher Application

Pre-Application

Submitted

Submitted

  VA case manager submits

  VA case manager

completed voucher

submits pre-

application and required

application to HACM

documents to HACSC

intake/eligibility

designated HUD-VASH

specialist.

email/ fax.

HACSC

Eligibility Verification

Specialist

  The pre-application and

Assigned

referral must be received to

  HACSC housing

schedule an appointment

programs

with the Veteran. The

manager assigns

Veteran’s information from

HACSC specialist

these documents is entered

and forwards

into the waiting list.

application

  HACM will process income

materials to

and HACM processes

HACSC specialist.

eligibility using the pre-

application submitted by the

VA case manager.

  HACM also completes sex

offender check once the

Veteran comes in for an

interview.to determine

eligibility

Eligibility

Voucher Application

Verification

Completed

  HACSC specialist

  VA case manager

completes sex

assists the Veteran in

offender check

completing the

and confirms

voucher application

Veteran

packet during second

eligibility.

meeting.

Intake Meeting

Voucher Application

& Voucher

Submitted

Briefing

  VA case manager

Scheduled

submits completed

  HACSC specialist

application packet to

contacts

Veterans and

the HACM by fax.

schedules intake

meeting and

voucher briefing.

  Veteran is

informed of any

additional

required

documents to

bring to meeting.

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Housing

Monterey

VA Case

San Jose

Authority of

Housing Authority of

Management

VA Case Management

the County of

VA Case

the County of

(All Teams)

Team

Santa Clara

Management

Monterey (HACM)

(HACSC)

Team

Intake Meeting

Eligibility Interview

& Voucher

Scheduled

Briefing

  Eligibility interview

  HACSC specialist

scheduled 1-2 weeks after

reviews

submission of voucher

application

materials with

application. The Veteran is

Veteran and VA

notified by mail, but HACM

case manager.

also sends a letter to the

  Voucher briefing

Veteran, and VA case

typically takes

manager is notified of the

place on the

date and time. VA case

same day of the

manager ensures Veteran is

intake meeting in

the afternoon.

aware of appointment.

  Intake meeting

and voucher

briefing held at

HACSC, generally

within 3 weeks

of completed

application.

Eligibility Interview

Eligibility Interview

  A VA case manager is

  HACM reviews application

present at all eligibility

and interviews Veterans

interviews, but it may

every Wednesday afternoon

not be the VA case

at HACM office .

manager assigned to

Veteran as VA case

managers are assigned

to attend this meeting

on a rotating basis.

Voucher Briefing

Scheduled

  Veteran is informed of

voucher briefing via letter.

Voucher Briefing

  Voucher briefing held every

1st and 3rd Thursday of the

month. If Veteran file is

done, they are scheduled for

the soonest briefing  at

HACM, usually 1 month after

submission of completed

packet.

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Housing

Monterey

VA Case

San Jose

Authority of

Housing Authority of

Management

VA Case Management

the County of

VA Case

the County of

(All Teams)

Team

Santa Clara

Management

Monterey (HACM)

(HACSC)

Team

Housing Search

Weekly Meetings

Weekly Meetings

  VA peer support specialist

  VA case management

offers weekly groups

team offers weekly

providing information

start up group to help

about the housing search;

Veteran prepare for

Veteran required to attend

the housing search.

at least 4 sessions.

  VA housing specialist

  VA case management team

and VA peer support

offers ride-alongs to visit

specialist offer weekly

available units 3 times each

housing searches

week.

tailored to Veteran’s

preferences.

RFTA Submitted

RFTA

RFTA Submitted

RFTA Processing

  VA case manager, Veteran,

Processing

  VA case manager,

  RFTA is hand carried to the

or property owner submits

  RFTA is hand

Veteran, or property

HACM by Veteran, VA case

RFTA to HACSC.

carried to the

owner submits RFTA

manager or property owner.

HACS by Veteran,

to HACM.

VA case manager

or property

owner.

Inspection & Rent Negotiation

RFTA Reviewed

RFTA Reviewed

  HACSC inspector

  HACM inspector reviews

reviews RFTA to

RFTA to determine if the

determine

unit is affordable and

affordability of

whether the Veteran

rent, review

qualifies for it.

property

ownership, and

evaluate rent

comparables.

Inspection

Rent Negotiation

Scheduled

  The inspector reviews the

  HACSC clerk

RFTA and file for

contacts

affordability based on HUD

property owner

guidelines.

to schedule

  Rent negotiation occurs at

inspection,

inspection.

generally about 3

days fol owing

RFTA

submission.

  HACSC clerk

informs VA case

manager of

inspection time,

and VA case

manager informs

Veteran.

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Housing

Monterey

VA Case

San Jose

Authority of

Housing Authority of

Management

VA Case Management

the County of

VA Case

the County of

(All Teams)

Team

Santa Clara

Management

Monterey (HACM)

(HACSC)

Team

Inspection &

Inspection Scheduled

Rent

  The inspector contacts the

Negotiation

property  owner to make

  Rent negotiation

sure the unit is ready and

occurs at

rent is reasonable. Inspector

inspection.

and property owner agree

on inspection date and

Veteran is notified.

Reinspection

Reinspection

  If initial

  If initial inspection does not

inspection does

pass, HACSC submits actions

not pass, HACSC

for correction to property

submits actions

owner; property owner

for correction to

completes actions and

property owner;

schedules reinspection with

property owner

HACSC.

completes

actions and

schedules

reinspection with

HACSC.

HAP Contract & Lease

Execution of HAP

Execution of

Execution of HAP

Contract & Lease

HAP Contract &

Contract & Lease

  VA case managers

Lease

  HAP contract and lease

often accompany

  HAP contract and

executed at property

Veterans during

lease executed at

fol owing inspection.

inspections and

property

signing of  HAP

fol owing

contracts.

inspection.

Move-In

Move-In Assistance

  Al  Palo Alto VA case

management teams rely

on local SSVF programs,

other community

organizations, and

government agencies for

move-in assistance. It has

been difficult to find

consistent sources of

furniture, especial y beds,

as well as furniture

delivery.

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APPENDIX H:

PHILADELPHIA SITE DESCRIPTION

The Philadelphia HUD-VASH program operates in Philadelphia County, Bucks County, and the

City of Camden. The

coordinating VA site is

the Philadelphia

VAMC in

Philadelphia, PA. The

HUD-VASH program

has 743 vouchers. The

majority of vouchers

are held by the

Philadelphia Housing

Authority (PHA, 743)

and Housing Authority

of the City of Camden

(HACC, 135). PHA

serves Veterans within

Philadelphia. HACC

serves Veterans within

the Camden, NJ, city

limits.

Housing Context

The following maps provide context for the housing markets in which Veterans participating in

the Philadelphia HUD-VASH program are conducting their housing search.

Map 1 outlines low, very low, and

extremely low income areas based on

median county income. The majority of

the City of Camden is low income. The

majority of low income areas in

Philadelphia are in the northern and

western parts of the city. The VAMC is

located near the western low income

areas but is farther from the northern

low income areas. The northern area

has one Vet Center/CBOC but it is not

in a low income area. The remaining

Vet Centers and CBOCs, as well as the

housing authority, are also not in low

income areas.

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Appendix H: Philadelphia Site Description

Map 2 depicts median gross rent by quartile;

the darkest areas have the lowest rent. In the

City of Camden, median rent varies

throughout the city, while in Philadelphia,

the areas with the lowest median rents align

with the low income areas.

Map 3 provides details on the rental vacancy

rate by quartile. Darker areas have lower

vacancy rates. The City of Camden has very

low vacancy across most of the city. In

Philadelphia, vacancy rates do not appear to

be as low, except in the southwest and parts

of the northeast. Low income areas and areas

with lower median rents seem to have units

available.

VA Case Management

The site has VA teams serving HUD-VASH Veterans. Teams include a supervisor, case

managers, a SUD specialist, a housing specialist, a peer support specialist and social workers.

The case load is 1:30.

Team

Associated Housing Authority

Service Location

Team

Composition

Philadelphia

Philadelphia VAMC

Veterans

Multi-Service  Philadelphia Housing Authority

Veterans Multi-Service Center

Center

Pathways to

Housing

ACT team

Camden

Housing Authority of the City of

Camden

Bucks County  Bucks County Housing Authority

1 person

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Appendix H: Philadelphia Site Description

OUTREACH

A large proportion of referrals to HUD-VASH are self-referrals or walk-ins; Veterans hear about

the program from other Veterans or other VHA Homeless Programs. Safe Haven, emergency

shelters, community partners, and SSVF also provide referrals. Staff at the VAMC refer Veterans

to HUD-VASH through primary care or inpatient mental health and psychiatry if a Veteran

identifies as homeless. Finally, the Grant and Per Diem program supplies the largest number of

HUD-VASH referrals.

Following a recent HUD-VASH Boot Camp, the VA case management team began working with

community-based homeless programs to coordinate outreach efforts throughout Philadelphia.

This effort minimizes overlap among programs and ensures that individuals experiencing

homelessness who are being contacted for services are receiving assistance through only one

provider. The VA case management team participates in a weekly meeting to identify Veterans

who are in need of immediate assistance; this meeting informs the team’s outreach efforts.

REFERRALS AND ELIGIBILITY

Philadelphia currently maintains an interest list for Veterans living in Philadelphia who want to

participate in HUD-VASH. Pathways to Housing has vouchers available for the most vulnerable

Veterans.

A member of the VA case management team conducts an initial screening with all potential

HUD-VASH participants, typically during a walk-in appointment. This screening is captured in

the Veteran’s medical record through a template that includes eligibility for healthcare services,

homelessness, open housing authority cases, sex offender status, psychosocial history, assets, and

future goals. A member of the VA case management team also completes the HOMES

assessment. Both of these assessments help the team determine whether the Veteran is eligible

for the program and where to prioritize him/her on the interest list. In addition, the assessments

provide an overview of the Veteran’s VA case management needs and whether s/he is in need of

mental health assistance or substance abuse counseling.

The most chronically homeless and severely mentally ill Veterans may qualify for Pathways to

Housing, a housing program that uses the HUD-VASH voucher in combination with an

Assertive Community Treatment (ACT) team case management approach. If the screening

indicates that a Veteran is likely to qualify for Pathways to Housing, s/he will be referred to that

team.

During the initial screening, the VA case manager informs the Veteran about the documentation

required to apply for a voucher. The VA case manager also asks the Veteran to provide

emergency contact information, including family members’ phone numbers and addresses, in

case the VA case manager is unable to contact the Veteran directly. The VA case manager also

refers the Veteran to community agencies for resources, such as housing and employment

services.

The program accepts non-service-connected Veterans and Veterans with zero income but will

immediately develop a financial plan with them. For Veterans with income approaching the

program’s maximum allowance, the VA case manager will ensure that s/he understands the VA

case management component of the program. If the Veteran is able to afford a unit without the

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voucher, s/he might opt not to be placed on the interest list. If that is the case, the VA case

manager will offer resources and other assistance.

TARGETING

The Philadelphia HUD-VASH program targets chronically homeless individuals, females,

families, and OEF/OIF Veterans. The interest list prioritizes Veterans in the following order:

chronically homeless, females, and families. Emergencies can also increase a Veteran’s

prioritization rank, as well as the combination of two or more target areas (e.g., a chronically

homeless OEF/OIF family would be at the top). Veterans who present as very high need are

referred to Pathways to Housing.

REFERRAL AND ADMISSION

When a voucher becomes available, the VA case management team completes a more detailed

intake screening during which the Veteran is again informed of required documentation to apply

for a voucher. Two VA case managers meet with the Veteran and then present his/her case to the

VA case management team at a weekly committee meeting. The team accepts or rejects the

Veteran, who is not present at the meeting; if the Veteran is accepted, s/he is assigned a VA case

manager. To avoid a lag between the Veteran’s acceptance into the program and application for a

voucher, Veterans are encouraged to have the required documentation ready at this point. If a

Veteran does not have the documents readily available, the Homeless Advocacy Project can

assist with obtaining them.

VOUCHER APPLICATION

Once the VA case management team accepts the Veteran into the HUD-VASH program the

Veteran’s VA case manager works with her/him to complete the HUD-VASH application and

mails it to the housing authority. The housing authority completes a background check and

contacts the Veteran’s VA case manager if there are any issues. Otherwise, the VA case manager

is notified when a voucher is available.

If a number of Veterans are receiving a voucher, the voucher briefing is generally held at the

Veterans Multi-Service Center. If only a few vouchers are being issued—or if the Veteran is

working with HACC—the briefing takes place at the housing authority. One-on-one briefings are

also offered for Veterans who are uncomfortable with crowds, as is often the case for those

suffering from PTSD. All materials required by the housing authority should be completed and

in-place prior to this briefing.

The VA case management team takes responsibility for the majority of the voucher processes

that the housing authorities previously completed. The VA case management team completes the

intake paperwork and orientation while the housing authorities conduct the voucher briefing.

HOUSING SEARCH

To expedite the housing search, the HUD-VASH voucher now expires in 60 days rather than 120

in Philadelphia. Extensions can be granted if circumstances permit. However, VA case managers

encourage Veterans to start the housing search process as soon as possible, even before the

voucher has been issued. The team feels this proactive approach has decreased the amount of

time that a Veteran remains homeless.

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The VA case management team offers a weekly orientation meeting at PVAMC or the Veterans

Multi-Service Center, which allows Veterans to learn about the program, what is expected from

them, what they can expect from the housing authority, and where they are in the housing

process. This meeting also provides an opportunity for Veterans to hear from others who have

been in the program and can offer advice on the housing search. Veterans who have been

accepted into HUD-VASH but are not yet housed are required to attend this meeting every week,

and they are welcome to attend before they have been issued a voucher. No similar meeting is

offered in Camden.

For the past year, the Philadelphia VA case management team has offered housing tours

following the weekly orientation meeting. Each week, the tour visits a different part of the city

that reflects areas of interest to Veterans. If a Veteran requires additional housing search

assistance, the VA case manager will also take her/him out one-on-one. The team tries to be

mindful of neighborhood triggers; many Veterans with a SUD history take part in a 12-step

program that encourages them to identify “people, places, and things” that act as triggers.

Neighborhoods where Veterans have contacts who sell or use illegal substances and

neighborhoods with widespread drug use are avoided.

The Philadelphia VA case management team has a good relationship with a number of local

property owners. They understand the clientele and appreciate the VA case management offered

to tenants. These property owners notify the VA case management team about upcoming

vacancies and sometimes hold units for Veterans who will be issued their vouchers shortly. In

addition, some property owners waive application fees, are more flexible with Veterans with

criminal backgrounds and poor credit histories, and may work with Veterans to create a payment

plan in lieu of an up-front security deposit. During inspections, the property owners often have a

maintenance person on site to make small repairs. Finally, these property owners are more

practiced at the paperwork and inspections, which makes the process faster.

INSPECTION

According to the VA case management team, inspections in Philadelphia have become stricter

over time and many units fail the first inspection, which can cause delays and create issues with

property owners new to HUD-VASH. Prior to some changes to this process, described below, an

initial inspection could take 30–60 days or more if a unit required a reinspection. However, PHA

expedites the inspection process for HUD-VASH participants.

Some pre-inspected units are available in Philadelphia. PHA offers preinspections for property

owners who they have worked with for a period of time, a change that is the result of a recent

HUD-VASH Boot Camp. The VA case management team sends PHA a list of properties—often

a set of units owned by one property management company—and PHA sends an inspector to

inspect all of the units at once. PHA emails the VA case management team a list of pre-inspected

units.

In addition, property owners may also have their units inspected prior to submission of the

RFTA, which speeds up the process of scheduling an initial inspection and possibly a

reinspection. It also creates competition for Veterans; since these units often move off the market

faster, Veterans compete with one another to get housed first. Other changes to the process

include ensuring that the same inspector who conducts the initial inspection conducts the

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reinspection and allowing some property managers to attend the initial inspection and make

repairs at that time.

MOVE-IN

The VA case management team described a fear of exhausting move-in resources. When funding

is tight, they try to ensure that each Veteran can access either a security deposit or furniture.

Unless they have special circumstances, such as being part of a family or very low income,

Veterans can only access one type of assistance or the other.

The VA case management team makes an effort to assist Veterans with move-in funds and

supplies. In Philadelphia, security deposit funding is available through SSVF as well as the City

of Philadelphia Office of Supportive Housing. In Camden, SSVF has provided funding for

security deposits, first month’s rent, and utility deposits, as well as beds.

VA case managers indicated that furniture assistance can be difficult to access; some Veterans

move into their units with only a sleeping bag and do not have furniture until they save enough

money to purchase it and have it delivered to their units. However, some furniture assistance is

available through community providers. Veterans can access a thrift store voucher through SSVF

to purchase furniture, which staff from the thrift store will deliver to the Veteran’s home. If

Veterans find free or inexpensive furniture on their own, the VA case manager will assist them in

delivering it to their apartment. Generally, the VA case management team discourages donations

due to issues with bed bugs and quality.

VA CASE MANAGEMENT

The following table describes VA case management requirements:

During housing

Veterans required to attend weekly orientation meetings; VA case manager

process

talks to Veteran on phone once a week and face-to-face once a month.

Year 1

VA case manager conducts monthly home visit for first year.

Year 2+

VA case manager calls Veteran at least once a month.

In lieu of monthly VA case management contact, Veteran can attend a group meeting.

Notes

SUD specialist offers weekly group meeting and individual appointments.

If Veteran is unreachable after being housed, VA case manager will conduct home visit.

VA case management often begins once a Veteran completes an official HUD-VASH intake

(i.e., after being pulled from the interest list and approved by the committee). At this point, the

Veteran is referred to services and resources. Because there are several steps between screening

and the voucher briefing, VA case managers work to decrease the amount of time that the

Veteran is homeless. However, VA case management officially begins once the Veteran attends

his/her voucher briefing.

When a Veteran first enters the program, and throughout the housing process, VA case managers

usually speak with her/him on the phone once a week and have face-to-face meetings at least

once a month. After the Veteran is housed, VA case managers conduct monthly home visits in

the first year. During the second year, VA case managers will call the Veteran at least once a

month. If a Veteran does not respond to a telephone call, the VA case managers conduct a home

visit. Generally, the intensity of VA case management steps down gradually, with less frequent

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Appendix H: Philadelphia Site Description

communication over time unless the Veteran experiences a crisis. The Philadelphia VA case

management team offers a number of group meetings that Veterans can attend in lieu of their

monthly contact with their VA case manager.

The VA case management team also includes a VA SUD specialist who offers a weekly HUD-

VASH group as well as individual appointments for Veterans. In addition, the Addiction

Recovery Unit affiliated with the Philadelphia VAMC offers classes and groups; Veterans’

participation in this program begins with two or three days a week and the frequency decreases

over time. Although the VA case management team follows a Housing First philosophy and

attendance at these groups is not required, VA case managers “repeatedly recommend”

participation as the housing authorities prefer that tenants be abstinent.

As part of their participation in HUD-VASH, Veterans are required to comply with VA

healthcare by attending doctors’ appointments. VA case mangers try to ensure Veterans’

compliance and will help them get to appointments if necessary.

Philadelphia VA case management utilizes the following evidence-based practices: Assertive

Community Treatment, Cognitive Behavioral Therapy, Harm Reduction, Motivational

Interviewing, Intensive Case Management, Peer Support/Mentoring, Supported Employment,

and Housing First.

PORTS

Philadelphia described porting as difficult because there are few vouchers remaining at other

sites to dedicate to one of their Veterans.

REASONS FOR EXITS

Leased-Up Exiters

The VA case management team identified a number of reasons why Veterans may exit HUD-

VASH after leasing a housing unit:

•  Nonpayment of rent—In Camden, nonpayment of rent is the largest reason that Veterans

exit HUD-VASH.

•  Problems with housing unit—Veterans may have issues with the property owners or

neighbors. Property owners may not make needed repairs, so Veterans refuse to stay in

the unit.

•  Isolation—Veterans may have no history of living alone and are uncomfortable doing so.

They may decide to leave the program to live with relatives or significant others.

•  Program violations—Veterans may allow friends or family to move into their unit

without following the proper procedure with the housing authority.

•  Moving—Veterans may want to port the voucher to another city and decide to move

there anyway, even when a port is impossible.

•  Withdrawal—Veterans may no longer need the support the program provides and

voluntarily leave the program.

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Appendix H: Philadelphia Site Description

•  Increase in income—Veterans who become over-income are no longer eligible to receive

housing assistance.

•  Homeownership—The Philadelphia program encourages Veterans to learn about VA

homeownership resources so that they can purchase a property rather than rent.

•  Unit abandonment

•  Loss of contact

•  Incarceration

•  Death

Nonleased Exiters

The VA case management team identified a number of reasons why Veterans may leave the

HUD-VASH program after they have received a voucher but prior to obtaining a housing unit:

•  Challenging process—Veterans may view the program as a significant commitment that

requires extensive paperwork. The process can seem overwhelming and protracted. While

staff have tried to alleviate these issues by providing the weekly orientation group and

making improvements to the inspections process, the process can still feel intimidating.

•  Motivation—Veterans may lack motivation to complete the process, including searching

for an apartment.

•  Readiness—Veterans may realize that independent housing is not right for them at the

time, or fear leaving a living situation that may not be ideal but is comfortable. Veterans

who are not accustomed to unstructured living, such as those who have been previously

incarcerated, face these difficulties as well. These Veterans may seek assistance from

another program with additional services and requirements.

•  Increase in income—Veterans may become over-income and ineligible for the program if

they secure employment or begin to receive additional benefits.

VETERANS IN CRISIS

VA case managers review Veterans’ medical records monthly to learn about medical or mental

health issues. Other Veterans may also report to a VA case manager that a Veteran is relapsing.

Veterans may inform their VA case managers about problems; however, the VA case

management team stated that it is often at the point of an emergency. VA case managers who are

closer to the Veteran or have been working with him/her longer are more likely to hear about

issues from the Veteran in a timely manner. Often, VA case managers learn that a Veteran is in

crisis when they are unable to contact her/him. In this case, the VA case manager will visit the

Veteran’s home, call emergency contacts, and/or reach out to the property owner. The VA case

manager may also review the Veteran’s medical record to see if any issues are noted.

If a Veteran is not paying rent, the property owner usually contacts the VA case manager

directly, either by phone or email. There have been instances when the VA case management

team did not learn about a Veteran’s nonpayment of rent until s/he owed significant back rent.

Since some Veterans pay such a small amount toward the rent, the property owner may not

realize that the payments have not been made. Typically, the VA case management team, the

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Appendix H: Philadelphia Site Description

housing authority, and property owner work together to set up a payment plan with the Veteran,

which may involve SSVF funds; however, the rent arrearages may be too much for the Veteran

to pay. If a Veteran is evicted for nonpayment of rent and then seeks a new HUD-VASH voucher

(or HCV), s/he must pay the balance owed to the housing authority in order to receive another

voucher.

GRADUATION

A Veteran has never graduated from the Philadelphia HUD-VASH program. No HCVs are

available for Veterans outside of HUD-VASH. If general vouchers were available, the VA case

management team would graduate a number of Veterans who are ready; however, as long as

Veterans are using a HUD-VASH voucher, they must continue to receive VA case management.

Interestingly, the VA case management team believes that some Veterans would not want to exit

VA case management, even if they were financially stable; many Veterans are more concerned

about losing VA case management than they are about losing financial assistance from the

housing authority, even Veterans who are primarily self-sufficient.

COMMUNICATION BETWEEN AGENCIES

The Philadelphia VA case management team has a good relationship with PHA. The VA case

management teams meet with PHA weekly to answer questions and address any housing

concerns. The program also collocates with PHA during voucher briefings and recertifications,

making the relationship much stronger.

FACILITATORS OF HOUSING SUSTAINABILITY

The Philadelphia VA case management team identified a number of facilitators of housing

sustainability for Veterans in the HUD-VASH program:

•  HUD-VASH Boot Camp

•  Decrease in initial voucher timeframe—Philadelphia decreased the initial issuance period

from 120 to 60 days, which has led Veterans to lease up more quickly.

•  Smaller case loads—Smaller case loads allow case managers to provide greater support

to the Veterans. Increases in HUD-VASH staff and VA specialists have been helpful for

the program.

•  VA SUD specialist—The VA SUD specialist prevents the team from losing Veterans or

being unable to provide specialized support to Veterans with a history of substance abuse.

•  VA peer support specialist—The VA peer support specialist provides needed assistance

to the team.

•  VA housing specialist—The VA housing specialist provides assistance with VA systems

and paperwork, giving VA case managers more time to dedicate to supporting Veterans.

•  Community connections—The Philadelphia program has formed community connections

in a number of ways: collocating VA case managers at the Veterans Multi-Service Center

; maintaining relationships with many community service providers, such as SSVF, GPD,

Safe Haven, and Veterans Empowerment Center; and forming relationships with local

property owners who house HUD-VASH participants.

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Appendix H: Philadelphia Site Description

•  Connection to resources—Community resources can assist Veterans in furthering their

education and finding employment or volunteer work. Engagement with outside

providers may help Veterans transition out of HUD-VASH.

•  Relationship with VA case manager—A close relationship may allow VA case managers

to identify issues Veterans are experiencing before they escalate.

BARRIERS FOR HOUSING SUSTAINABILITY

Veterans in Philadelphia face a number of challenges to accessing and sustaining permanent

housing, including the following:

•  Personal history—Poor credit and criminal backgrounds are a barrier to Veterans being

accepted into a unit.

•  Financial issues—Lack of a fiduciary or the length of time it takes to get a fiduciary if a

Veteran requires one can make it difficult to get housing.

•  Housing process—The timeframe can be too long for property owners. Additionally,

there seems to be much duplicated paperwork that causes delays and draws out the

process.

•  Cost of rent—PHA has reduced the amount that is offered to property owners, leading to

protracted rent negotiations. For Veterans who are already in housing, some have been

forced to move when their lease expired because PHA would no longer pay the same

rental amount. These decreases have even caused some property owners to drop out of

HUD-VASH.

•  SUD—Veterans in recovery from substance abuse may relapse when they have a space

of their own. For some, there is a “honeymoon period” when they first move into housing

and feel that their lives are in order, but the pressure to keep up with the new

responsibility may lead to relapse.

•  Mental illness

PROCESS IMPROVEMENTS / RECOMMENDATIONS

The Philadelphia VA case management teams believe that they would be able to better serve

Veterans if they had additional transportation (i.e., a car for each VA case manager). Currently,

the VA case managers must share cars and vans.

Computer access for Veterans would enable the program to help Veterans with job searches and

email communication. Veterans currently use VA case managers’ computers for these tasks,

which is not ideal.

Additional resources for furniture and other items Veterans need for move-in would improve that

process. The team described that furniture and funding assistance for these types of items are

difficult to find. This often leads to Veterans renting furniture, which is cost prohibitive.

Philadelphia Housing Authority

PHA has three staff who work on HUD-VASH, including one special programs director, one

special programs team leader, and one HUD-VASH leasing coordinator dedicated entirely to the

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program. The case load for the HUD-VASH leasing coordinator is 1:460. PHA recently

restructured their services: previously, offices were located in five major neighborhoods

throughout the city; now there is only one centralized branch. The housing authority typically

meets with HUD-VASH participants in the community at the Veterans Multi-Service Center as

they have found that Veterans are more familiar with and comfortable in this location. PHA staff

may meet with Veterans at the housing authority or the VAMC as well.

HUD-VASH clients are given priority within the HCV Program; Veterans’ files (indicated with a

purple folder), are placed at the top of the list for inspections and rent negotiations. Details on

PHA’s voucher issuance and payment standards are shown in the table below:

Payment Standard

1BR - $942, 2BR - $1,135, 3BR - $1,414, 4BR - $1,518, 5BR - $1,746, 6BR - $1,973

Portion of Rent that is Veteran’s

Responsibility

Based on family size: 1BR - 28%, 2–3BR - 27%, 4+BR - 26%

Initial Voucher Issuance Period  60 days

VOUCHER APPLICATION

The VA case management team assists the Veteran in completing the HUD-VASH application

and submits the application to PHA. The housing authority confirms receipt of all necessary

documents, completes a background check on the Veteran to ensure eligibility for the program,

and then schedules a voucher briefing.

VOUCHER BRIEFING

The voucher briefing includes an overview of general program polices, including expectations

for the Veteran and what to expect from the housing authority. Voucher briefings typically take

place with small groups of Veterans at the Veterans Multi-Service Center or PVAMC and they

generally receive their voucher that day.

HOUSING SEARCH

PHA has relationships with many area property owners. In fact, the housing authority offers

weekly landlord classes with prospective property owners interested in becoming certified for the

HCV Program. Because the property owners have many properties in the program already, the

housing authority is familiar with area rent and shares this information with Veterans. In

addition, PHA offers some pre-inspected units as well as some project-based units for families.

PHA indicated that rent in Philadelphia can fluctuate a great deal from block to block, and

Veterans are expected to pay between 30% and 40% of their income. PHA is experiencing a rent

freeze; rent increases have not occurred in Philadelphia since sequestration.

INSPECTION

Once the housing authority receives the RFTA, PHA schedules an inspection unless the unit has

already been pre-inspected. Inspections are expedited for HUD-VASH clients, usually taking

place within five business days of RFTA receipt. The Veteran does not need to be present during

the inspection. If the unit fails inspection, a reinspection generally extends the process by another

week or two. Veterans or their VA case managers can also contact PHA for inspections any time

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during the year if there are issues with the unit. This enables Veterans to ensure necessary repairs

are made by the property owner.

HAP CONTRACT AND LEASE

The housing authority described intense rent negotiations, which, at times, delay the housing

process, even with property owners familiar with the HCV Program and pre-inspected units.

Higher rent requests require an additional inspection, which occurs in about 10–15% of cases.

After the rent negotiation, the HAP contract and lease agreement are executed in-person at the

housing authority with the property owner, tenant, case manager, and housing authority leasing

agent present.

PORTS

PHA does not port many vouchers. However, Veterans can port to another area once they have

been approved by the receiving VA and housing authority. When the Veteran moves to another

service area, s/he must use a local HUD-VASH voucher.

REEXAMINATIONS

Veterans are not required to report increases in income until the annual recertification. Decreases

in income are processed immediately and changes in rent take effect the following month.

Veterans can also add children to the household composition at any time throughout the year.

ANNUAL RECERTIFICATION

Annual recertification meetings are conducted monthly at the PVAMC. The meeting is

scheduled through PHA, which mails the Veteran a letter and copies the case manager on email.

At the meeting, the housing authority verifies income to ensure the Veteran remains eligible for

the program and updates the household composition. If the household composition has increased,

PHA often encourages the Veteran to consider applying for a bigger unit during the

recertification process, as recertification is the only time that a Veteran can request a move. The

Inspections Department will also schedule a reinspection of the unit annually.

During the recertification, the property owner may increase the Veteran’s rent. Since PHA

currently has a freeze on rent increases, the Veteran is responsible for the increase. If the Veteran

does not believe that s/he can afford the new rent amount, PHA will ensure the accuracy of the

income information on file and may issue a new voucher to the Veteran to find a new housing

unit that is affordable. PHA described recertification as difficult for some Veterans.

REASONS FOR EXITS

Leased-Up Exiters

Veterans who exit the program after leasing a unit often experience eviction for nonpayment of

rent or submit incomplete recertification materials.

Nonleased Exiters

The housing authority indicated that being over-income or deciding to move in with family were

common reasons why Veterans did not rent a unit with their HUD-VASH voucher. Additionally,

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PHA said that many of the Veterans enrolled in the program in Philadelphia are older and have

medical concerns and may decide to exit the program because they need a higher level of care.

VETERANS IN CRISIS

PHA generally learns that Veterans are experiencing housing issues when a VA case manager

reaches out to the housing authority. Property owners may also contact the housing authority if a

Veteran is not paying the rent but they generally speak directly with the tenant. The housing

authority tries to work with Veterans in crisis as much as they can, reaching out to the VA case

manager and doing their due diligence. At times, the housing authority will learn that a Veteran

has been evicted only after the eviction has taken place. While PHA will issue the Veteran a new

voucher, the Veteran must satisfy any debt on his/her previous rental or risk losing the new

voucher.

COMMUNICATION BETWEEN AGENCIES

When working with HUD-VASH clients, VA case managers serve as the Veterans’ first point of

contact. The housing authority indicated that having the VA case manager serve as a liaison is

very effective for communication. Veterans can contact PHA directly, but the housing authority

finds it useful to keep the VA involved in all communications with Veterans. PHA has one point

person within the VA, who sends specific issues to the designated VA case manager working

with the Veteran. The housing authority may get more involved with a specific VA case

manager, depending on individual circumstances.

PHA sends a weekly report to the VA outlining where Veterans are in the housing process and

listing pre-inspected units available for HUD-VASH Veterans. Two weekly meetings also assist

with communication between service providers. One meeting takes place between PHA and the

VA. Prior to this meeting, VA will email a list of questions for the housing authority to respond

to at the meeting. The second meeting is coordinated through the Philadelphia Office of

Supportive Housing (OSH) to ensure that all Veterans known to local service providers are

receiving appropriate services. This meeting includes representatives from OSH, HUD, and

community groups who work with the Veteran population, including the VAMC.

FACILITATORS TO HOUSING SUSTAINABILITY

PHA described a number of facilitators that have made housing sustainability easier for

Veterans:

•  HUD-VASH Boot Camp—The HUD-VASH Boot Camp opened dialogue between

service providers and enabled the program to operate more quickly and effectively.

•  Streamlining paperwork—PHA has tried to streamline the application process and

provide VA and Veterans with checklists to ensure that everything is clear and completed

correctly.

•  Decrease in initial voucher timeframe—PHA decreased the initial voucher period from

120 days to 60 days, which has resulted in Veterans leasing units more quickly.

•  Pre-inspection—Having pre-inspected units available for Veterans has expedited the

lease-up process and the number of steps that must be completed between the selection of

a unit and move-in.

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•  Meeting with Veterans in the community or at the VAMC—PHA said that Veterans are

more likely to attend meetings held at locations where they are more comfortable.

•  Regular communication between VA and PHA—Weekly reporting has improved

communication between the agencies and provided better Veteran supports.

•  One point of contact—PHA appreciates having just one point person at the VA who can

communicate issues to the correct case manager.

BARRIERS FOR HOUSING SUSTAINABILITY

PHA indicated several challenges for housing sustainability:

•  Selecting a unit in a timely manner

•  Tension between HUD and VA performance measures—The housing authority’s priority

is to have Veterans leased through HUD-VASH. However, VA has prioritized housing

chronically homeless Veterans, a group that is very difficult to serve and often takes a

longer time to house. Though both HUD and VA want to house Veterans, the way this

outcome is measured can cause tension between the two agencies.

PROCESS IMPROVEMENTS / RECOMMENDATIONS

PHA is working with VA on refurbishing a project-based building for HUD-VASH recipients.

Veterans who are interested in being housed near other Veterans may prefer this type of housing.

The housing authority gauges its success by the number of Veterans who lease housing through

HUD-VASH. VA, by contrast, measures performance by the number of Veterans enrolled in the

program. Being enrolled does not necessarily mean the Veteran is housed. Rather, the Veterans,

many of whom have been chronically homeless and are difficult to serve, are receiving case

management and typically require a great deal of support and encouragement to reach the point

of leasing an apartment. The housing authority, however, needs to ensure that it reaches the

performance objectives outlined by HUD, which can be difficult with HUD-VASH participants.

Housing Authority of the City of Camden

HACC has staff who work with both HUD-VASH and other HCV clients, including a HCV

Program manager and leasing coordinator. Veterans are served by HACC staff at the housing

authority. Details on HACC’s voucher issuance and payment standards are shown in the table

below:

Payment Standard

90% FMR

Portion of Rent that is Veteran’s

Responsibility

Veteran is responsible for a portion of rent

Initial Voucher Issuance Period  60 days

HACC’s administrative plan prioritizes services to Veterans; in the case of a funding shortage,

Veterans would retain their vouchers.

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VOUCHER APPLICATION

VA case managers complete the HUD-VASH application with Veterans and are responsible for

ensuring that Veterans have all necessary documents. The VA case manager submits the

application to the housing authority. The housing authority runs a background check and

confirms Veteran eligibility.

VOUCHER BRIEFING

Voucher briefings are held at HACC. Briefings are typically one-on-one, but if several Veterans

are applying for HUD-VASH at the same time a group briefing can be held. The housing

authority indicated that if the Veteran attends the briefing and remains for the entire session, they

are guaranteed a voucher. The initial voucher issuance period is 60 days but can be extended to a

maximum of 120 days.

HOUSING SEARCH

Veterans who enroll in HUD-VASH in Camden must live within the city limits. HACC

described Camden as a “tough city” and said that the majority of Veterans do not want to live

there. However, the housing authority does have relationships with local property owners and

offers pre-inspected units. They also refer Veterans to recommended websites and the housing

authority’s bulletin board during their housing search.

The housing authority said that it can be difficult to find a unit in Camden. More apartment

complexes in the city are running credit and criminal history checks, and conducting drug tests

on applicants. In addition, while most of the bigger property owners will accept HCVs, many

smaller ones do not, particularly as the housing authority pays only 90% FMR. These property

owners often use non-negotiation of a set rent as a way of avoiding acceptance of these clients.

INSPECTION

Once the housing authority receives the RFTA, an inspection is scheduled unless the unit has

already been pre-inspected. The inspection process in Camden is expedited for Veterans and

often takes place the next day following receipt of the RFTA. However, reinspections are not

prioritized for Veterans.

HAP CONTRACT AND LEASE

Some property owners in Camden do not accept the rent offered by the housing authority,

especially since it is set at 90% FMR. Once a unit passes inspection and the rent offered by the

housing authority is accepted by the property owner, the contract and lease are signed at the

housing authority offices.

PORTS

Veterans can port to another area if they choose. In most of the current Camden ports, the

Veteran ports to an area that is still within the Philadelphia VAMC service area, usually Bucks

County, or to another part of New Jersey. The State of New Jersey Department of Community

Affairs processes Bucks County ports. HACC is then billed for and pays the Veteran’s rent

above the amount for which the Veteran is responsible, in addition to the administrative fees

associated with the lease-up. In this way, HACC becomes more of a “pass through” than a

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service provider for these clients. However, the housing authority said this process can take a

very long time and few Veterans do it. Veterans may also move to another part of New Jersey. In

these cases, HACC still administers the voucher even though it is outside of their jurisdiction.

REEXAMINATIONS

When a Veteran experiences a change in income, it must be reported to the housing authority

immediately. Often, the housing authority says this occurs because the Veteran starts to work or

receive additional benefits. If a Veteran becomes over-income and can pay the full rental amount

for six months, the housing authority revokes the voucher and assigns it to another Veteran.

ANNUAL RECERTIFICATION

HACC notifies Veterans of an upcoming recertification via mail. If the Veteran does not respond

to the first letter, HACC sends a second letter. If a Veteran remains unresponsive after these two

communications, the voucher is terminated. The housing authority does not typically inform the

VA case manager of an upcoming recertification unless there is a problem.

REASONS FOR EXITS

The housing authority described losing many Veterans from the HUD-VASH program,

indicating that for every two Veterans that lease, three Veterans exit the program, whether before

signing a lease or after being housed.

Leased-Up Exiters

HACC identified the following reasons why Veterans may exit HUD-VASH after leasing a

housing unit:

•  Eviction—The housing authority has experienced many cause for eviction notices, from

nonpayment of rent to drug use to compromising the peaceful enjoyment of the

neighbors. HACC indicated that these social issues are similar to those experienced by

regular HCV clients.

•  Death

Nonleased Exiters

HACC identified a number of reasons why Veterans may leave the HUD-VASH program after

they have received a voucher but prior to obtaining a housing unit:

•  Readiness—Veterans may not be ready to accept assistance. Their personal

circumstances, such as mental health issues and drug dependency, may also make it more

difficult for them to move successfully through the application and housing process.

•  Challenging process—Some Veterans are not interested in the HUD-VASH program

once they learn about the paperwork and VA case management components. They are not

interested in answering questions or being interviewed and find the process invasive,

overwhelming, or both.

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•  Application requirements—Veterans must meet the property owner’s leasing criteria,

which could involve paying an application fee and taking part in a credit check, criminal

history check, and drug tests. Property owners may then deny the Veteran.

•  Housing authority boundaries—Some Veterans who enter the HUD-VASH program

through Camden are not interested in living within the city limit, so they exit the program

to seek housing elsewhere.

VETERANS IN CRISIS

HACC usually learns about issues with Veterans from property owners, who sometimes look to

the housing authority to serve as a management company so they do not have to take a Veteran

to court. When this occurs, the HACC leasing coordinator will reach out to the VA case

management team. If a property owner evicts a Veteran, HACC contacts the VA case manager

and provides him/her with a copy of the eviction paperwork and the letter sent to the Veteran.

COMMUNICATION BETWEEN AGENCIES

Monthly meetings are held with the housing authority and Camden VA case management team.

At these meetings, the teams discuss Veterans who are going through the housing process and

any issues individual clients may be experiencing or that will be coming up in the future.

FACILITATORS OF HOUSING SUSTAINABILITY

HACC described a number of facilitators that have made housing sustainability easier for

Veterans:

•  Program flexibility—The smaller size of HACC allows the housing authority to have

more leeway on the services they offer, which can be beneficial for clients.

•  Communication with VA—Having regular meetings with the VA case management team

enables both the VA and the housing authority to provide better, more efficient, and more

personalized services for Veterans.

BARRIERS TO HOUSING SUSTAINABILITY

HACC indicated several challenges for housing sustainability:

•  Readiness—Some Veterans are not ready to accept the assistance that is being offered

through HUD-VASH due to their personal circumstances, including mental health

challenges and/or drug dependency.

•  Motivation—The housing authority said that the HUD-VASH population can be difficult

to work with as there are some program components that must be completed by the

Veterans.

•  Attrition—Property owners need to lease their units quickly and keep them leased.

Having Veterans drop out of HUD-VASH both prior to lease-up and following lease-up

can cause difficulties in working with property owners.

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PROCESS IMPROVEMENTS / RECOMMENDATIONS

The HUD-VASH program is unique within HACC. HACC reports to the Newark HUD Field

Office and typically interacts only with other entities in New Jersey. HUD-VASH, however,

operates through the Philadelphia VAMC in Philadelphia, PA. HACC often feels like an

independent entity, and while they do receive support from their field office, they were not

included in the local HUD-VASH Boot Camp to improve program efficiencies. It would be

helpful to participate in more local HUD-VASH events.

The use of data by HUD and VA is helpful in ensuring that all parties are reaching their goals.

HACC indicated that since HUD-VASH is just one of several special programs it manages, it is

important to analyze data related to performance and targets.

Step-By-Step Processes

The following chart summarizes the steps in the process of housing Veterans in HUD-VASH—

from initial referral to the program to moving into the housing unit—as well as the roles of the

VA case managers and housing authorities.

VA Case Management

Housing Authority of the City of

Philadelphia Housing Authority

Camden (HACC)

(PHA)

Referral & Admission

Referral & Referral Processing

Walk-In Appointment Initial

Screening

  VA case manager conducts initial

screening with Veteran to determine

eligibility using Veteran medical

records and HOMES assessment

templates. VA case manager informs

Veteran of documentation needed to

complete voucher application.

Prioritization on Interest List

  Initial screening assessment

determines Veteran eligibility and

priority on interest list.

Intake Screening

  Two VA case managers meet with

Veteran to complete more detailed

intake screening.

Case Review & VA Case Manager

Assignment

  VA case managers present Veteran’s

case at weekly committee meeting; if

Veteran is accepted into HUD-VASH,

s/he is assigned a case manager.

Veteran Enrollment in VA Case

Management

HUD-VASH Exit Study

277

Final Report

Appendix H: Philadelphia Site Description

VA Case Management

Housing Authority of the City of

Philadelphia Housing Authority

Camden (HACC)

(PHA)

Voucher Application & Briefing

Voucher Application Completed

  VA case manager assists Veteran in

completing voucher application.

Voucher Application Submitted

  VA case manager submits completed

voucher application and required

documents to housing authority by

mail.

Eligibility Verification

Eligibility Verification

  HACC completes sex offender check

  PHA completes sex offender check

and confirms Veteran eligibility.

and confirms Veteran eligibility.

Voucher Briefing

Voucher Briefing

  Voucher briefing held at HACC

  PHA emails the VA when the HUD-

office.

VASH applicants are “voucher

ready”. The VA contacts the

Veteran.

  Voucher briefings usual y held

every Friday at the Veterans Multi-

Service Center or at the PHA office.

Housing Search

Weekly Meetings

Pre-inspected Units

  Philadelphia VA case management

  PHA pre-inspects units and emails

team offers orientation meetings

list of pre-inspected units to VA

about the program and housing

case management team.

process; attendance required for

Veterans who have not yet been

housed.

  Philadelphia VA case management

team offers housing tour after

orientation meeting to a different

part of the city each week.

  Meetings not offered with Camden

VA case management team.

RFTA Submission

RFTA Processing

RFTA Processing

  The Veteran submits the RFTA to

the VA case worker who then

submits it to PHA’s Special

Programs team.

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278

Final Report

Appendix H: Philadelphia Site Description

VA Case Management

Housing Authority of the City of

Philadelphia Housing Authority

Camden (HACC)

(PHA)

Inspection & Rent Negotiation

Inspection Scheduled

Inspection Scheduled

  HACC expedites inspection process

  PHA expedites inspection process

for HUD-VASH; inspections take

for HUD-VASH; inspections take

place 1 business day following RFTA

place 4-5 business days following

submission.

RFTA submission. Once the RFTA is

submitted, the inspection is added

to the Inspections Dept queue. The

inspection is labeled as “VASH” so

the Inspection Dept knows to

expedite.

Inspection

Inspection

Reinspection

Reinspection

  Reinspections are not expedited;

  Reinspections occur within 1-2

they occur at same rate as other

weeks

clients

Rent Negotiation

Rent Negotiation

  Once the unit is approved, the

Veteran’s file is forwarded to the

Owner Services Dept which then

negotiates the rent with the

property owner.

HAP Contract & Lease

Execution of HAP Contract and

Execution of HAP Contract and

Execution of HAP Contract and

Lease

Lease

Lease

  HAP contract and lease are executed

  HAP contract and lease are

at PHA with PHA leasing agent,

executed at PHA with PHA leasing

property owner, Veteran, and VA

agent, property owner, Veteran and

case manager

VA case manager.

Move-In

Move-In Assistance

  VA case management team tries to

assist with move-in funds and

supplies. Security deposit funding is

available through SSVF and City of

Philadelphia Office of Supportive

Housing. SSVF can also provide thrift

store voucher for furniture purchase.

HUD-VASH Exit Study

279

Final Report

APPENDIX I:

SUPPORTING DATA

CHARACTERISTICS OF HUD-VASH PARTICIPANTS

By Study Group

Exhibit I.1 Sample details, HUD-VASH participants, by study group

HUD-VASH participant count

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Houston

495

17.8

1,013

32.8

260

17.3

Los Angeles

1,643

58.9

1,251

40.5

873

57.9

Palo Alto

314

11.3

680

22.0

293

19.4

Philadelphia

336

12.0

144

4.7

81

5.4

Total

2,788

100

3,088

100

1,507

100

Year of program admission

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

2008 or before

49

1.8

85

2.8

1

0.1

2009

350

12.6

500

16.2

20

1.3

2010

489

17.6

668

21.6

43

2.9

2011

1,018

36.6

914

29.6

243

16.2

2012

832

29.9

585

18.9

338

22.5

2013

45

1.6

312

10.1

502

33.4

2014

0

0.0

24

0.8

356

23.7

Total

2,783

100

3,088

100

1,503

100

Days in HUD-VASH, by quartile

25%

50%

75%

Mean

Stayers

Voucher issuance to end of observation period

917

1,153

1,462

1,230

Move-in to end of observation period

844

1,076

1,391

1,148

Leased-up exiters

Voucher issuance to exit

433

651

968

731

Move-in to exit

365

573

889

658

Nonleased exiters

Voucher issuance to exit

89

129

177

148

Years in HUD-VASH housing

Any

Leased-Up Exiters

N

%

N

%

1 year or longer

5,089

86.6

2,309

74.8

2 years or longer

3,551

60.4

1,116

36.1

Source: VA Homeless Operations Management and Evaluation System (HOMES)

HUD-VASH Exit Study

280

Final Report

Appendix I: Supporting Data

Exhibit I.2 Demographics, HUD-VASH participants, by study group

Gender

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Female

307

11.1

336

10.9

142

9.5

Male

2,469

88.9

2,738

89.1

1,349

90.5

Total

2,776

100

3,074

100

1,491

100

Age

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

<35

233

8.4

357

11.6

229

15.4

35-44

269

9.7

366

11.9

190

12.7

45-54

1,006

36.2

1,045

34.0

417

28.0

55-64

1,025

36.9

1,087

35.4

501

33.6

≥65

243

8.8

219

7.1

154

10.3

Total

2,776

100

3,074

100

1,491

100

Race

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Black or African American

1,627

60.4

1,721

57.4

634

44.6

White

925

34.3

1,105

36.8

683

48.0

Other

141

5.2

173

5.8

106

7.4

Total

2,693

100

2,999

100

1,423

100

Ethnicity

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Hispanic/Latino

189

7.0

234

7.7

148

10.2

Non-Hispanic/Non-Latino

2,500

92.1

2,758

91.2

1,278

88.1

Multiple

25

0.9

32

1.1

24

1.7

Total

2,714

100

3,024

100

1,450

100

Marital status

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Married

286

10.3

360

11.7

207

13.9

Widowed

80

2.9

90

2.9

38

2.6

Separated

252

9.1

310

10.1

141

9.5

Divorced

1,048

37.9

1,372

44.7

554

37.3

Never married

1,099

39.7

939

30.6

546

36.7

Total

2,765

100

3,071

100

1,486

100

VA enrollment priority group

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

≥50% service-connected disability

476

17.2

824

26.9

398

26.9

<50% service-connected disability

528

19.0

552

18.0

262

17.7

No service-connected disability; Medicaid-eligible

1,653

59.6

1,510

49.3

736

49.8

No service-connected disability; Not Medicaid-eligible

3

0.1

4

0.1

5

0.3

Other

114

4.1

174

5.7

76

5.1

Total

2,774

100

3,064

100

1,477

100

Source: VA Medical Record

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281

Final Report

Appendix I: Supporting Data

Exhibit I.3 Military history, HUD-VASH participants, by study group

Period of service

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

World War II

7

0.3

9

0.3

4

0.3

Korean War

44

1.6

24

0.8

14

0.9

Vietnam Era

1,097

39.5

1,197

38.9

480

32.2

Post-Vietnam

993

35.8

980

31.9

444

29.8

Persian Gulf War

574

20.7

796

25.9

508

34.1

Other

61

2.2

68

2.2

40

2.7

Total

2,776

100

3,074

100

1,490

100

OEF/OIF deployment

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

No

2,653

95.6

2,874

93.5

1,314

88.1

Yes

123

4.4

200

6.5

177

11.9

Total

2,776

100

3,074

100

1,491

100

Combat exposure

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

No

2,687

96.8

2,928

95.3

1,427

95.7

Yes

89

3.2

146

4.7

64

4.3

Total

2,776

100

3,074

100

1,491

100

Source: VA Medical Record

Exhibit I.4 Medical and mental/behavioral health conditions, HUD-VASH participants, by study group

Medical conditions

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Any medical condition

703

25.3

853

27.7

388

26.0

Hypertension

378

13.6

452

14.7

203

13.6

Diabetes, uncomplicated

151

5.4

181

5.9

64

4.3

Chronic pulmonary disease

111

4.0

142

4.6

72

4.8

Obesity

106

3.8

144

4.7

50

3.4

Traumatic brain injury

4

0.1

12

0.4

5

0.3

Mental/behavioral health conditions

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Any mental/behavioral health condition

931

33.5

1243

40.4

564

37.8

Post-traumatic stress disorder

165

5.9

251

8.2

158

10.6

Depression

315

11.3

420

13.7

191

12.8

Psychoses

327

11.8

456

14.8

247

16.6

Schizophrenia

212

7.6

332

10.8

176

11.8

Alcohol abuse

435

15.7

594

19.3

299

20.1

Drug abuse

592

21.3

818

26.6

355

23.8

Suicide and intentional self-inflicted injury

100

3.6

169

5.5

92

6.2

Source: VA Medical Record

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Final Report

Appendix I: Supporting Data

By Study Site

Exhibit I.5 Sample details, HUD-VASH participants, by study site

HUD-VASH participant count

Houston

Los Angeles

Palo Alto

Philadelphia

N

%

N

%

N

%

N

%

Stayers

495

28.0  1,643

43.6

314

24.4

336

59.9

Leased-up exiters

1,013

57.3

1,251

33.2

680

52.8

144

25.7

Nonleased exiters

260

14.7

873

23.2

293

22.8

81

14.4

Total

1,768

100

3,767

100

1,287

100

561

100

Year of program admission

Houston

Los Angeles

Palo Alto

Philadelphia

N

%

N

%

N

%

N

%

2008 or before

30

1.7

59

1.6

23

1.8

23

4.1

2009

163

9.2

563

14.9

46

3.6

98

17.5

2010

339

19.2

435

11.6

318

24.8

108

19.3

2011

424

24.0

1,373

36.5

258

20.1

120

21.5

2012

458

25.9

798

21.2

363

28.3

136

24.3

2013

293

16.6

317

8.4

198

15.5

51

9.1

2014

61

3.5

221

5.9

75

5.9

23

4.1

Total

1,768

100

3,766

100

1,281

100

559

100

Source: VA Homeless Operations Management and Evaluation System (HOMES)

Exhibit I.6 Demographics, HUD-VASH participants, by study site

Gender

Houston

Los Angeles

Palo Alto

Philadelphia

N

%

N

%

N

%

N

%

Female

267

15.2

329

8.8

101

7.9

88

15.8

Male

1,493

84.8

3,423

91.2

1,172

92.1

468

84.2

Total

1,760

100

3,752

100

1,273

100

556

100

Age

Houston

Los Angeles

Palo Alto

Philadelphia

N

%

N

%

N

%

N

%

<35

234

13.3

414

11.0

117

9.2

54

9.7

35-44

255

14.5

388

10.3

121

9.5

61

11.0

45-54

614

34.9

1,168

31.1

487

38.3

199

35.8

55-64

590

33.5

1,391

37.1

426

33.5

206

37.1

≥65

67

3.8

391

10.4

122

9.6

36

6.5

Total

1,760

100

3,752

100

1,273

100

556

100

Race

Houston

Los Angeles

Palo Alto

Philadelphia

N

%

N

%

N

%

N

%

Black or African American

1,215

69.5

2,035

56.4

337

27.6

395

73.0

White

455

26.0

1,338

37.1

793

64.9

127

23.5

Other

77

4.4

233

6.5

91

7.5

19

3.5

Total

1,747

100

3,606

100

1,221

100

541

100.0

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Appendix I: Supporting Data

Exhibit I.6 Demographics, HUD-VASH participants, by study site

Ethnicity

Houston

Los Angeles

Palo Alto

Philadelphia

N

%

N

%

N

%

N

%

Hispanic/Latino

69

3.9

337

9.3

153

12.3

12

2.2

Non-Hispanic/Non-Lation

1,670

95.3

3,268

89.7

1,064

85.5

534

97.3

Multiple

13

0.7

37

1.0

28

2.2

3

0.5

Total

1,752

100

3,642

100

1,245

100

549

100

Marital status

Houston

Los Angeles

Palo Alto

Philadelphia

N

%

N

%

N

%

N

%

Married

229

13.0

430

11.5

134

10.5

60

10.8

Widowed

57

3.2

83

2.2

48

3.8

20

3.6

Separated

206

11.7

339

9.1

85

6.7

73

13.2

Divorced

792

45.1

1,402

37.5

611

48.1

169

30.5

Never married

474

27.0

1,485

39.7

393

30.9

232

41.9

Total

1,758

100

3,739

100

1,271

100

554

100

VA enrollment priority group

Houston

Los Angeles

Palo Alto

Philadelphia

N

%

N

%

N

%

N

%

≥50% service-connected disability

361

20.6

912

24.4

311

24.5

114

20.7

<50% service-connected disability

407

23.2

638

17.1

208

16.4

89

16.1

No service-connected disability;

Medicaid-eligible

883

50.3

2,010

53.7

691

54.5

315

57.1

No service-connected disability; Not

Medicaid-eligible

5

0.3

3

0.1

2

0.2

2

0.4

Other

98

5.6

178

4.8

56

4.4

32

5.8

Total

1,754

100

3,741

100

1,268

100

552

100

Source: VA Medical Record

Exhibit I.7 Military history, HUD-VASH participants, by study site

Period of service

Houston

Los Angeles

Palo Alto

Philadelphia

N

%

N

%

N

%

N

%

World War II

1

0.1

15

0.4

3

0.2

1

0.2

Korean War

4

0.2

59

1.6

15

1.2

4

0.7

Vietnam Era

572

32.5

1,492

39.8

478

37.5

232

41.7

Post-Vietnam

556

31.6

1,212

32.3

453

35.6

196

35.3

Persian Gulf War

597

33.9

878

23.4

288

22.6

115

20.7

Other

30

1.7

95

2.5

36

2.8

8

1.4

Total

1,760

100

3,751

100

1,273

100

556

100

HUD-VASH Exit Study

284

Final Report

Appendix I: Supporting Data

Exhibit I.7 Military history, HUD-VASH participants, by study site

OEF/OIF deployment

Houston

Los Angeles

Palo Alto

Philadelphia

N

%

N

%

N

%

N

%

No

1,638

93.1

3,504

93.4

1,174

92.2

525

94.4

Yes

122

6.9

248

6.6

99

7.8

31

5.6

Total

1,760

100

3,752

100

1,273

100

556

100

Combat exposure

Houston

Los Angeles

Palo Alto

Philadelphia

N

%

N

%

N

%

N

%

No

1,677

95.3

3,626

96.6

1,204

94.6

535

96.2

Yes

83

4.7

126

3.4

69

5.4

21

3.8

Total

1,760

100

3,752

100

1,273

100

556

100

Source: VA Medical Record

Exhibit I.8 Medical and mental/behavioral health conditions, HUD-VASH participants, by study site

Medical conditions

Houston

Los Angeles

Palo Alto

Philadelphia

N

%

N

%

N

%

N

%

Any medical condition

446

25.3

954

25.4

396

31.1

148

26.6

Hypertension

246

14.0

490

13.1

214

16.8

83

14.9

Diabetes, uncomplicated

85

4.8

193

5.1

83

6.5

35

6.3

Chronic pulmonary disease

54

3.1

175

4.7

68

5.3

28

5.0

Obesity

51

2.9

181

4.8

54

4.2

14

2.5

Traumatic brain injury

2

0.1

14

0.4

5

0.4

0

0.0

Mental/behavioral health conditions

Houston

Los Angeles

Palo Alto

Philadelphia

N

%

N

%

N

%

N

%

Any mental/behavioral health

condition

735

41.8

1249

33.3

573

45.0

181

32.6

Post-traumatic stress disorder

100

5.7

286

7.6

153

12.0

35

6.3

Depression

237

13.5

431

11.5

196

15.4

62

11.2

Psychoses

293

16.6

419

11.2

246

19.3

72

12.9

Schizophrenia

223

12.7

289

7.7

160

12.6

48

8.6

Alcohol abuse

342

19.4

542

14.4

346

27.2

98

17.6

Drug abuse

551

31.3

714

19.0

377

29.6

123

22.1

Suicide and intentional self-inflicted

injury

132

7.5

89

2.4

104

8.2

36

6.5

Source: VA Medical Record

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Appendix I: Supporting Data

FEATURES OF STUDY SITES

Exhibit I.9 Adult population, 2013

Houston

Los Angeles

Palo Alto

Philadelphia

Overall

3,148,444

7,690,569

4,652,993

1,259,073

Veterans

162,451

295,347

236,174

68,553

% Veterans

5.2

3.8

5.1

5.4

Overall poverty rate

15.2

16.4

12.1

24.0

Veteran poverty rate

8.3

9.6

7.4

11.7

Source: U.S. Census Bureau

Exhibit I.10 Homeless population, 2009-2014

Homeless population – 2009

Houston

Los Angeles

Palo Alto

Philadelphia

All homeless

10,881

47,247

18,494

8,729

Unsheltered

4,068

32,948

10,272

756

Sheltered

6,812

14,299

8,222

7,973

Veterans

1,171

7,052

2,106

509

Unsheltered

517

5,056

1,252

78

Sheltered

654

1,997

854

431

Chronic

2,109

10,269

5,095

785

Unsheltered

1,356

7,949

4,257

446

Sheltered

753

2,320

838

339

Homeless population – 2010

Houston

Los Angeles

Palo Alto

Philadelphia

All homeless

9,732

46,984

18,360

8,417

Unsheltered

4,184

32,372

10,272

863

Sheltered

5,548

14,612

8,088

7,554

Veterans

1,125

6,899

2,039

481

Unsheltered

562

4,766

1,249

85

Sheltered

563

2,133

790

396

Chronic

2,025

10,416

5,083

730

Unsheltered

1,435

7,897

4,257

397

Sheltered

590

2,519

826

333

Homeless population – 2011

Houston

Los Angeles

Palo Alto

Philadelphia

All homeless

12,038

45,042

18,614

8,783

Unsheltered

6,830

28,298

11,468

719

Sheltered

5,208

16,744

7,146

8,064

Veterans

1,574

7,375

1,702

472

Unsheltered

1,019

4,507

1,210

84

Sheltered

554

2,867

492

388

Chronic

2,655

10,969

5,325

801

Unsheltered

2,053

8,591

4,673

415

Sheltered

602

2,378

652

387

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Appendix I: Supporting Data

Exhibit I.10 Homeless population, 2009-2014

Homeless population – 2012

Houston

Los Angeles

Palo Alto

Philadelphia

All homeless

10,429

42,038

17,558

8,092

Unsheltered

6,162

28,234

11,468

702

Sheltered

4,267

13,804

6,090

7,390

Veterans

1,522

5,867

1,550

512

Unsheltered

1,052

4,468

1,210

100

Sheltered

470

1,398

340

412

Chronic

1,966

10,017

5,383

735

Unsheltered

1,719

8,554

4,673

446

Sheltered

248

1,462

709

289

Homeless population – 2013

Houston

Los Angeles

Palo Alto

Philadelphia

All homeless

9,153

51,193

18,996

7,975

Unsheltered

4,670

37,970

12,980

794

Sheltered

4,483

13,223

6,016

7,182

Veterans

1,259

5,776

1,782

534

Unsheltered

645

4,425

1,305

101

Sheltered

614

1,351

477

433

Chronic

1,820

14,900

5,707

851

Unsheltered

1,454

13,354

4,923

481

Sheltered

365

1,546

784

370

Homeless population – 2014

Houston

Los Angeles

Palo Alto

Philadelphia

All homeless

8,067

35,090

18,955

8,803

Unsheltered

3,982

23,005

12,778

507

Sheltered

4,085

12,085

6,177

8,296

Veterans

839

3,627

1,855

525

Unsheltered

453

2,517

1,290

31

Sheltered

387

1,111

565

494

Chronic

1,350

9,390

5,620

1,049

Unsheltered

1,107

7,976

4,846

297

Sheltered

243

1,414

774

753

Source: Point-in-Time Count

Exhibit I.11 Rental market, 2013

Houston

Los Angeles

Palo Alto

Philadelphia

Median rent

$872

$1,205

$1,397

$912

Rent-occupied housing (% of housing  45.7

54.5

45.0

49.7

units that are occupied by renters)

Source: U.S. Census Bureau

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Appendix I: Supporting Data

Exhibit I.12 HUD-VASH program characteristics

HUD-VASH voucher allocation, 2008-2014⌾

Houston

Los Angeles

Palo Alto

Philadelphia

2008

385

840

70

105

2009

280

455

210

140

2010

125

650

250

100

2011

125

425

150

75

2012

200

950

250

135

2013

277

819

265

65

2014

303

930

283

123

Total

1,695

5,069

1,478

743

HUD-VASH average days to placement in permanent housing, 2009-2014⊠

Houston

Los Angeles

Palo Alto

Philadelphia

All

N-CH  CH

All

N-CH  CH

All

N-CH  CH

All

N-CH  CH

Referral to admission

34.3  33.1  36.9  54.6  51.7  57.8  63.4  92.5  55.2  25.5  23.0  30.6

Admission to HA referral

9.6

10.5  7.7

38.8  43.4  33.6  26.7  23.3  27.6  19.0  20.6  15.8

HA referral to receipt of voucher

4.4

4.5

4.1

40.8  42.6  38.9  21.0  24.3  20.1  22.6  23.9  19.9

Receipt of voucher to move-in

63.8  63.0  65.8  87.6  87.2  88.1  66.5  58.6  68.7  81.2  82.7  78.2

Referral to move-in

112.1  111.1  114.4  221.8  224.9  218.4  177.6  198.8  171.6  148.3  150.2  144.4

Admission to move-in

77.9  78.0  77.5  167.2  173.2  160.6  114.2  106.3  116.5  122.7  127.2  113.9

VA performance measures, 2014⊚

Houston

Los Angeles

Palo Alto

Philadelphia

2013 %

2014 %

2013 %  2014 %

2013 %  2014 %

2013 %  2014 %

% vouchers resulting in housing

88.5

93.1

86.1

90.3

97.9

92.7

89.0

91.5

% housed within 90 days

74.6

63.5

22.7

40.2

44.4

40.1

37.5

51.9

% chronic

68.0

84.2

66.1

80.0

73.4

78.1

76.4

83.0

Targeted/prioritized populationsº

Houston

Los Angeles

Palo Alto

Philadelphia

Homeless continuously for 1 year or

longer

X

X

X

X

4+ episodes of homelessness over 3

years

X

X

X

X

Veterans at risk for becoming

homeless

-

-

X

-

Females

-

X

X

-

OEF/OIF/OND Veterans

-

X

X

X

Young adults, ages 18-25

-

-

X

-

Older adults, ages 55 and over

-

X

X

-

Families

-

X

X

X

Substance abuse or dependence

only

-

-

X

-

Mentally ill only

-

-

X

-

Co-occurring substance use and

mental illness

-

X

X

X

Barriers impacting implementation and/or service deliveryº (1=strongly agree, 5=strongly disagree)

Houston

Los Angeles

Palo Alto

Philadelphia

Difficulties hiring qualified staff

5

4

1

3

Difficulties retaining qualified staff  5

4

5

2

Shortfall in recruiting or enrolling  4

4

4

4

target Veterans

Veteran reluctance to access HUD- 4

4

4

2

VASH services

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Appendix I: Supporting Data

Exhibit I.12 HUD-VASH program characteristics

Difficulties retaining target

2

4

4

2

Veterans in HUD-VASH program

Difficulties following up with

2

4

4

2

Veterans in HUD-VASH program

Difficulties providing services as

2

4

4

5

planned

Existing agency rules or regulations  2

4

5

1

Sources: ⌾ HUD (2014b), ⊠Northeast Program Evaluation Center, ⊚VHA Support Service Center, ºStaff Interview/Pre-Interview Questionnaire

PROGRAM ENGAGEMENT AND HOUSING PROCESS

Exhibit I.13 Days to placement in permanent housing, HUD-VASH participants

Stayers

Leased-Up Exiters  Nonleased Exiters

M

SD

M

SD

M

SD

Assessment to admission

46.34

82.19

47.71

94.42

45.01

103.48

Admission to HA referral**

30.46

97.49

25.77

89.81

22.59

68.54

HA referral to receipt of voucher***

34.03

42.66

27.55

36.06  31.29

32.05

Voucher receipt to housing selection***

53.29

53.99

47.68

57.34

57.69

49.20

Housing selection to inspection

16.97

24.45

15.95

23.96

20.12

20.82

Inspection to execution of HAP Contract***

11.12

14.23

9.35

13.05

9.38

13.37

Execution of HAP Contract to move-in

8.26

26.29

8.05

25.87

NA

NA

Admission to receipt of voucher***

64.50

106.25  53.28

97.53

52.96

72.65

Receipt of voucher to move-in***

82.32

62.42

72.93

63.12

NA

NA

Admission to move-in***

146.85

124.54  126.23

117.77  NA

NA

Source: VA Homeless Operations Management and Evaluation System

**p≤0.05, ***p≤0.01

Exhibit I.14 Multiple regression analysis for days between admission and HA referral, HUD-VASH

participantsa (N=6,055)

Estimate

SE

t-value

p

Intercept

12.631

0.793

15.936

0.000

Houston

-3.105

0.376

-8.252

0.000

Palo Alto

-0.644

0.379

-1.701

0.089

Philadelphia

1.274

0.506

2.519

0.012

Leased-Up Exiter

0.695

0.301

2.309

0.021

Nonleased Exiter

1.103

0.446

2.473

0.013

Age

0.031

0.013

2.373

0.018

Male

-0.844

0.462

-1.827

0.068

White

-0.413

0.297

-1.390

0.165

Other race

-0.508

0.582

-0.874

0.382

Service-connected disability

-0.021

0.281

-0.073

0.942

Housing First

0.097

0.499

0.194

0.847

VA case management contact between

admission and HA referral (monthly  -0.219

0.009

-25.556

0.000

average)

a Reference categories: Study site—Los Angeles; Study group—Stayers; Gender—Female; Race—Black; Service-connected disability—No service-connected disability; Housing First—Pre-Housing First.

Note: Adjusted R2=0.166

Bold font indicates p≤0.05

Sources: VA Homeless Operations Management and Evaluation System, VA Medical Record

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Exhibit I.15 Multiple regression analysis for days between HA referral and receipt of voucher, HUD-

VASH participantsa  (N=6,102)

Estimate

Standard Error

t-value

p

Intercept

38.649

1.506

25.670

0.000

Houston

-23.967

0.738

-32.461

0.000

Palo Alto

-2.342

0.712

-3.292

0.001

Philadelphia

-12.661

1.062

-11.922

0.000

Leased-Up Exiter

-0.419

0.572

-0.732

0.464

Nonleased Exiter

2.088

0.923

2.263

0.024

Age

-0.058

0.025

-2.335

0.020

Male

0.626

0.877

0.714

0.475

White

-0.257

0.562

-0.457

0.648

Other race

1.369

1.127

1.215

0.225

Service-connected disability

1.450

0.547

2.650

0.008

Housing First

-7.162

0.989

-7.238

0.000

VA case management contact between

HA referral and receipt of voucher

-0.411

0.037

-11.245

0.000

(monthly average)

a Reference categories: Study site—Los Angeles; Study group—Stayers; Gender—Female; Race—Black; Service-connected disability—No service-connected disability; Housing First—Pre-Housing First.

Note: Adjusted R2=0.255

Bold font indicates p≤0.05

Sources: VA Homeless Operations Management and Evaluation System, VA Medical Record

Exhibit I.16 Multiple regression analysis for days between receipt of voucher and move-in, HUD-VASH

participantsa (N=5,308)

Estimate

Standard Error

t-value

p

Intercept

93.286

3.438

27.132

0.000

Houston

-17.753

1.471

-12.070

0.000

Palo Alto

-11.865

1.767

-6.714

0.000

Philadelphia

-8.317

2.568

-3.238

0.001

Leased-Up Exiter

-2.217

1.230

-1.802

0.072

Age

-0.120

0.058

-2.076

0.038

Male

-0.118

1.989

-0.059

0.953

White

-3.547

1.288

-2.755

0.006

Other race

-3.463

2.615

-1.324

0.186

Service-connected disability

2.446

1.240

1.972

0.049

Housing First

-13.591

2.526

-5.380

0.000

VA case management contact between

receipt of voucher and move-in

-2.913

0.232

-12.537

0.000

(monthly average)

a Reference categories: Study site—Los Angeles; Study group—Stayers; Gender—Female; Race—Black; Service-connected disability—No service-connected disability; Housing First—Pre-Housing First.

Note: Adjusted R2=0.090

Bold font indicates p≤0.05

Sources: VA Homeless Operations Management and Evaluation System, VA Medical Record

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Exhibit I.17 Multiple regression analysis for days between admission and receipt of voucher, HUD-

VASH participantsa (N=5,724)

Estimate

Standard Error

t-value

p

Intercept

60.969

2.681

22.742

0.000

Houston

-35.310

1.652

-21.376

0.000

Palo Alto

-6.384

1.263

-5.056

0.000

Philadelphia

-14.179

1.825

-7.768

0.000

Leased-Up Exiter

-0.394

0.996

-0.395

0.693

Nonleased Exiter

5.414

1.597

3.390

0.001

Age

-0.006

0.043

-0.138

0.890

Male

-0.892

1.604

-0.556

0.578

White

-1.573

0.996

-1.580

0.114

Other race

1.102

1.937

0.569

0.569

Service-connected disability

1.258

0.952

1.322

0.186

Housing First

-12.796

1.798

-7.115

0.000

VA case management contact between

admission and HA referral (monthly  -0.252

0.032

-7.905

0.000

average)

VA case management contact between

HA referral and receipt of voucher

-0.656

0.098

-6.665

0.000

(monthly average)

a Reference categories: Study site—Los Angeles; Study group—Stayers; Gender—Female; Race—Black; Service-connected disability—No service-connected disability; Housing First—Pre-Housing First.

Note: Adjusted R2=0.211

Bold font indicates p≤0.05

Sources: VA Homeless Operations Management and Evaluation System, VA Medical Record

Exhibit I.18 Multiple regression analysis for days between admission and move-in, HUD-VASH

participantsa (N=4,882)

Estimate

Standard Error

t-value

p

Intercept

71.230

3.944

18.062

0.000

Houston

-38.811

2.460

-15.779

0.000

Palo Alto

-10.627

1.999

-5.317

0.000

Philadelphia

-15.501

2.975

-5.210

0.000

Leased-Up Exiter

-0.598

1.387

-0.431

0.666

Age

-0.014

0.065

-0.215

0.830

Male

-3.516

2.369

-1.484

0.138

White

-0.789

1.485

-0.531

0.595

Other race

-1.555

2.923

-0.532

0.595

Service-connected disability

1.851

1.418

1.306

0.192

Housing First

-10.769

3.574

-3.013

0.003

VA case management contact between

admission and HA referral (monthly  -0.373

0.048

-7.725

0.000

average)

VA case management contact between

HA referral and receipt of voucher

-0.780

0.169

-4.623

0.000

(monthly average)

VA case management contact between

receipt of voucher and move-in

-0.505

0.299

-1.687

0.092

(monthly average)

a Reference categories: Study site—Los Angeles; Study group—Stayers; Gender—Female; Race—Black; Service-connected disability—No service-connected disability; Housing First—Pre-Housing First.

Note: Adjusted R2=0.158

Bold font indicates p≤0.05

Sources: VA Homeless Operations Management and Evaluation System, VA Medical Record

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Exhibit I.19 Living situation during HUD-VASH housing process, study respondents

Living situation at voucher receipt

Stayers

Leased-up Exiters  Nonleased Exiters

N

%

N

%

N

%

Emergency shelter

38

10.5

2

2.6

6

12.0

Place not meant for human habitation

41

11.4

9

11.5

9

18.0

Permanent housing

28

7.8

5

6.4

4

8.0

Transitional housing for homeless person

86

23.8

22

28.2

7

14.0

Substance abuse treatment facility or detox center

85

23.5

16

20.5

8

16.0

Family member or friend’s room, apartment or house

72

19.9

19

24.4

14

28.0

Other

11

3.0

5

6.4

2

4.0

Total

361

100

78

100

50

100

Living situation at apartment selection

Stayers

Leased-up Exiters  Nonleased Exiters

N

%

N

%

N

%

Emergency shelter

36

10.0

1

1.3

1

5.9

Place not meant for human habitation

38

10.6

9

11.7

6

35.3

Permanent housing

29

8.1

7

9.1

1

5.9

Transitional housing for homeless person

86

23.9

21

27.3

1

5.9

Substance abuse treatment facility or detox center

80

22.2

16

20.8

3

17.6

Family member or friend's room, apartment or house

79

21.9

17

22.1

4

23.5

Other

12

3.3

6

7.8

1

5.9

Total

360

100

77

100

17

100

Source: Veteran Survey

Exhibit I.20 HUD-VASH enrollment and housing process, study respondents

Ease of HUD-VASH enrollment and housing process (1 = very difficult, 5 = very easy)

Stayers

Leased-Up Exiters Nonleased Exiters

M

SD

M

SD

M

SD

Enrolling in the HUD-VASH program

4.02

1.19

3.98

1.14

3.81

1.16

Submitting applications to HA***

4.01

1.13

3.90

1.15

3.41

1.41

Providing documentation of identity and income to HA***  4.14

1.16

4.18

0.97

3.60

1.44

Finding listings of available apartments

3.89

1.28

3.65

1.33

NA

NA

Finding an acceptable apartment option

3.36

1.46

3.48

1.45

NA

NA

Getting an apartment inspected by HA

4.05

1.17

3.96

1.10

NA

NA

Being selected as a tenant by a landlord

4.17

1.20

4.20

1.12

NA

NA

Obtaining money for rent, security deposit, moving costs  3.62

1.36

3.74

1.24

NA

NA

Steps completed in the housing process by Nonleased exiters before exit

Nonleased Exiters

N

%

Finding listing of available apartments

34

61.8

Finding an acceptable apartment option

25

43.1

Getting an apartment inspected by HA

5

8.6

Being selected as a tenant by a landlord

9

15.5

Obtaining money for rent, security deposit, moving costs

13

22.4

Source: Veteran Survey

*p≤0.10, **p≤0.05, ***p≤0.01

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Appendix I: Supporting Data

Exhibit I.21 Housing selection, study respondents

Number of apartments visited during housing search

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

None

4

1.1

1

1.3

18

34.0

One

104

28.1

21

26.6

5

9.4

Two

52

14.1

14

17.7

2

3.8

Three

56

15.1

12

15.2

2

3.8

Four or more

154

41.6

31

39.2

26

49.1

Total

370

100

79

100

53

100

Proportion of “acceptable” apartments*

Stayers

Leased-Up Exiters  Nonleased Exiters

M

SD

M

SD

M

SD

70.92

33.53

68.41

33.40  42.40

35.15

Reason for apartment choice

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Location/neighborhood

234

63.4

51

65.4

NA

NA

Good repair/quality

27

7.3

3

3.8

NA

NA

Particular features of apartment

56

15.2

10

12.8

NA

NA

I didn't have a choice

52

14.1

14

17.9

NA

NA

Total

369

100

78

100

NA

NA

Comfort during first few nights in apartment

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Not comfortable

38

10.3

10

12.5

NA

NA

Moderately comfortable

116

31.4

18

22.5

NA

NA

Very comfortable

216

58.4

52

65.0

NA

NA

Total

370

100

80

100

NA

NA

Source: Veteran Survey

Exhibit I.22 Services received during housing process and move-in, study respondents

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Assistance getting and receiving appointment with HA

301

81.4

66

82.5

47

83.9

Assistance providing proof of identity or income

171

46.2

36

45.0

26

44.8

Assistance completing and submitting HA application

263

71.3

59

73.8

37

66.1

Assistance finding apartment options

170

46.1

35

43.8

15

26.3

Assistance getting essential move-in items

107

29.0

32

40.0

NA

NA

Assistance moving belongings into the apartment

58

15.7

17

21.3

NA

NA

Assistance setting up utilities

31

8.4

4

5.1

NA

NA

Source: Veteran Survey

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Appendix I: Supporting Data

Exhibit I.23 Housing satisfaction while in HUD-VASH and after exit, study respondents (1 = very

dissatisfied, 5 = completely satisfied)

Housing satisfaction while in HUD-VASH

Stayers

Leased-Up Exiters Nonleased Exiters

M

SD

M

SD

M

SD

Apartment condition

3.78

1.16

3.81

1.13

NA

NA

Affordability

3.84

1.16

3.89

1.16

NA

NA

Building safety and security

3.61

1.23

3.59

1.33

NA

NA

Access to shopping*

4.10

0.97

3.86

1.13

NA

NA

Access to public transportation**

4.31

0.90

4.01

1.15

NA

NA

Neighborhood safety

3.60

1.24

3.39

1.28

NA

NA

Opportunities to socialize

3.63

1.20

3.47

1.23

NA

NA

Housing satisfaction after exit

Stayers

Leased-Up Exiters Nonleased Exiters

M

SD

M

SD

M

SD

Apartment condition***

NA

NA

3.73

1.10

2.98

1.46

Affordability

NA

NA

3.91

1.19

3.67

1.47

Building safety and security*

NA

NA

3.88

1.12

3.31

1.44

Access to shopping

NA

NA

3.83

1.17

3.49

1.26

Access to public transportation

NA

NA

3.76

1.17

3.96

0.94

Neighborhood safety***

NA

NA

3.91

1.13

3.30

1.43

Opportunities to socialize***

NA

NA

3.79

1.26

3.09

1.38

Difference in housing satisfaction of leased-up exiters while in HUD-VASH and after

HUD-VASH

Exit

Difference

M

M

%

Apartment condition

3.81

3.73

-1.6

Affordability

3.89

3.91

0.4

Building safety and security

3.59

3.88

5.8

Access to shopping

3.86

3.83

-0.6

Access to public transportation

4.01

3.76

-5.0

Neighborhood safety

3.39

3.91

10.4

Opportunities to socialize

3.47

3.79

6.4

Source: Veteran Survey

*p≤0.10, **p≤0.05, ***p≤0.01

Exhibit I.24 Program satisfaction, study respondents

Veteran believes HUD-VASH was a good fit for his/her needs

Stayers

Leased-up Exiters  Nonleased Exiters

N

%

N

%

N

%

Yes

354

95.9

72

90.0

51

87.9

No

15

4.1

8

10.0

7

12.1

Total

369

100

80

100

58

100

Reason Veteran does not believe HUD-VASH was a good fit for his/her needs

Stayers

Leased-up Exiters  Nonleased Exiters

N

%

N

%

N

%

Veteran did not need as much support as offered

0

0.0

2

28.6

1

14.3

Veteran needed more support than offered

5

31.3

4

57.1

1

14.3

Program had more rules than acceptable to Veteran

4

25.0

0

0.0

1

14.3

Housing unit did not fit Veteran’s needs

0

0.0

0

0.0

1

14.3

Other

7

43.8

1

14.3

3

42.9

Total

16

100.0  7

100.0

7

100.1

Source: Veteran Survey

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Appendix I: Supporting Data

VA CASE MANAGEMENT

Exhibit I.25 Frequency of VA case management

HUD-VASH participants○

Stayers

Leased-Up Exiters  Nonleased Exiters

M

SD

M

SD

M

SD

30 days prior to admission**

1.06

1.86

0.95

1.57

1.08

1.63

Between admission and HA referral (monthly average)

8.96

14.61

9.54

16.72

9.69

15.96

Between HA referral and receipt of voucher (monthly

average)

3.54

8.03

4.22

9.43

4.08

7.82

Between receipt of voucher and move-in (monthly

average)

2.52

3.88

2.45

3.53

NA

NA

30 days post-move-in

1.93

2.82

2.01

2.75

NA

NA

31-60 days post-move-in

1.59

2.56

1.54

2.41

NA

NA

61-90 days post-move-in

1.49

2.43

1.52

2.25

NA

NA

91-180 days post-move-in (monthly average)

1.45

2.47

1.43

1.86

NA

NA

181 – 360 days post-move-in (monthly average)*

1.41

2.03

1.32

1.41

NA

NA

361-720 days post-move-in (monthly average)***

0.88

1.31

1.22

1.40

NA

NA

Self-reported number of monthly meetings with VA case manager, study respondentsº

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Do not meet with case manager

22

6.1

4

5.0

3

5.5

Less than once per month

70

19.3

12

15.0

1

1.8

Once per month

215

59.2

45

56.3

14

25.5

One to two times per month

40

11.0

11

13.8

18

32.7

More than twice per month

16

4.4

8

10.0

19

34.5

Total

363

100

80

100

55

100

Sources: ○VA Medical Record, ºVeteran Survey

*p≤0.10, **p≤0.05, ***p≤0.01

Exhibit I.26 VA case management satisfaction, study respondents (1 = never, 5 = always)

Stayers

Leased-Up Exiters Nonleased Exiters

M

SD

M

SD

M

SD

My case manager was able to help me***

4.30

0.93

3.86

1.25

3.56

1.30

My case manager and I agreed on goals***

4.39

0.83

3.74

1.35

3.92

1.10

My case manager and I had the same ideas about what my  4.01

1.18

3.89

1.22

4.19

1.10

problems were

My case manager and I trusted each other***

4.46

0.96

3.95

1.40

4.15

1.11

Source: Veteran Survey

*p≤0.10, **p≤0.05, ***p≤0.01

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Appendix I: Supporting Data

VA HEALTH SERVICES UTILIZATION

Exhibit I.27 VA services utilization, HUD-VASH participants

90 days prior to entry

Stayers

Leased-up Exiters  Nonleased Exiters

M

SD

M

SD

M

SD

Outpatient

Medical**

5.37

10.73

6.02

11.02

4.83

10.15

Mental/behavioral health***

4.05

7.67

4.61

8.19

3.16

6.44

Substance use***

3.81

13.76

4.40

12.66

2.25

10.28

N

%

N

%

N

%

Inpatient

Medical

130

4.9

168

5.7

91

6.4

Mental/behavioral health*

111

4.2

159

5.4

75

5.3

Substance use**

97

3.6

153

5.2

71

5.0

M

SD

M

SD

M

SD

Average inpatient length of stay

Medical

18.34

43.38

19.67

53.06

20.77

49.94

Mental/behavioral health

31.22

65.36

28.03

54.02

30.25

59.09

Substance use

27.62

52.18

26.39

51.49

22.79

46.40

N

%

N

%

N

%

Emergency care***

453

17.0

622

21.0

305

21.4

90 days post entry

Stayers

Leased-up Exiters  Nonleased Exiters

M

SD

M

SD

M

SD

Outpatient

Medical**

4.59

9.08

4.68

8.51

3.98

8.70

Mental/behavioral health***

3.73

7.96

4.13

8.07

2.56

5.99

Substance use***

2.92

12.09

3.15

10.60

1.63

8.42

N

%

N

%

N

%

Inpatient

Medical**

101

3.6

156

5.1

68

4.7

Mental/behavioral health**

83

3.0

129

4.2

60

4.1

Substance use***

61

2.2

92

3.0

65

4.5

M

SD

M

SD

M

SD

Average inpatient length of stay

Medical

18.32

48.17

22.90

61.76

21.18

51.38

Mental/behavioral health

33.63

61.67

36.97

68.11

26.74

60.95

Substance use

23.43

53.75

19.77

43.60

23.18

50.97

N

%

N

%

N

%

Emergency care***

404

14.6

534

17.4

307

21.2

90 days post move-in

Stayers

Leased-up Exiters  Nonleased Exiters

M

SD

M

SD

M

SD

Outpatient

Medical

3.46

7.48

3.37

7.60

NA

NA

Mental/behavioral health

2.72

6.72

2.99

6.91

NA

NA

Substance use

1.98

9.61

2.01

8.49

NA

NA

N

%

N

%

N

%

Inpatient

Medical*

79

2.8

112

3.7

NA

NA

Mental/behavioral health

61

2.2

81

2.7

NA

NA

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Appendix I: Supporting Data

Exhibit I.27 VA services utilization, HUD-VASH participants

Substance use**

35

1.3

61

2.0

NA

NA

M

SD

M

SD

M

SD

Average inpatient length of stay

Medical

23.13

68.95

17.98

55.28

NA

NA

Mental/behavioral health***

57.47

103.87  33.61

74.51

NA

NA

Substance use

20.39

54.87

18.71

58.09

NA

NA

N

%

N

%

N

%

Emergency care***

314

11.3

472

15.8

NA

NA

90 days pre-exit

Leased-up Exiters  Nonleased Exiters

M

SD

M

SD

Outpatient

Medical

3.34

9.03

3.15

6.91

Mental/behavioral health

1.52

5.13

1.79

5.76

Substance use

0.88

5.83

0.94

5.64

N

%

N

%

Inpatient

Medical

136

4.5

47

4.3

Mental/behavioral health***

64

2.1

48

4.4

Substance use*

71

2.3

36

3.3

M

SD

M

SD

Average inpatient length of stay

Medical**

9.20

22.80

18.13

52.19

Mental/behavioral health***

10.02

30.28

29.15

71.61

Substance use*

9.81

35.74

18.88

56.59

N

%

N

%

Emergency care

502

16.5

194

17.9

30 days post-exit

Leased-up Exiters  Nonleased Exiters

M

SD

M

SD

Outpatient

Medical**

0.87

3.21

1.12

3.87

Mental/behavioral health***

0.45

1.78

0.61

2.23

Substance use

0.28

2.21

0.23

1.65

N

%

N

%

Inpatient

Medical

54

1.8

36

2.5

Mental/behavioral health

39

1.3

23

1.6

Substance use**

40

1.3

33

2.3

M

SD

M

SD

Average inpatient length of stay

Medical**

8.71

25.35

22.94

63.82

Mental/behavioral health

14.44

40.14

20.35

51.94

Substance use

20.33

58.70

23.52

61.65

N

%

N

%

Emergency care**

151

5.1

97

6.8

31-90 days post-exit

Leased-up Exiters  Nonleased Exiters

M

SD

M

SD

Outpatient

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Appendix I: Supporting Data

Exhibit I.27 VA services utilization, HUD-VASH participants

Medical

1.68

5.05

1.79

5.18

Mental/behavioral health

0.83

3.44

0.90

2.69

Substance use*

0.59

4.11

0.36

2.67

N

%

N

%

Inpatient

Medical*

66

2.4

43

3.3

Mental/behavioral health

46

1.7

30

2.3

Substance use**

40

1.4

32

2.5

M

SD

M

SD

Average inpatient length of stay

Medical**

7.51

23.40

20.21

55.22

Mental/behavioral health

13.98

35.85

12.18

36.16

Substance use

9.19

25.67

14.96

42.98

N

%

N

%

Emergency care**

237

8.6

137

10.6

91-180 days post-exit

Leased-up Exiters  Nonleased Exiters

M

SD

M

SD

Outpatient

Medical*

2.32

7.25

2.72

7.15

Mental/behavioral health

1.05

3.89

1.27

4.03

Substance use

0.79

5.47

0.58

4.21

N

%

N

%

Inpatient

Medical**

70

2.9

48

4.3

Mental/behavioral health

45

1.8

24

2.2

Substance use**

37

1.5

29

2.6

M

SD

M

SD

Average inpatient length of stay

Medical

5.67

19.71

9.62

23.73

Mental/behavioral health

12.56

32.47

10.28

29.06

Substance use*

10.48

32.29

21.38

56.10

N

%

N

%

Emergency care

286

11.7

150

13.6

181-360 days post-exit

Leased-up Exiters  Nonleased Exiters

M

SD

M

SD

Outpatient

Medical

4.72

10.95

4.67

10.69

Mental/behavioral health

2.17

6.47

2.34

6.51

Substance use

1.63

11.92

1.08

8.86

N

%

N

%

Inpatient

Medical

95

5.2

57

6.7

Mental/behavioral health

56

3.1

24

2.8

Substance use*

43

2.4

32

3.7

M

SD

M

SD

Average inpatient length of stay

Medical

7.03

22.29

5.94

13.01

Mental/behavioral health

7.42

25.20

8.77

29.06

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Appendix I: Supporting Data

Exhibit I.27 VA services utilization, HUD-VASH participants

Substance use

10.04

38.54

13.22

42.69

N

%

N

%

Emergency care

340

18.7

168

19.7

Source: VA Medical Record

*p≤0.10, **p≤0.05, ***p≤0.01

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Appendix I: Supporting Data

Exhibit I.28 Self-reported health in HUD-VASH, study respondents

Self-reported health status

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Excellent

26

7.0

2

2.5

2

3.4

Very good

72

19.5

11

13.8

15

25.9

Good

128

34.6

30

37.5

13

22.4

Fair

114

30.8

31

38.8

20

34.5

Poor

30

8.1

6

7.5

8

13.8

Total

370

100

80

100

58

100

Self-reported medical problems

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Experienced serious medical problems

213

57.6

41

51.3

31

53.4

Hospitalized for medical problem

143

38.6

25

31.3

14

24.1

Experienced serious medical problems AND were

127

34.3

24

30.0

13

22.4

hospitalized for medical problem

Self-reported mental health problems

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Experienced serious mental health problems

143

38.9

48

60.0

24

41.4

Hospitalized for mental health problem

37

10.0

12

15.0

6

10.3

Experienced serious mental health problems AND were

33

8.9

12

15.0

5

8.6

hospitalized for mental health problem

Self-reported being “troubled” by drugs/alcohol

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Not at all

253

68.6

43

53.8

37

63.8

Slightly

67

18.2

15

18.8

14

24.1

Moderately

34

9.2

8

10.0

3

5.2

Considerably

11

3.0

6

7.5

1

1.7

Extremely

4

1.1

8

10.0

3

5.2

Total

369

100.1

80

100.1

58

100.0

Self-reported drug/alcohol treatment

Stayers

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

N

%

Inpatient

15

4.1

0

0.0

5

8.6

Outpatient

55

14.9

13

16.3

7

12.1

Both inpatient and outpatient

22

6.0

6

7.5

3

5.2

No treatment

276

75.0

61

76.3

43

74.1

Total

368

100

80

100

58

100

Source: Veteran Survey

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Appendix I: Supporting Data

EXITS FROM HUD-VASH

Exhibit I.29 Logistic regression modeling exits from HUD-VASH (leased-up exit vs. stay), HUD-VASH

participantsa (N=5,850)

Estimate

Standard Error

Odds Ratio

p

Intercept

-0.148

0.159

0.863

0.352

Houston

0.975

0.067

2.652

0.000

Palo Alto

1.066

0.081

2.903

0.000

Philadelphia

-0.553

0.107

0.575

0.000

Age

-0.008

0.003

0.992

0.002

Male

0.199

0.092

1.221

0.030

White

0.011

0.061

1.011

0.859

Other race

0.033

0.124

1.034

0.789

Service-connected disability

0.312

0.058

1.366

0.000

a Reference categories: Study site—Los Angeles; Gender—Female; Race—Black; Service-connected disability—No service-connected disability.

Note: Nagelkerke R2=0.107

Bold font indicates p≤0.05

Sources: VA Homeless Operations Management and Evaluation System (HOMES), VA Medical Record

Exhibit I.30 Logistic regression modeling exits from HUD-VASH (Nonleased vs. leased-up exit), HUD-

VASH participantsa (N=4,565)

Estimate

Standard Error

Odds Ratio

p

Intercept

-0.270

0.183

0.763

0.139

Houston

-0.960

0.084

0.383

0.000

Palo Alto

-0.606

0.086

0.545

0.000

Philadelphia

-0.185

0.149

0.831

0.213

Age

-0.007

0.003

0.993

0.021

Male

0.085

0.112

1.088

0.451

White

0.434

0.070

1.544

0.000

Other race

0.373

0.134

1.452

0.005

Service-connected disability

-0.070

0.069

0.932

0.306

PTSD

0.226

0.111

1.254

0.042

a Reference categories: Study site—Los Angeles; Gender—Female; Race—Black; Service-connected disability—No service-connected disability; PTSD—No diagnosis.

Note: Nagelkerke R2=0.065

Bold font indicates p≤0.05

Sources: VA Homeless Operations Management and Evaluation System, VA Medical Record

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Appendix I: Supporting Data

Exhibit I.31 Reasons for exits reported by VA case managers, HUD-VASH participants

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

Accomplished goals or obtained access to services and no longer needs

program

1,306

42.5

28

1.9

Cannot be located

91

3

247

16.6

Deceased

268

8.7

18

1.2

Evicted by HA or landlord or other housing issues

280

9.1

10

0.1

Found/chose other housing

248

8.1

212

14.2

Incarcerated

115

3.7

54

3.6

No longer financially eligible

151

4.9

90

6

No longer interested in participating in HUD-VASH

176

5.7

327

21.9

Noncompliance with HUD-VASH case management

82

2.7

151

10.1

Too ill to participate in HUD-VASH

48

1.6

25

1.7

Transferred to another HUD-VASH program site

46

1.5

31

2.1

Unhappy with HUD-VASH housing

16

0.5

NA

NA

Other

243

7.9

299

20

Total

3,070

100

1,855

100

Source: VA Homeless Operations Management and Evaluation System

Exhibit I.32 Reasons for exits identified by housing authority and VA staff

Houston

Los Angeles

Palo Alto

Philadelphia

Leased-

Nonleased  Leased-

Nonleased  Leased

Nonleased  Leased-

Nonleased

Up Exiters  Exiters

Up Exiters  Exiters

fee-Up

Exiters

Up Exiters  Exiters

Exiters

Challenging process

-

X

-

-

-

X

-

X

Death

-

-

-

-

X

-

X

-

Eviction

X

-

-

-

-

-

-

-

Homeownership

-

-

-

-

-

-

X

-

Housing preference

-

-

-

X

-

-

-

-

Incarceration

X

-

X

-

X

X

X

-

Increase in income

X

-

-

X

X

X

X

X

Isolation

-

X

-

-

-

-

X

-

Lease or program

violations

X

-

X

-

-

-

X

-

Loss of contact

-

X

X

X

X

X

X

-

Mass briefings

-

X

-

-

-

-

-

-

Mental illness

-

-

-

X

-

X

-

-

Motivation

-

X

-

-

-

X

-

X

Move/port

-

-

-

-

-

-

X

-

Noncompliance with

VA case management

X

-

-

-

-

-

-

-

Nonpayment of rent

X

-

-

-

-

-

X

-

Personal history (e.g.,

bad credit, poor rental

-

-

-

-

-

X

-

-

record)

Problem with housing

unit

-

-

-

-

-

-

X

-

Readiness

X

-

-

-

X

-

-

X

SUD

X

-

-

X

-

X

-

-

Unit abandonment

X

-

-

-

-

-

X

-

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Appendix I: Supporting Data

Exhibit I.32 Reasons for exits identified by housing authority and VA staff

Voucher as safety net

-

X

-

-

-

-

-

-

Withdrawal

-

-

x

X

x

-

X

-

Source: Staff Interview

Exhibit I.33 Reasons for exits, study respondents

Main reason for exit

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

Apartment that was found did not pass inspection

NA

NA

2

3.8

Conflict with HUD-VASH case manager or other program staff

4

5.4

3

5.7

Conflict with landlord

3

4.1

NA

NA

Conflict with neighbors

2

2.7

NA

NA

Couldn't find an available apartment to rent with the voucher

NA

NA

3

5.7

Difficulty paying the rent

6

8.1

NA

NA

Disagreement with program rules

0

0

3

5.7

Dissatisfaction with apartment

2

2.7

NA

NA

Dissatisfaction with available apartments

NA

NA

6

11.3

Dissatisfaction with neighborhood

2

2.7

NA

NA

Evicted from apartment

5

6.8

NA

NA

Improvement in health condition

0

0

1

1.9

Improvement in substance abuse condition

1

1.4

0

0

Increase in income

20

27.0

6

11.3

Legal trouble such as arrest, jail, warrant, probation, lawsuit or trial

3

4.1

2

3.8

Offer from family or friends to move into their housing

8

10.8

8

15.1

Voucher revoked by HA

3

4.1

12

22.6

Worsening in medical condition

6

8.1

2

3.8

Worsening in mental health condition

3

4.1

2

3.8

Worsening in substance abuse condition

6

8.1

3

5.7

Total

74

100

53

100

Contributing factors to exit, %

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

Apartment that was found did not pass inspection

NA

NA

3

5.2

Conflict with HUD-VASH case manager or other program staff

9

11.4

5

8.6

Conflict with landlord

15

19

NA

NA

Conflict with neighbors

11

13.9

NA

NA

Couldn’t find an available apartment to rent with voucher

NA

NA

15

25.9

Did not have money to pay for security deposit or furniture

NA

NA

9

15.5

Difficulty paying the rent

19

24.1

NA

NA

Disagreement with program rules

4

5.1

6

10.3

Dissatisfaction with apartment

11

13.9

NA

NA

Dissatisfaction with available apartments

NA

NA

19

32.8

HUD-VASH Exit Study

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Appendix I: Supporting Data

Exhibit I.33 Reasons for exits, study respondents

Dissatisfaction with neighborhood

10

12.7

NA

NA

Evicted from apartment

16

20.3

NA

NA

Improvement in health condition

7

8.9

2

3.4

Improvement in mental health condition

6

7.6

1

1.7

Improvement in substance abuse condition

5

6.3

1

1.7

Increase in income

29

36.7

6

10.3

Legal trouble such as arrest, jail, warrant, probation, lawsuit or trial

7

8.9

3

5.2

Offer from family or friend to move into their housing

11

13.9

13

22.4

Voucher revoked by HA

9

11.4

15

26.3

Worsening in medical condition

11

13.9

9

15.5

Worsening in mental health condition

13

16.5

8

13.8

Worsening in substance abuse condition

15

19.0

6

10.3

Contributing factors to exit, mean (1=yes, 2=no)

Leased-Up Exiters  Nonleased Exiters

M

SD

M

SD

Apartment that was found did not pass inspection

NA

NA

1.95

.223

Conflict with HUD-VASH case manager or other program staff

1.89

.320

1.91

.283

Conflict with landlord

1.81

.395

NA

NA

Conflict with neighbors

1.86

.348

NA

NA

Couldn’t find an available apartment to rent with voucher

NA

NA

1.74

.442

Did not have money to pay for security deposit or furniture

NA

NA

1.84

.365

Difficulty paying the rent

1.76

.430

NA

NA

Disagreement with program rules

1.95

.221

1.90

.307

Dissatisfaction with apartment

1.86

.348

NA

NA

Dissatisfaction with available apartments

NA

NA

1.67

.473

Dissatisfaction with neighborhood

1.87

.335

NA

NA

Evicted from apartment

1.80

.404

NA

NA

Improvement in health condition

1.91

.286

1.97

.249

Improvement in mental health condition

1.92

.267

1.98

.131

Improvement in substance abuse condition

1.94

.245

1.98

.131

Increase in income***

1.63

.485

1.90

.307

Legal trouble such as arrest, jail, warrant, probation, lawsuit or trial

1.91

.286

1.95

.223

Offer from family or friend to move into their housing

1.86

.348

1.78

.421

Voucher revoked by HA**

1.89

.320

1.74

.444

Worsening in medical condition

1.86

.348

1.84

.365

Worsening in mental health condition

1.84

.373

1.86

.348

Worsening in substance abuse condition

1.81

.395

1.90

.307

Leased-up exiters’ most common main exit reason categories with related contributing factors, %

Leased-Up Exiters

N

%

Increase in income

20

27.0

Improvement in health condition

4

20.0

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Appendix I: Supporting Data

Exhibit I.33 Reasons for exits, study respondents

Improvement in mental health condition

3

15.0

Improvement in substance abuse condition

3

15.0

Worsening in medical, mental health or substance use condition

15

20.3

Conflict with HUD-VASH case manager or other program staff

2

13.3

Conflict with landlord

3

20.0

Conflict with neighbors

3

20.0

Difficulty paying the rent

5

33.3

Dissatisfaction with the apartment

3

20.0

Evicted from apartment

4

26.7

Voucher revoked by HA

3

20.0

Worsening in medical condition

7

46.7

Worsening in mental health condition

10

66.7

Worsening in substance use condition

9

60.0

Difficulty with housing (combination of conflict with landlord, conflict with

9

12.2

neighbors, dissatisfaction with apartment and dissatisfaction with

neighborhood)

Evicted from apartment

2

22.2

Increase in income

2

22.2

Nonleased exiters’ most common main exit reason categories with related contributing factors, %

Nonleased Exiters

N

%

Voucher revoked by HA

12

22.6

Couldn’t find an available apartment to rent with voucher

3

25.0

Dissatisfaction with available apartments

2

16.7

Offer from family or friend to move into their housing

2

16.7

Difficulty with housing (combination of dissatisfaction with available

11

20.8

apartments, couldn’t find an available apartment to rent with voucher, and

apartment that was found did not pass inspection)

Did not have money to pay for security deposit or furniture

2

18.2

Offer from family or friend to move into their housing

2

18.2

Worsening in medical condition

2

18.2

Offer from family or friend to move into their housing

8

15.1

Did not have money to pay for security deposit or furniture

2

25.0

Exit type

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

I decided to leave

45

58.4

33

57.9

I was asked to leave

32

41.6

24

42.1

Total

77

100.0

57

100.0

Contributing factors to exit by exit type

Leased-Up Exiters  Leased-up Exiters  Nonleased Exiters  Nonleased Exiters

Decided to Leave

Asked to Leave

Decided to Leave

Asked to Leave

N

%

N

%

N

%

N

%

Apartment that was found did not

NA

NA

NA

NA

1

3.0

2

8.3

pass inspection

HUD-VASH Exit Study

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Appendix I: Supporting Data

Exhibit I.33 Reasons for exits, study respondents

Conflict with HUD-VASH case

4

8.9

4

12.5

2

6.1

3

12.5

manager or other program staff

Conflict with landlord

5

11.1

10

31.3

NA

NA

NA

NA

Conflict with neighbors

5

11.1

6

18.8

NA

NA

NA

NA

Couldn’t find an available apartment  NA

NA

NA

NA

7

21.2

8

33.3

to rent with voucher

Did not have money to pay for

NA

NA

NA

NA

7

21.2

2

8.3

security deposit or furniture

Difficulty paying the rent

4

8.9

14

43.8

NA

NA

NA

NA

Disagreement with program rules

1

2.2

3

9.4

3

9.1

3

12.5

Dissatisfaction with apartment

8

17.8

3

9.4

NA

NA

NA

NA

Dissatisfaction with available

NA

NA

NA

NA

14

42.4

5

20.8

apartments

Dissatisfaction with neighborhood

7

15.6

3

9.4

NA

NA

NA

NA

Evicted from apartment

0

0.0

16

50.0

NA

NA

NA

NA

Improvement in health condition

5

11.1

2

6.3

1

3.0

1

4.2

Improvement in mental health

4

8.9

2

6.3

1

3.0

0

0.0

condition

Improvement in substance abuse

4

8.9

1

3.1

1

3.0

0

0.0

condition

Increase in income

21

46.7

7

21.9

4

12.1

2

8.3

Legal trouble such as arrest, jail,

1

2.2

6

18.8

0

0.0

3

12.5

warrant, probation, lawsuit or trial

Offer from family or friend to move  10

22.2

1

3.1

11

33.3

2

8.3

into their housing

Voucher revoked by HA

2

4.4

7

21.9

2

6.3

12

50.0

Worsening in medical condition

6

13.3

5

15.6

5

15.2

4

16.7

Worsening in mental health

6

13.3

7

21.9

6

18.2

2

8.3

condition

Worsening in substance abuse

6

13.3

9

28.1

2

6.1

4

16.7

condition

Plans for living arrangement following exit where Veteran decided to leave

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

Plan

43

84.3

26

72.2

No plan

8

15.7

10

27.8

Total

51

100.0

36

100.0

Contributing factors to exit for those with plans for living arrangement following exit where Veteran decided to leave

Leased-Up Exiters  Leased-Up Exiters  Nonleased Exiters  Nonleased Exiters

Plan

No Plan

Plan

No Plan

N

%

N

%

N

%

N

%

Apartment that was found did not

NA

NA

NA

NA

1

3.8

1

10.0

pass inspection

Conflict with HUD-VASH case

5

11.6

0

0.0

1

3.8

2

20.0

manager or other program staff

Conflict with landlord

4

9.3

2

25.0

NA

NA

NA

NA

Conflict with neighbors

5

11.6

0

0.0

NA

NA

NA

NA

Couldn’t find an available apartment  NA

NA

NA

NA

5

19.2

3

30.0

to rent with voucher

HUD-VASH Exit Study

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Appendix I: Supporting Data

Exhibit I.33 Reasons for exits, study respondents

Did not have money to pay for

NA

NA

NA

NA

4

15.4

3

30.0

security deposit or furniture

Difficulty paying the rent

4

9.3

3

37.5

NA

NA

NA

NA

Disagreement with program rules

1

2.3

0

0.0

2

7.7

2

20.0

Dissatisfaction with apartment

6

14.0

3

37.5

NA

NA

NA

NA

Dissatisfaction with available

NA

NA

NA

NA

10

38.5

5

50.0

apartments

Dissatisfaction with neighborhood

6

14.0

2

25.0

NA

NA

NA

NA

Evicted from apartment

0

0.0

1

12.5

NA

NA

NA

NA

Improvement in health condition

5

11.6

0

0.0

1

3.8

0

0.0

Improvement in mental health

4

9.3

0

0.0

1

3.8

0

0.0

condition

Improvement in substance abuse

4

9.3

0

0.0

1

3.8

0

0.0

condition

Increase in income

21

48.8

1

12.5

3

11.5

1

10.0

Legal trouble such as arrest, jail,

1

2.3

1

12.5

0

0.0

2

2.3

warrant, probation, lawsuit or trial

Offer from family or friend to move  9

20.9

1

12.5

12

46.2

1

10.0

into their housing

Voucher revoked by HA

1

2.3

1

12.5

0

0.0

2

20.0

Worsening in medical condition

5

11.6

2

25.0

1

3.8

4

40.0

Worsening in mental health

5

11.6

3

37.5

2

7.7

4

40.0

condition

Worsening in substance abuse

6

14.0

2

25.0

0

0.0

2

20.0

condition

Source: Veteran Survey

*p≤0.10, **p≤0.05, ***p≤0.01

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Appendix I: Supporting Data

Exhibit I.34 Latent class analysis of leased-up exiters, HUD-VASH participants

Class 1

Class 2

Class 3

Class 4

Class 5

N=666, 20.9%  N=536, 16.4%  N=507, 16.6%  N=833, 32.2%  N=417, 13.9%

N

%

N

%

N

%

N

%

N

%

Study site

Houston

316

47.5

0

0.0

199

39.3

352

42.3

122

29.3

Los Angeles

268

40.3

172

32

147

29.0

429

51.5

173

41.5

Palo Alto

45

6.7

364

68

151

29.8

0

0.0

88

21.1

Philadelphia

37

5.5

0

0.0

10

1.9

52

6.2

34

8.2

Gender

Female

223

33.5

24

4.5

66

13.0

8

1.0

5

1.2

Male

443

66.5

512

95.5

441

87.0

825

99.0

412

98.9

Age

<35

230

34.6

30

5.6

77

15.1

0

0.0

0

0.0

35-44

194

29.1

41

7.6

100

19.8

22

2.7

1

0.2

45-54

150

22.5

205

38.3

200

39.5

302

36.2

146

35.1

55-64

90

13.5

196

36.5

115

22.7

418

50.2

239

57.3

≥65

2

0.3

64

11.9

15

3.0

92

11.0

31

7.4

Race

Black

478

71.7

169

31.6

234

46.2

592

71.1

224

53.6

White

161

24.1

322

60.0  233

45.9

197

23.7

181

43.3

Other

28

4.2

46

8.5

40

7.9

44

5.3

13

3.1

Enrollment priority group

≥50% service-connected

disability

314

47.2

102

19.1

251

49.5

78

9.4

51

12.3

<50% service-connected

disability

145

21.8

84

15.6

107

21.2

133

16.0

58

14.0

No service-connected disability  168

25.3

321

59.8

134

26.4

558

67.0

286

68.5

Other

38

5.7

29

5.5

15

2.9

63

7.6

22

5.2

Medical and mental/behavioral health conditions and service use

Any medical condition

37

5.5

75

14

247

48.8

130

15.6

343

82.2

Any mental health condition

34

5.1

41

7.7

415

81.9

53

6.4

316

75.7

Any substance use condition

23

3.4

53

9.8

401

79.1

142

17.1

354

84.8

Any inpatient stay pre-exit

13

2.0

31

5.8

45

8.9

75

9.0

103

24.8

VA case managers’ reason for exit

Accomplished goals

282

42.4

349

65.1

237

46.7

314

37.7

80

19.1

Cannot be located, too ill,

incarcerated, or deceased

28

4.2

62

11.6

47

9.2

197

23.6

166

39.8

No longer financially eligible

69

10.3

6

1.2

58

11.5

11

1.3

1

0.3

Non-compliant with VA case

management or evicted

87

13.1

27

5.1

41

8.1

111

13.3

86

20.6

Transferred to another HUD-

VASH program or found other  91

13.6

31

5.8

55

10.8

77

9.3

30

7.3

housing

Unhappy with housing or no

longer interested in participating 52

7.8

24

4.4

37

7.3

47

5.6

26

6.3

Other

58

8.7

38

7

77

9.2

28

6.6

32

6.4

Sources: VA Homeless Operations Management and Evaluation System, VA Medical Record

HUD-VASH Exit Study

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Appendix I: Supporting Data

Exhibit I.35 Latent class analysis of nonleased exiters, HUD-VASH participants

Class 1

Class 2

Class 3

N=273, 25.2%  N=451, 44.9%  N=313, 29.9%

N

%

N

%

N

%

Study site

Houston

54

19.9

66

14.7

46

14.7

Los Angeles

176

64.5

298

66.1

180

57.5

Palo Alto

35

13.0

73

16.1

73

23.3

Philadelphia

7

2.6

16

3.5

14

4.5

Gender

Female

79

28.8

7

1.5

11

3.4

Male

194

71.2

444

98.5

303

96.7

Age group

<35

95

34.9

10

2.3

49

15.5

35-44

89

32.6

16

3.5

33

10.6

45-54

52

19.2

150

33.3

102

32.5

55-64

37

13.4

200

44.3

113

36.0

≥65

0

0.0

75

16.6

17

5.5

Race

Black

130

47.6

230

51.0

116

37.1

White

105

38.4

206

45.7

171

54.7

Other

38

14.1

15

3.3

26

8.2

Enrollment priority group

≥50% service-connected

disability

124

45.3

53

11.8

104

33.2

<50% service-connected

disability

78

28.6

68

15.0

50

16.1

No service-connected disability

64

23.4

294

65.2

148

47.4

Other

7

2.7

36

8.0

11

3.4

Medical and mental/behavioral health conditions and service use

Any medical condition

18

6.5

62

13.8

203

64.8

Any mental health condition

26

9.5

17

3.8

271

86.6

Any substance use condition

11

4.0

38

8.4

270

86.2

Any inpatient stay pre-exit

27

6.0

75

24.0

15

5.4

VA case managers’ reason for exit

Accomplished goals

10

3.5

9

1.9

4

1.2

Cannot be located, too ill, incarcerated, or deceased

38

14.1

124

27.6

99

31.6

No longer financially eligible

17

6.1

18

4.0

8

2.6

Non-compliant with VA case management or evicted

37

13.6

55

12.1

41

13.2

Transferred to another HUD-VASH program or found other

housing

61

22.5

71

15.7

49

15.6

Unhappy with housing or no longer interested in participating

56

20.6

93

20.7

57

18.1

Other

54

19.7

81

17.9

55

17.7

Sources: VA Homeless Operations Management and Evaluation System, VA Medical Record

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Appendix I: Supporting Data

Exhibit I.36 Veterans’ status post-exit

VA case manager assisted in finding new place to stay following exit, study respondentsº

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

Yes

14

17.7%

6

10.7%

No

65

82.3

50

89.3

Total

79

100

56

100

Plan to continue utilizing VA services, study respondentsº

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

Yes

75

94.9

55

96.5

No

4

5.1

2

3.5

Total

79

100

57

100

Ongoing contact with VA case manager, study respondentsº

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

Yes

13

16.5

10

18.2

No

66

83.5

45

81.8

Total

79

100

55

100

Frequency of VA case management following exit, HUD-VASH participants○

Leased-Up Exiters  Nonleased Exiters

M

SD

M

SD

30 days post-exit***

0.67

1.40

0.46

1.01

31-60 days post-exit**

0.15

1.06

0.08

0.69

61-90 days post-exit*

0.13

0.83

0.07

0.79

Returns to VA homeless programs, HUD-VASH participants●

Leased-Up Exiters  Nonleased Exiters

N

%

N

%

Any

228

7.3

154

10.2

Within 30 days

41

1.3

21

1.4

Within 60 days

74

2.4

38

2.5

Within 90 days

91

2.9

52

3.5

Within 180 days

127

4.1

82

5.4

Within 360 days

183

5.9

120

8.0

Sources: ● VA Homeless Operations Management and Evaluation System, ○ VA Medical Record,

*p≤0.10,

**p≤0.05, ***p≤0.01

ºVeteran Survey

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Appendix I: Supporting Data

Exhibit I.37 Cox proportional hazards survival analysis for time to return to homelessness within 360

days, HUD-VASH participantsa (N=303)

Estimate

Standard Error

Hazard Ratio

p

Houston

-0.261

0.144

0.770

0.070

Palo Alto

-0.314

0.160

0.731

0.050

Philadelphia

0.060

0.246

1.062

0.807

Nonleased exiters

0.371

0.121

1.449

0.002

Age

-0.007

0.006

0.993

0.183

Male

0.563

0.258

1.757

0.029

White

-0.117

0.126

0.890

0.353

Other race

-0.069

0.245

0.934

0.779

Service-connected disability

-0.339

0.122

0.713

0.006

Drug abuse

0.859

0.118

2.360

0.000

a Reference categories: Study site—Los Angeles; Study group—Leased-up exiters; Gender—Female; Race—Black; Service-connected disability—No service-connected disability; Drug abuse—No diagnosis.

Sources: VA Homeless Operations Management and Evaluation System, VA Medical Record

Bold font indicates p≤0.05

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APPENDIX J:

REFERENCES

Andrews, D.E. & Bonta, J. (2010). Rehabilitating criminal justice policy and practice.

Psychology, Public Policy, and Law, 16(1), 39–55.

Austin, E. L., Pollio, D. E., Holmes, S., Schumacher, J., White, B., Lukas, C. V., & Kertesz, S.

(2014). VA’s expansion of supportive housing: Successes and challenges on the path toward

Housing First. Psychiatric Services, 65(5), 641–647.

Blanch, A. K., Carling, P. J., & Ridgway, P. (1988). Normal housing with specialized supports:

A psychiatric rehabilitation approach to living in the community. Rehabilitation Psychology,

33(1), 47–55.

Brenner, L. A., Ignacio, R. V., & Blow, F. C. (2001). Suicide and traumatic brain injury among

individuals seeking Veterans Health Administration services. Journal of Head Trauma and

Rehabilitation, 26(4):257–264.

Byrne, T. H., Fargo, J. D., Montgomery, A. E., Roberts, C. B., Culhane, D. P., & Kane, V.

(2015). Screening for homelessness and risk in a national healthcare system: Monitoring housing

stability through repeat screening. Public Health Reports, 130, 702–710.

Carling, P. J. (1990). Major mental illness, housing and supports. American Psychologist, 45(8),

969–975.

Caton, C. L., Wilkins, C., & Anderson, J. (2007). People who experience long-term

homelessness: Characteristics and Interventions. In D Dennis, G Locke, J Khadduri (Eds.).

Toward understanding homelessness: The 2007 National Symposium on Homelessness

Research. Washington, DC: US Department of Health and Human Services and Department of

Housing and Urban Development.

Caton, C. L., Wyatt, R., & Felix, A. (1992). Follow-up of chronically homeless mentally ill men.

American Journal of Psychiatry, 150, 1639–1642.

Chew, L. D., Bradley, K. A., & Boyko, E. J. (2004). Brief questions to identify patients with

inadequate health literacy. Family Medicine, 36(8), 588–594.

Chew, L. D., Griffin, J. M., Partin, M. R., Noorbaloochi, S., Grill, J. P., Snyder, A., Bradley, K.

A., Nugent, S. M., Baines, A. D., & Vanryn, M. (2008). Validation of screening questions for

limited health literacy in a large VA out-patient population. Journal of General Internal

Medicine, 23(5), 561–566.

Collins, S. E., Malone, D. K., Clifasefi, S. L., Ginzler, J. A., Garner, M. D., Burlingham, B.,

Lonczak, H. S., Dana, E. A., Kirouac, M., Tanzer, K., Hobson, W. G., Marlatt, G. A., & Larimer,

M. E. (2012). Project-based Housing First for chronically homeless individuals with alcohol

problems: Within-subjects analyses of 2-year alcohol trajectories. American Journal of Public

Health, 102(3), 511–519.

Culhane, D. P., Metraux, S., & Hadley, T. (2002). Public service reductions associated with

placement of homeless persons with severe mental illness in supportive housing. Housing Policy

Debate, 13(1), 107–163.

HUD-VASH Exit Study

312

Final Report

Appendix J: References

Elder, J. (2014, September). Connecting Veterans to Social Security Disability benefits: A key

component in ending Veteran homelessness. Accessed 2/24/2015 at:

http://soarworks.prainc.com/sites/soarworks.prainc.com/files/Connecting_Veterans_SSI_SSDI_1

00714.pdf

Elixhauser, A., Steiner, C., Harris, D. R., & Coffey, R. M. (1998). Comorbidity measures for use

with administrative data. Medical Care, 36(1):8–27.

Fargo, J. D., Metraux, S., Byrne, T. H., Munley, E. A., Montgomery, A. E., Jones, H., Sheldon,

G., & Culhane, D. P. (2012). Prevalence and Risk of Homelessness among US Veterans: a

multisite investigation. Preventing Chronic Disease, 9, 110–112.

Glaser, B., & Strauss, A. (1967). The discovery of grounded theory: Strategies for qualitative

research. New York, NY: Aldine De Gruyter.

Goldfinger, S., Schutt, R., Tolomiczenko, G., Seidman, L., Penk, W., Turner, W., & Caplan, B.

(1999). Housing placement and subsequent days homeless among formerly homeless adults with

mental illness. Psychiatric Services, 50(5), 674–679.

Gounis, K., & Susser, E. (1990). Shelterization and its implication for mental health services. In

N. Cohen (Ed.), Psychiatry takes to the streets, pages 231–257. New York: Guilford.

Griffin, D.W., & Bartholomew, K. (1994). The metaphysics of measurement: The case of adult

attachment. Advances in Personal Relationships, 5, 17–52.

Guest, G., MacQueen, K., & Namey, E. (2012). Applied thematic analysis. Los Angeles, CA:

Sage Publications, Inc.

Haley, C. (2013, July). CHA Moving On Pilot. Oral presentation at the National Alliance to End

Homelessness, National Conference on Ending Homelessness, Washington, DC.

Harkness, J., Newman, S., & Salkever, D. (2004). The cost-effectiveness of independent housing

for the chronically mentally ill: Do neighborhood features matter? Health Services Research,

39(5), 1341–1360.

Hays, R. D. (1994). The Medical Outcomes Study (MOS) measures of patient adherence.

Accessed 9/17/2014 at:

http://www.rand.org/health/surveys_tools/mos/mos_core_36item_survey.html

Heitzman, C. (2015). Ending Veteran and Veteran family homelessness: The Homeless Veteran

Supported Employment Program (HVSEP). Accessed 2/25/2015 at:

http://www.pschousing.org/files/IForum_2013_6_19_Carma-

HVSEP%20Slide%20show%202013.pdf

Herman, D. B., Conover, S., Gorroochurn, P., Hinterland, K., Hoepner, L., & Susser, E. (2011).

A randomized trial of critical time intervention to prevent homelessness in persons with severe

mental illness following institutional discharge. Psychiatric Services, 62(7), 713–719.

Herman, D. B., Opler, L., Felix, A., Valencia, E., Wyatt, R. J., & Susser, E. (2000). A critical

time intervention with mentally ill homeless men: impact on psychiatric symptoms. The Journal

of Nervous and Mental Disease, 188(3), 135–140.

Hintze, J. (2008). PASS 2008. NCSS, LLC. Kaysville, Utah, USA.

HUD-VASH Exit Study

313

Final Report

Appendix J: References

Hulburt, M., Hough, R., & Wood, P. (1996). Effects of substance abuse on housing stability of

homeless mentally ill persons in supported housing. Psychiatric Services, 47, 731–736.

Kasprow, W., Rosenheck, R., Frisman, & DiLella, D. (2000). Referral and housing processes in

a long-term supported housing program for homeless Veterans. Psychiatric Services, 51(8),

1017–1023.

Kimerling, R., Gima, K., Smith, M. W., Street, A., & Frayne, S. (2007). The Veterans Health

Administration and military sexual trauma. American Journal of Public Health, 97(12), 2160–

2166.

Kresky-Wolff, M., Larson, M. J., O’Brien, R. W., & McGraw, S. A. (2010). Supportive housing

approaches in the Collaborative Initiative to Help End Chronic Homelessness. Journal of

Behavioral Health Services & Research, 37(2), 213–225.

Linzer, D. A., & Lewis, J. B. (2011). poLCA: An R package for polytomous variable latent class

analysis. Journal of Statistical Software, 42(10), 1-29.

Mares, A., Kasprow, W., & Rosenheck, R. (2004). Outcomes of supported housing for homeless

Veterans with psychiatric and substance abuse problems. Mental Health Services Research, 6(4),

199–211.

McCutcheon, A. L. (1987). Quantitative applications in the social sciences series, number 64:

Latent class analysis. London: Sage Publications. Montgomery, A. E., Dichter, M. E.,

Thomasson, A. M., Fu, X., & Roberts, C. B. (2015). Demographic characteristics associated with

homelessness and risk among female and male Veterans accessing VHA outpatient care.

Women's Health Issues, 25(1), 42–48.

Montgomery, A. E., Hill, L. L., Kane, V., & Culhane, D. P. (2013). Housing chronically

homeless Veterans: Evaluating the efficacy of a housing first approach to HUD-VASH. Journal

of Community Psychology, 41(4), 505–514.

Mulpuri, M., Harris, K. W., & Ruege, A. (2014). Transforming point in time (PIT) counts of

homeless Veterans from Continuums of Care (CoC) to VA Medical Center (VAMC) catchment

areas. VA Center for Applied Systems Engineering.

National Center for Health Statistics. (1980). International Classification of Diseases, Ninth

Revision, Clinical Modification. Hyattsville, MD.

Pearson, C. L., Montgomery, A. E., & Locke, G. (2009). Housing stability among homeless

individuals with serious mental illness participating in Housing First programs. Journal of

Community Psychology, 37(3), 404–417.

QSR International. (2012). NVivo qualitative data analysis software.

Riley, J., Gasper, J., Caperna, K., Liu, H., Sigman, R., Karakus, M., & May, L. (2014).

Vocational rehabilitation and employment longitudinal study: Report to Congress, annual report

2014 for FY 2013. Accessed 2/25/2015 at:

http://www.benefits.va.gov/VOCREHAB/docs/VRELongitudinalStudyReporttoCongressAnnual

Report2014forFY2013.pdf

Rog, D. (2004). The evidence on supported housing. Psychiatric Rehabilitation Journal, 27(4),

334–344.

HUD-VASH Exit Study

314

Final Report

Appendix J: References

Social Security Administration. (2016). Information for Wounded Warriors and Veterans Who

Have a Compensation Rating of 100% Permanent & Total (P&T). Accessed 7/8/2016 at:

https://www.ssa.gov/people/veterans/#&ht=1

Susser, E., Valencia, E., Conover, S., Felix, A., Tsai, W., & Wyatt, R. J. (1997). Preventing

recurrent homelessness among mentally ill men: a “critical time” intervention after discharge

from shelter. American Journal of Public Health, 87(2), 256–262.

Tempel, C. (2013, July). Moving on from supportive housing: Creating successful exits. Oral

presentation at the National Alliance to End Homelessness, National Conference on Ending

Homelessness, Washington, DC.

Treatment Research Institute. (1998). Addiction severity index, fifth edition, 1998 version.

Accessed 9/16/2014 at: http://www.tresearch.org/wp-content/uploads/2012/09/ASI_5th_Ed.pdf

Tsemberis, S. (2010). Housing First: The Pathways model to end homelessness for people with

mental illness and addiction. Hazelden: Center City, MN.

Tsemberis, S., McHugo, G., Williams, V., Hanrahan, P., & Stefancic, A. (2007). Measuring

homelessness and residential stability: The residential time-line follow-back inventory. Journal

of Community Psychology, 35(1), 29–42.

Tsemberis, S., Rogers, E. S., Rodis, E., Dushuttle, P., & Skryha, V. (2003). Housing satisfaction

for persons with psychiatric disabilities. Journal of Community Psychology, 31(6), 581–590.

U.S. Census Bureau. (2013). 2013 American Community Survey. Accessed 9/15/2014 at:

www.http://factfinder2.census.gov

U.S. Department of Housing and Urban Development. (2016a). HUD-VASH vouchers.

Accessed 2/9/2016 at:

http://portal.hud.gov/hudportal/HUD?src=/program_offices/public_indian_housing/programs/hc

v/vash

U.S. Department of Housing and Urban Development. (2016b). Flowchart of HUD’s Definition

of Chronic Homelessness. Washington, DC: Author. Accessed 2/15/2016 at:

https://www.hudexchange.info/resource/5181/flowchart-of-huds-definition-of-chronic-

homelessness/

U.S. Department of Housing and Urban Development. (2015a). The 2015 annual homeless

assessment report to Congress, Part 1: Point-in-time estimates of homelessness. Washington,

DC: Author

U.S. Department of Housing and Urban Development. (2015b). The 2014 annual homeless

assessment report to Congress, Part 2: Estimates of homelessness in the United States.

Washington, DC: Author.

U.S. Department of Housing and Urban Development. (2013). The 2012 annual homeless

assessment report to Congress. Washington, DC: Author.

U.S. Department of Housing and Urban Development, & U.S. Department of Veterans Affairs.

(2011). Veteran homelessness: A supplemental report to the 2010 annual homeless assessment

report to Congress. Washington, DC: Authors.

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Appendix J: References

U.S. Department of Veterans Affairs. (2016). Health benefits: Veterans eligibility. Accessed

2/1/2016 at: http://www.va.gov/healthbenefits/apply/veterans.asp

U.S. Department of Veterans Affairs. (2015). Compensated Work Therapy. Accessed 2/25/2015

at: http://www.va.gov/health/cwt/

U.S. Interagency Council on Homelessness. (2014). Opening doors: Federal strategic plan to

prevent and end homelessness, update 2013. Washington, DC: Author.

U.S. Interagency Council on Homelessness. (2010). Opening doors: Federal strategic plan to

prevent and end homelessness. Washington, DC: Author.

Viera, A. J., & Garrett, J. M. (2005). Understanding inter-observer agreement: The kappa

statistic. Family Medicine, 37(5), 360–363.

Wong, Y-L. I., Hadley, T. R., Culhane, D. P., Poulin, S. R., Davis, M. R., Cirksey, B. A., &

Brown, J. L. (2006). Predicting staying in or leaving permanent supportive housing that serves

homeless people with serious mental illness. Washington, DC: U.S. Department of Housing and

Urban Development, Office of Policy Development and Research.

Wong, Y-L. I., Poulin, S. R., Lee, S., Davis, M. R., & Hadley, T. R. (2008). Tracking residential

outcomes of supported independent living programs for persons with serious mental illness.

Evaluation and Program Planning, 31, 416–426.

Zimet, G.D., Dahlem, N.W., Zimet, S.G., & Farley, G.K. (1988). The Multidimensional Scale of

Perceived Social Support. Journal of Personality Assessment, 52, 30–41.

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U.S. Department of Housing and Urban Development

Office of Policy Development and Research

Washington, DC 20410-6000

September 2017

Document Outline

- Cover

- TItle Page

- ACKNOWLEDGMENTS

- DISCLAIMER

- PREFACE

- MESSAGE FROM THE U.S. DEPARTMENT OF VETERANS AFFAIRS

- TABLE OF CONTENTS

- LIST OF EXHIBITS

- EXECUTIVE SUMMARY

- Summary Exhibit 1. Veteran Data Sources and Sample Sizes

- Summary Exhibit 2. Reasons for Exits Reported by VA Case Managers, Percent of HUD-VASH Participants

- Summary Exhibit 3. Profiles of Leased-Up Exiters, HUD-VASH Participants

- Summary Exhibit 4. Profiles of Nonleased Exiters, HUD-VASH Participants

- Summary Exhibit 5. Overview of HUD-VASH Processes

- CHAPTER 1: INTRODUCTION AND OVERVIEW OF STUDY

- BACKGROUND

- PREVIOUS RESEARCH

- OVERVIEW OF STUDY

- THIS REPORT

- CHAPTER 2: METHODS

- STUDY SITE SELECTION

- VETERAN SAMPLE SELECTION

- Exhibit 2.1 Study Group Pathways Into and Out of HUD-VASH

- Exhibit 2.2 HUD-VASH Participant Count

- Exhibit 2.3 Year of Program Admission, HUD-VASH Participants

- Exhibit 2.4 Days in HUD-VASH, by Quartile, HUD-VASH Participants

- Exhibit 2.5 Years in HUD-VASH Housing, HUD-VASH Participants

- Exhibit 2.6 Study Site Recruitment and Enrollment

- Exhibit 2.7 Study Respondent Count

- Exhibit 2.8 Qualitative Respondent Count

- DATA COLLECTION

- Exhibit 2.9 Administrative Data Sources and Variables

- DATA ANALYSIS

- CHAPTER 3: CHARACTERISTICS OF HUD-VASH PARTICIPANTS

- DEMOGRAPHICS

- Exhibit 3.1 Age, HUD-VASH Participants

- Exhibit 3.2 Race and Ethnicity, HUD-VASH Participants

- Exhibit 3.3 Marital Status, HUD-VASH Participants

- Exhibit 3.4 VA Enrollment Priority Group, HUD-VASH Participants

- MILITARY HISTORY

- Exhibit 3.5 Period of Service and Combat Exposure, HUD-VASH Participants

- MEDICAL CONDITIONS AND MENTAL OR BEHAVIORAL HEALTH CONDITIONS

- Exhibit 3.6 Medical Conditions and Mental or Behavioral Health Conditions, HUD-VASH Participants

- DESCRIPTIVE BACKGROUND CHARACTERISTICS

- Exhibit 3.7 Background Characteristics, Qualitative Respondents

- SUMMARY

- CHAPTER 4: FEATURES OF STUDY SITES

- POPULATION DATA

- Exhibit 4.1 Adult Population, 2013

- HOMELESSNESS AND HOUSING CONTEXT

- Exhibit 4.2 Homeless Population, 2009–2014 | count

- Exhibit 4.3 Veteran Homeless Population, 2009–2014 | count

- Exhibit 4.4 Proportion Sheltered/Unsheltered Veteran Homeless, 2014 | count and percent

- Exhibit 4.5 Rental Market, 2013

- HUD-VASH VOUCHER ALLOCATION

- Exhibit 4.6 HUD-VASH Voucher Allocation, 2008–2014 | count

- HUD-VASH PROCESSES

- Exhibit 4.7 Overview of HUD-VASH Processes

- STUDY SITE PROCESSES

- Exhibit 4.8 Houston HUD-VASH Processes

- Exhibit 4.9 Los Angeles HUD-VASH processes

- Exhibit 4.10 Palo Alto HUD-VASH Processes

- Exhibit 4.11 Philadelphia HUD-VASH Processes

- STUDY SITE OUTCOMES

- Exhibit 4.12 HUD-VASH Days to Placement in Permanent Housing, 2009–2014 (N=7,383) | mean

- Exhibit 4.13 VA Performance Measures, 2014 | percent

- Exhibit 4.14 Ease of HUD-VASH Enrollment Process, Study Respondents (N=508) | mean

- Exhibit 4.15 Ease of HUD-VASH Housing Process, Study Respondents (N=508) | mean

- SUMMARY

- CHAPTER 5: PROGRAM ENGAGEMENT AND HOUSING PROCESS

- TIME TO PLACEMENT IN PERMANENT HOUSING

- Exhibit 5.1 Days to Placement in Permanent Housing, HUD-VASH Participants (N=7,383) | mean

- Exhibit 5.2 Summary of Multiple Regression Analyses, HUD-VASH Participants

- LIVING SITUATION PRIOR TO HUD-VASH AND SOURCE OF REFERRAL

- Exhibit 5.3 Living Situation at Voucher Receipt, Study Respondents (N=489) | percent

- Exhibit 5.4 Living Situation at Apartment Selection, Study Respondents (N=454) | percent

- Exhibit 5.5 Living Situations, Qualitative Respondents

- Exhibit 5.6 Exposure to Program/Referral Source, Qualitative Respondents

- HUD-VASH ENROLLMENT PROCESS

- Exhibit 5.7 Ease of HUD-VASH Enrollment Process, Study Respondents (N=508) | mean

- Exhibit 5.8 Enrollment Process Experiences, Qualitative Respondents

- Exhibit 5.9 Negative Program Orientation Experiences, Qualitative Respondents

- Exhibit 5.10 Program Rules and Regulations, Qualitative Respondents

- HUD-VASH HOUSING PROCESS

- Exhibit 5.11 Ease of HUD-VASH Housing Process, Study Respondents (N=508) | mean

- Exhibit 5.12 Number of Apartments Visited During Housing Search, Study Respondents (N=502) | percent

- Exhibit 5.13 Services Received During Housing Process, Study Respondents (N~508) | percent

- Exhibit 5.14 Services Received During Move-in, Study Respondents (N=458) | percent

- FACILITATORS AND BARRIERS

- Exhibit 5.15 HUD-VASH Housing Process Facilitators and Barriers, Qualitative Respondents

- HOUSING SATISFACTION

- Exhibit 5.16 Housing Satisfaction While in HUD-VASH and After Exit, Study Respondents (N=508) | mean

- Exhibit 5.17 HUD-VASH Housing Satisfaction Experiences, Qualitative Respondents

- PROGRAM SATISFACTION

- SUMMARY

- CHAPTER 6: VA CASE MANAGEMENT

- FREQUENCY OF VA CASE MANAGEMENT CONTACTS

- Exhibit 6.1 VA Case Management Requirements

- Exhibit 6.2 Frequency of VA Case Management During Housing Process, HUD-VASH Participants (N=7,383) | mean

- Exhibit 6.3 Frequency of VA Case Management Following Move-in, HUD-VASH Participants (N=7,383) | mean

- Exhibit 6.4 Self-Reported Number of Monthly Meetings With VA Case Manager, Study Respondents (N=498) | percent

- VA CASE MANAGEMENT SATISFACTION

- Exhibit 6.5 VA Case Management Satisfaction, Study Respondents (N=508) | mean

- FACILITATORS AND BARRIERS

- Exhibit 6.6 VA Case Management Facilitators and Barriers, Qualitative Respondents

- SUMMARY

- CHAPTER 7: VA HEALTH SERVICES USE

- VA HEALTH SERVICES USE DURING HOUSING PROCESS

- Exhibit 7.1 Monthly Outpatient Visits During Housing Process, HUD-VASH Participants (N=7,383) | mean

- Exhibit 7.2 Inpatient Stays and Emergency Care During Housing Process, HUD-VASH Participants (N=7,294) | percent

- VA HEALTH SERVICES USE BEFORE AND AFTER EXIT

- Exhibit 7.3 Monthly Outpatient Visits Before and After Exit, HUD-VASH Participants (N=5,876) | mean

- Exhibit 7.4 Inpatient Stays and Emergency Care Before and After Exit, HUD-VASH Participants (N=4,387) | percent

- SELF-REPORTED HEALTH IN HUD-VASH

- Exhibit 7.5 Self-Reported Health Status, Study Respondents (N=508) | percent

- Exhibit 7.6 Self-Reported Medical and Mental Health Problems, Study Respondents (N=508) | percent

- Exhibit 7.7 Self-Reported Being “Troubled” by Drugs/Alcohol, Study Respondents (N=507) | percent

- SUMMARY

- CHAPTER 8: EXITS FROM HUD-VASH

- FREQUENCY AND TIMING OF EXITS

- Exhibit 8.1 Days Between Receipt of Voucher and Exit, HUD-VASH Participants (N=3,415) | count

- ADMINISTRATIVE DATA

- Exhibit 8.2 Reasons for Exits Reported by VA Case Managers, HUD-VASH Participants (N=4,925) | percent

- Exhibit 8.3 Reasons for Exits Identified by Housing Authority and VA Staff

- Exhibit 8.4 Main Reason for Exit Reported by Leased-up Exiters, Study Respondents (N=74) | percent

- Exhibit 8.5 Main Reason for Exit Reported by Nonleased Exiters, Study Respondents (N=53) | percent

- Exhibit 8.6 Reasons for Exit, Qualitative Respondents

- CHARACTERISTICS PREDICTING EXIT

- Exhibit 8.7 Logistic Regression Modeling Exits From HUD-VASH, HUD-VASH Participants

- PROFILES OF EXITERS

- Exhibit 8.8 Profiles of Leased-Up Exiters, HUD-VASH Participants (N=2,959) | percent

- Exhibit 8.9 Profiles of Nonleased Exiters, HUD-VASH Participants (N=1,037) | percent

- Exhibit 8.10 Latent Class Analysis of Leased-Up Exiters, HUD-VASH Participants

- Exhibit 8.11 Latent Class Analysis of Nonleased Exiters, HUD-VASH Participants

- VETERANS’ STATUS AFTER EXIT

- RETURNS TO HOMELESSNESS

- Exhibit 8.12 Avoiding Returns to VA Homeless Programs 360 Days After Exit, HUD-VASH Participants (N=4,595) | count

- Exhibit 8.13 Cox Proportional Hazards Survival Analysis for Time To Return to Homelessness Within 360 Days, HUD-VASH Participants (N = 303)

- SUMMARY

- CHAPTER 9: PROGRAM FACILITATORS AND BARRIERS

- FACILITATORS

- Exhibit 9.1 Program Facilitators Identified by Housing Authority and VA Staff

- Exhibit 9.2 Program Facilitators Identified by Qualitative Respondents

- BARRIERS

- Exhibit 9.3 Program Barriers Identified by Housing Authority and VA Staff

- Exhibit 9.4 Program Barriers Identified by Qualitative Respondents

- RECOMMENDATIONS

- Exhibit 9.5 Recommendations Identified by Housing Authority and VA Staff

- Exhibit 9.6 Recommendations Identified by Qualitative Respondents

- SUMMARY

- CHAPTER 10: CONCLUSIONS

- HUD-VASH IS SUCCESSFUL

- VETERANS LEAVE HUD-VASH HOUSING FOR A VARIETY OF REASONS

- SOME VETERANS NEVER USE THEIR HUD-VASH VOUCHERS

- FACILITATORS AND BARRIERS

- OPPORTUNITIES FOR PROGRAM IMPROVEMENTS

- STRENGTHS AND LIMITATIONS

- NEXT STEPS

- APPENDIX A: GLOSSARY

- APPENDIX B: TERMS

- APPENDIX C: METHODS

- VETERAN INTERVIEW MATERIALS

- STAFF INTERVIEW MATERIALS

- QUANTITATIVE VARIABLES & ANALYSES

- Exhibit C.1 Administrative data

- ExhibitC.2 Survey respondent data

- QUALITATIVE CODING DICTIONARY

- APPENDIX D: STUDY RESPONDENTS

- STUDY RESPONDENT SUBSAMPLE

- Exhibit D.1 Study respondent count

- Exhibit D.2 Year of program admission, study respondents

- Exhibit D.3 Days in HUD-VASH, by quartile, study respondents

- Exhibit D.4 Years in HUD-VASH housing, study respondents

- DEMOGRAPHICS

- Exhibit D.5 Age, study respondents

- Exhibit D.6 Race and ethnicity, study respondents

- Exhibit D.7 Marital status, study respondents

- Exhibit D.8 VA enrollment priority group, study respondents

- MILITARY HISTORY

- Exhibit D.9 Period of service and combat exposure, study respondents

- MEDICAL AND MENTAL OR BEHAVIORAL HEALTH CONDITIONS

- Exhibit D.10 Medical and mental/behavioral health conditions, study respondents

- REPRESENTATIVENESS OF STUDY RESPONDENT SUBSAMPLE

- APPENDIX E: HOUSTON SITE DESCRIPTION

- HOUSING CONTEXT

- VA Case Management

- Houston Housing Authority

- Harris County Housing Authority

- Step-by-Step Processes

- APPENDIX F: LOS ANGELES SITE DESCRIPTION

- Housing Context

- Housing Authority of the City of Los Angeles

- Housing Authority of the County of Los Angeles

- Step-By-Step Processes

- APPENDIX G: PALO ALTO SITE DESCRIPTION

- Housing Context

- VA Case Management

- Housing Authority of the County of Santa Clara

- Housing Authority of Monterey County

- Step-By-Step Processes

- APPENDIX H: PHILADELPHIA SITE DESCRIPTION

- Housing Context

- VA Case Management

- Housing Authority of the City of Camden

- Step-By-Step Processes

- APPENDIX I: SUPPORTING DATA

- CHARACTERISTICS OF HUD-VASH PARTICIPANTS

- Exhibit I.1 Sample details, HUD-VASH participants, by study group

- Exhibit I.2 Demographics, HUD-VASH participants, by study group

- Exhibit I.3 Military history, HUD-VASH participants, by study group

- Exhibit I.4 Medical and mental/behavioral health conditions, HUD-VASH participants, by study group

- Exhibit I.5 Sample details, HUD-VASH participants, by study site

- Exhibit I.6 Demographics, HUD-VASH participants, by study site

- Exhibit I.7 Military history, HUD-VASH participants, by study site

- Exhibit I.8 Medical and mental/behavioral health conditions, HUD-VASH participants, by study site

- Exhibit I.9 Adult population, 2013

- Exhibit I.10 Homeless population, 2009-2014

- Exhibit I.11 Rental market, 2013

- Exhibit I.12 HUD-VASH program characteristics

- PROGRAM ENGAGEMENT AND HOUSING PROCESS

- Exhibit I.13 Days to placement in permanent housing, HUD-VASH participants

- Exhibit I.14 Multiple regression analysis for days between admission and HA referral, HUD-VASH participantsa (N=6,055)

- Exhibit I.15 Multiple regression analysis for days between HA referral and receipt of voucher, HUD-VASH participantsa (N=6,102)

- Exhibit I.16 Multiple regression analysis for days between receipt of voucher and move-in, HUD-VASH participantsa (N=5,308)

- Exhibit I.17 Multiple regression analysis for days between admission and receipt of voucher, HUD-VASH participantsa (N=5,724)

- Exhibit I.18 Multiple regression analysis for days between admission and move-in, HUD-VASH participantsa (N=4,882)

- Exhibit I.19 Living situation during HUD-VASH housing process, study respondents

- Exhibit I.20 HUD-VASH enrollment and housing process, study respondents

- Exhibit I.21 Housing selection, study respondents

- Exhibit I.22 Services received during housing process and move-in, study respondents

- Exhibit I.23 Housing satisfaction while in HUD-VASH and after exit, study respondents (1 = very dissatisfied, 5 = completely satisfied)

- Exhibit I.24 Program satisfaction, study respondents

- VA CASE MANAGEMENT

- Exhibit I.25 Frequency of VA case management

- Exhibit I.26 VA case management satisfaction, study respondents (1 = never, 5 = always)

- Exhibit I.27 VA services utilization, HUD-VASH participants

- Exhibit I.28 Self-reported health in HUD-VASH, study respondents

- Exhibit I.29 Logistic regression modeling exits from HUD-VASH (leased-up exit vs. stay), HUD-VASH participantsa (N=5,850)

- Exhibit I.30 Logistic regression modeling exits from HUD-VASH (Nonleased vs. leased-up exit), HUD-VASH participantsa (N=4,565)

- Exhibit I.31 Reasons for exits reported by VA case managers, HUD-VASH participants

- Exhibit I.32 Reasons for exits identified by housing authority and VA staff

- Exhibit I.33 Reasons for exits, study respondents

- Exhibit I.34 Latent class analysis of leased-up exiters, HUD-VASH participants

- Exhibit I.35 Latent class analysis of nonleased exiters, HUD-VASH participants

- Exhibit I.36 Veterans’ status post-exit

- Exhibit I.37 Cox proportional hazards survival analysis for time to return to homelessness within 360 days, HUD-VASH participantsa (N=303)

- APPENDIX J: REFERENCES

- Back Cover

Table of Contents

Cover

TItle Page

ACKNOWLEDGMENTS

DISCLAIMER

PREFACE

MESSAGE FROM THE U.S. DEPARTMENT OF VETERANS AFFAIRS

TABLE OF CONTENTS

LIST OF EXHIBITS

EXECUTIVE SUMMARY

Summary Exhibit 1. Veteran Data Sources and Sample Sizes

Summary Exhibit 2. Reasons for Exits Reported by VA Case Managers, Percent of HUD-VASH Participants

Summary Exhibit 3. Profiles of Leased-Up Exiters, HUD-VASH Participants

Summary Exhibit 4. Profiles of Nonleased Exiters, HUD-VASH Participants

Summary Exhibit 5. Overview of HUD-VASH Processes

CHAPTER 1: INTRODUCTION AND OVERVIEW OF STUDY

BACKGROUND

PREVIOUS RESEARCH

OVERVIEW OF STUDY

THIS REPORT

CHAPTER 2: METHODS

STUDY SITE SELECTION

VETERAN SAMPLE SELECTION

Exhibit 2.1 Study Group Pathways Into and Out of HUD-VASH

Exhibit 2.2 HUD-VASH Participant Count

Exhibit 2.3 Year of Program Admission, HUD-VASH Participants

Exhibit 2.4 Days in HUD-VASH, by Quartile, HUD-VASH Participants

Exhibit 2.5 Years in HUD-VASH Housing, HUD-VASH Participants

Exhibit 2.6 Study Site Recruitment and Enrollment

Exhibit 2.7 Study Respondent Count

Exhibit 2.8 Qualitative Respondent Count

DATA COLLECTION

Exhibit 2.9 Administrative Data Sources and Variables

DATA ANALYSIS

CHAPTER 3: CHARACTERISTICS OF HUD-VASH PARTICIPANTS

DEMOGRAPHICS

Exhibit 3.1 Age, HUD-VASH Participants

Exhibit 3.2 Race and Ethnicity, HUD-VASH Participants

Exhibit 3.3 Marital Status, HUD-VASH Participants

Exhibit 3.4 VA Enrollment Priority Group, HUD-VASH Participants

MILITARY HISTORY

Exhibit 3.5 Period of Service and Combat Exposure, HUD-VASH Participants

MEDICAL CONDITIONS AND MENTAL OR BEHAVIORAL HEALTH CONDITIONS

Exhibit 3.6 Medical Conditions and Mental or Behavioral Health Conditions, HUD-VASH Participants

DESCRIPTIVE BACKGROUND CHARACTERISTICS

Exhibit 3.7 Background Characteristics, Qualitative Respondents

SUMMARY

CHAPTER 4: FEATURES OF STUDY SITES

POPULATION DATA

Exhibit 4.1 Adult Population, 2013

HOMELESSNESS AND HOUSING CONTEXT

Exhibit 4.2 Homeless Population, 2009–2014 | count

Exhibit 4.3 Veteran Homeless Population, 2009–2014 | count

Exhibit 4.4 Proportion Sheltered/Unsheltered Veteran Homeless, 2014 | count and percent

Exhibit 4.5 Rental Market, 2013

HUD-VASH VOUCHER ALLOCATION

Exhibit 4.6 HUD-VASH Voucher Allocation, 2008–2014 | count

HUD-VASH PROCESSES

Exhibit 4.7 Overview of HUD-VASH Processes

STUDY SITE PROCESSES

Exhibit 4.8 Houston HUD-VASH Processes

Exhibit 4.9 Los Angeles HUD-VASH processes

Exhibit 4.10 Palo Alto HUD-VASH Processes

Exhibit 4.11 Philadelphia HUD-VASH Processes

STUDY SITE OUTCOMES

Exhibit 4.12 HUD-VASH Days to Placement in Permanent Housing, 2009–2014 (N=7,383) | mean

Exhibit 4.13 VA Performance Measures, 2014 | percent

Exhibit 4.14 Ease of HUD-VASH Enrollment Process, Study Respondents (N=508) | mean

Exhibit 4.15 Ease of HUD-VASH Housing Process, Study Respondents (N=508) | mean

SUMMARY

CHAPTER 5: PROGRAM ENGAGEMENT AND HOUSING PROCESS

TIME TO PLACEMENT IN PERMANENT HOUSING

Exhibit 5.1 Days to Placement in Permanent Housing, HUD-VASH Participants (N=7,383) | mean

Exhibit 5.2 Summary of Multiple Regression Analyses, HUD-VASH Participants

LIVING SITUATION PRIOR TO HUD-VASH AND SOURCE OF REFERRAL

Exhibit 5.3 Living Situation at Voucher Receipt, Study Respondents (N=489) | percent

Exhibit 5.4 Living Situation at Apartment Selection, Study Respondents (N=454) | percent

Exhibit 5.5 Living Situations, Qualitative Respondents

Exhibit 5.6 Exposure to Program/Referral Source, Qualitative Respondents

HUD-VASH ENROLLMENT PROCESS

Exhibit 5.7 Ease of HUD-VASH Enrollment Process, Study Respondents (N=508) | mean

Exhibit 5.8 Enrollment Process Experiences, Qualitative Respondents

Exhibit 5.9 Negative Program Orientation Experiences, Qualitative Respondents

Exhibit 5.10 Program Rules and Regulations, Qualitative Respondents

HUD-VASH HOUSING PROCESS

Exhibit 5.11 Ease of HUD-VASH Housing Process, Study Respondents (N=508) | mean

Exhibit 5.12 Number of Apartments Visited During Housing Search, Study Respondents (N=502) | percent

Exhibit 5.13 Services Received During Housing Process, Study Respondents (N~508) | percent

Exhibit 5.14 Services Received During Move-in, Study Respondents (N=458) | percent

FACILITATORS AND BARRIERS

Exhibit 5.15 HUD-VASH Housing Process Facilitators and Barriers, Qualitative Respondents

HOUSING SATISFACTION

Exhibit 5.16 Housing Satisfaction While in HUD-VASH and After Exit, Study Respondents (N=508) | mean

Exhibit 5.17 HUD-VASH Housing Satisfaction Experiences, Qualitative Respondents

PROGRAM SATISFACTION

SUMMARY

CHAPTER 6: VA CASE MANAGEMENT

FREQUENCY OF VA CASE MANAGEMENT CONTACTS

Exhibit 6.1 VA Case Management Requirements

Exhibit 6.2 Frequency of VA Case Management During Housing Process, HUD-VASH Participants (N=7,383) | mean

Exhibit 6.3 Frequency of VA Case Management Following Move-in, HUD-VASH Participants (N=7,383) | mean

Exhibit 6.4 Self-Reported Number of Monthly Meetings With VA Case Manager, Study Respondents (N=498) | percent

VA CASE MANAGEMENT SATISFACTION

Exhibit 6.5 VA Case Management Satisfaction, Study Respondents (N=508) | mean

FACILITATORS AND BARRIERS

Exhibit 6.6 VA Case Management Facilitators and Barriers, Qualitative Respondents

SUMMARY

CHAPTER 7: VA HEALTH SERVICES USE

VA HEALTH SERVICES USE DURING HOUSING PROCESS

Exhibit 7.1 Monthly Outpatient Visits During Housing Process, HUD-VASH Participants (N=7,383) | mean

Exhibit 7.2 Inpatient Stays and Emergency Care During Housing Process, HUD-VASH Participants (N=7,294) | percent

VA HEALTH SERVICES USE BEFORE AND AFTER EXIT

Exhibit 7.3 Monthly Outpatient Visits Before and After Exit, HUD-VASH Participants (N=5,876) | mean

Exhibit 7.4 Inpatient Stays and Emergency Care Before and After Exit, HUD-VASH Participants (N=4,387) | percent

SELF-REPORTED HEALTH IN HUD-VASH

Exhibit 7.5 Self-Reported Health Status, Study Respondents (N=508) | percent

Exhibit 7.6 Self-Reported Medical and Mental Health Problems, Study Respondents (N=508) | percent

Exhibit 7.7 Self-Reported Being “Troubled” by Drugs/Alcohol, Study Respondents (N=507) | percent

SUMMARY

CHAPTER 8: EXITS FROM HUD-VASH

FREQUENCY AND TIMING OF EXITS

Exhibit 8.1 Days Between Receipt of Voucher and Exit, HUD-VASH Participants (N=3,415) | count

ADMINISTRATIVE DATA

Exhibit 8.2 Reasons for Exits Reported by VA Case Managers, HUD-VASH Participants (N=4,925) | percent

Exhibit 8.3 Reasons for Exits Identified by Housing Authority and VA Staff

Exhibit 8.4 Main Reason for Exit Reported by Leased-up Exiters, Study Respondents (N=74) | percent

Exhibit 8.5 Main Reason for Exit Reported by Nonleased Exiters, Study Respondents (N=53) | percent

Exhibit 8.6 Reasons for Exit, Qualitative Respondents

CHARACTERISTICS PREDICTING EXIT

Exhibit 8.7 Logistic Regression Modeling Exits From HUD-VASH, HUD-VASH Participants

PROFILES OF EXITERS

Exhibit 8.8 Profiles of Leased-Up Exiters, HUD-VASH Participants (N=2,959) | percent

Exhibit 8.9 Profiles of Nonleased Exiters, HUD-VASH Participants (N=1,037) | percent

Exhibit 8.10 Latent Class Analysis of Leased-Up Exiters, HUD-VASH Participants

Exhibit 8.11 Latent Class Analysis of Nonleased Exiters, HUD-VASH Participants

VETERANS’ STATUS AFTER EXIT

RETURNS TO HOMELESSNESS

Exhibit 8.12 Avoiding Returns to VA Homeless Programs 360 Days After Exit, HUD-VASH Participants (N=4,595) | count

Exhibit 8.13 Cox Proportional Hazards Survival Analysis for Time To Return to Homelessness Within 360 Days, HUD-VASH Participants (N = 303)

SUMMARY

CHAPTER 9: PROGRAM FACILITATORS AND BARRIERS

FACILITATORS

Exhibit 9.1 Program Facilitators Identified by Housing Authority and VA Staff

Exhibit 9.2 Program Facilitators Identified by Qualitative Respondents

BARRIERS

Exhibit 9.3 Program Barriers Identified by Housing Authority and VA Staff

Exhibit 9.4 Program Barriers Identified by Qualitative Respondents

RECOMMENDATIONS

Exhibit 9.5 Recommendations Identified by Housing Authority and VA Staff

Exhibit 9.6 Recommendations Identified by Qualitative Respondents

SUMMARY

CHAPTER 10: CONCLUSIONS

HUD-VASH IS SUCCESSFUL

VETERANS LEAVE HUD-VASH HOUSING FOR A VARIETY OF REASONS

SOME VETERANS NEVER USE THEIR HUD-VASH VOUCHERS

FACILITATORS AND BARRIERS

OPPORTUNITIES FOR PROGRAM IMPROVEMENTS

STRENGTHS AND LIMITATIONS

NEXT STEPS

APPENDIX A: GLOSSARY

APPENDIX B: TERMS

APPENDIX C: METHODS

VETERAN INTERVIEW MATERIALS

STAFF INTERVIEW MATERIALS

QUANTITATIVE VARIABLES & ANALYSES

Exhibit C.1 Administrative data

ExhibitC.2 Survey respondent data

QUALITATIVE CODING DICTIONARY

APPENDIX D: STUDY RESPONDENTS

STUDY RESPONDENT SUBSAMPLE

Exhibit D.1 Study respondent count

Exhibit D.2 Year of program admission, study respondents

Exhibit D.3 Days in HUD-VASH, by quartile, study respondents

Exhibit D.4 Years in HUD-VASH housing, study respondents

DEMOGRAPHICS

Exhibit D.5 Age, study respondents

Exhibit D.6 Race and ethnicity, study respondents

Exhibit D.7 Marital status, study respondents

Exhibit D.8 VA enrollment priority group, study respondents

MILITARY HISTORY

Exhibit D.9 Period of service and combat exposure, study respondents

MEDICAL AND MENTAL OR BEHAVIORAL HEALTH CONDITIONS

Exhibit D.10 Medical and mental/behavioral health conditions, study respondents

REPRESENTATIVENESS OF STUDY RESPONDENT SUBSAMPLE

APPENDIX E: HOUSTON SITE DESCRIPTION

HOUSING CONTEXT

VA Case Management

Houston Housing Authority

Harris County Housing Authority

Step-by-Step Processes

APPENDIX F: LOS ANGELES SITE DESCRIPTION

Housing Context

Housing Authority of the City of Los Angeles

Housing Authority of the County of Los Angeles

Step-By-Step Processes

APPENDIX G: PALO ALTO SITE DESCRIPTION

Housing Context

VA Case Management

Housing Authority of the County of Santa Clara

Housing Authority of Monterey County

Step-By-Step Processes

APPENDIX H: PHILADELPHIA SITE DESCRIPTION

Housing Context

VA Case Management

Housing Authority of the City of Camden

Step-By-Step Processes

APPENDIX I: SUPPORTING DATA

CHARACTERISTICS OF HUD-VASH PARTICIPANTS

Exhibit I.1 Sample details, HUD-VASH participants, by study group

Exhibit I.2 Demographics, HUD-VASH participants, by study group

Exhibit I.3 Military history, HUD-VASH participants, by study group

Exhibit I.4 Medical and mental/behavioral health conditions, HUD-VASH participants, by study group

Exhibit I.5 Sample details, HUD-VASH participants, by study site

Exhibit I.6 Demographics, HUD-VASH participants, by study site

Exhibit I.7 Military history, HUD-VASH participants, by study site

Exhibit I.8 Medical and mental/behavioral health conditions, HUD-VASH participants, by study site

Exhibit I.9 Adult population, 2013

Exhibit I.10 Homeless population, 2009-2014

Exhibit I.11 Rental market, 2013

Exhibit I.12 HUD-VASH program characteristics

PROGRAM ENGAGEMENT AND HOUSING PROCESS

Exhibit I.13 Days to placement in permanent housing, HUD-VASH participants

Exhibit I.14 Multiple regression analysis for days between admission and HA referral, HUD-VASH participantsa (N=6,055)

Exhibit I.15 Multiple regression analysis for days between HA referral and receipt of voucher, HUD-VASH participantsa (N=6,102)

Exhibit I.16 Multiple regression analysis for days between receipt of voucher and move-in, HUD-VASH participantsa (N=5,308)

Exhibit I.17 Multiple regression analysis for days between admission and receipt of voucher, HUD-VASH participantsa (N=5,724)

Exhibit I.18 Multiple regression analysis for days between admission and move-in, HUD-VASH participantsa (N=4,882)

Exhibit I.19 Living situation during HUD-VASH housing process, study respondents

Exhibit I.20 HUD-VASH enrollment and housing process, study respondents

Exhibit I.21 Housing selection, study respondents

Exhibit I.22 Services received during housing process and move-in, study respondents

Exhibit I.23 Housing satisfaction while in HUD-VASH and after exit, study respondents (1 = very dissatisfied, 5 = completely satisfied)

Exhibit I.24 Program satisfaction, study respondents

VA CASE MANAGEMENT

Exhibit I.25 Frequency of VA case management

Exhibit I.26 VA case management satisfaction, study respondents (1 = never, 5 = always)

Exhibit I.27 VA services utilization, HUD-VASH participants

Exhibit I.28 Self-reported health in HUD-VASH, study respondents

Exhibit I.29 Logistic regression modeling exits from HUD-VASH (leased-up exit vs. stay), HUD-VASH participantsa (N=5,850)

Exhibit I.30 Logistic regression modeling exits from HUD-VASH (Nonleased vs. leased-up exit), HUD-VASH participantsa (N=4,565)

Exhibit I.31 Reasons for exits reported by VA case managers, HUD-VASH participants

Exhibit I.32 Reasons for exits identified by housing authority and VA staff

Exhibit I.33 Reasons for exits, study respondents

Exhibit I.34 Latent class analysis of leased-up exiters, HUD-VASH participants

Exhibit I.35 Latent class analysis of nonleased exiters, HUD-VASH participants

Exhibit I.36 Veterans’ status post-exit

Exhibit I.37 Cox proportional hazards survival analysis for time to return to homelessness within 360 days, HUD-VASH participantsa (N=303)

APPENDIX J: REFERENCES

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