AMA Journal of Ethics^®

Veterans' Recovery for the Homeless

The issue of homelessness troubles many Americans, particularly when it involves individuals who have made selfless personal sacrifices for our country— U.S. veterans. Although the numbers of homeless veterans have decreased steadily over the last 10 years, it is estimated that there were 154,000 homeless veterans on any night in the United States in 2007 [1]. The decline notwithstanding, the presence of one homeless veteran is unquestionably too many.

A common misperception about homelessness is that it is caused by poverty, lack of affordable housing, or unemployment. Those who have fought to end homelessness know these factors are only part of the story. A majority of homeless people have health conditions that interfere with their ability to become productive citizens. Health care agencies report that homeless patients have high incidences of respiratory infections, trauma, skin ailments, gastrointestinal ailments, and hypertension. Dental problems are common, as are communicable diseases such as HIV and tuberculosis, with HIV being three times as prevalent as in the general population [2, 3]. Most noteworthy is that substance abuse and mental illness are widespread and play a significant role in contributing to chronic homelessness. These contributors are not specific to veteran homeless; nonveteran homeless people suffer from similar health conditions.

The Department of Veterans Affairs (VA) has provided services to homeless veterans for 21 years, during which time it has collected extensive data on homeless veterans through VA's Northeast Program Evaluation Center (NEPEC). NEPEC has been actively involved in the design, implementation, and evaluation of VA's specialized programs for homeless veterans from their beginning. Fifty-eight percent of homeless veterans report health problems. Even more striking is the fact that 66 percent carry diagnoses of alcohol or drug abuse and 51 percent have serious psychiatric diagnoses. Thirty-seven percent have both a substance-abuse diagnosis and serious psychiatric diagnosis [4]. Clearly, this data confirms that health care must play a critical role in addressing homelessness and achieving lasting results in ending it.

The VA programs have been built on the recognition that health care plays a critical role in rehabilitation of homeless veterans. The Veterans Health Administration has more than 330 staff members who reach out to 40,000-plus new veterans annually and offer services to 65,000 veterans through its specialized programs [4]. A detailed assessment of each veteran is conducted almost immediately and produces a comprehensive package of rehabilitative services designed to meet that veteran's housing needs; medical, psychiatric, dental, and substance-abuse treatment needs; case management; vocational and employment needs; and, in many cases, assistance with obtaining benefits for disabilities.

Although the VA is uniquely positioned to provide many of these services, its strategy has been to deliver them in collaboration with nonprofit community and faith-based organizations, state programs, other federal agencies, and Indian tribal governments. These collaborations are critical to meet the complex needs of the homeless veteran and his or her family. Providing one or two services to a homeless person in hopes that it will lift him or her out of homelessness is not realistic and sometimes contributes to yet another failure on the part of the individual to end his or her homelessness. At present, the VA's Homeless Providers Grant and Per Diem Program offers transitional housing with supportive services through 330 community-based programs, with almost 9,000 beds currently available that grant rehabilitative care to more than 15,000 veterans per year [4]. In 2008, the VA initiated a 10,500-unit expansion of the Housing and Urban Development-VA Supportive Housing (HUD-VASH) permanent housing program. Through the endeavor, permanent community housing, subsidized through HUD-housing vouchers and managed by local public housing authorities, is paired with clinical VA staff case-management services.

Health issues prevalent in this population can significantly interfere with the veteran's ability to fully utilize other support services. To ensure that veterans receive these health care services, the Veterans Health Administration has initiated three national performance monitors which measure whether homeless veterans have timely access to primary care, mental health care, and substance-abuse treatment. A fourth monitor measures VA's performance of guaranteeing continuity of care for veterans who depart from those specialized programs.

Many homeless veterans receive care through outreach activities in which social workers and other health care professionals bring services to street missions and other places where homeless people congregate. But homeless veterans also come directly to VA's health care facilities and meet with professionals who are knowledgeable and trained to connect them with services. The VA recently issued a mental health handbook that describes a uniform mental health services package and requirements for care. If a veteran and his or her family come to a VA clinic or hospital, the veteran must be given access to a variety of options that include emergency shelter, placement in a residential treatment setting, and transitional or permanent housing with supportive services in addition to medical, psychiatric, or substance-abuse care.

Deferring care or sending a veteran back to the street is considered unacceptable by the Veterans Health Administration, which has adopted standards that spell out the requirement that services must be made available. All health care professionals and organizations should adopt standards of care that follow the VA's model. Recent instances of health care organizations dumping sick, homeless people on the street in skid row areas are deplorable.

In 2008, 21,000 homeless veterans received rehabilitative care services in VA residential programs [4]. More than $334 million was spent on these specialized programs, and almost $2 billion was spent in overall health care costs for homeless veterans [5]. It is the least that can be done for those who made great sacrifices for our nation.

At this point, the question must be asked, "Does the VA's strategy for delivering comprehensive care via collaborative relationships succeed?" The experience of the VA and its partners is that this approach has produced results--many formerly homeless veterans have been able to end their homelessness. The VA has conducted at least eight studies and followed more than 3,000 veterans for up to 3 years after entry in the VA program in a series of systematic program evaluations. All of these studies showed positive results, consistently estimating that 80 percent of veterans who entered the programs remained housed 1 year after entry, with even higher percentages of housing for those who successfully completed the programs [6-13].

The complexity of the problems of the homeless calls for a comprehensive, coordinated approach that can best be accomplished through partnerships between private and public agencies. Health care services are a critical component of a homeless individual's recovery--the reason the VA has taken a leadership role in coordinating health care and other services for U.S. veterans. With high levels of performance accountability, the efforts have shown results as good as those of any other program. The standard of providing homeless care delineated in VA's mental health uniform-services package is a model that can be emulated by other health care organizations. For the VA, the debt owed to our nation's veterans calls for no less.