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QUERI Helps VA Reduce Homelessness among Veterans

Addressing homelessness among Veterans is a VA priority, and VA recently released a Learning Agenda Supplement on Homelessness to describe next steps for preventing and ending homelessness among Veterans. Since early 2020, the number of Veterans experiencing homelessness fell by 11%. Moreover, during 2022, VA placed more than 40,000 Veterans experiencing homelessness into permanent housing.  For 2023, VA is striving to place 38,000 Veterans experiencing homelessness in permanent housing and ensure that they do not return to homelessness during the year.

We will not rest until every Veteran has a safe, stable place to call home in this country they fought to defend. —VA Secretary Denis McDonough

In partnership with multi-level health system leaders, providers, and sites across VA, QUERI is supporting the scale-up and spread of effective programs and policies to help VA reach this goal. Here are brief descriptions of these partnered initiatives.

Housing Transitions QUERI

Led by Drs. Sonya Gabrielian, Kristina Cordasco, and Erin Finley, the Housing Transitions QUERI Partnered Implementation Initiative was created to implement and evaluate the Critical Time Intervention in 32 VA Grant and Per Diem case management grantees in six VISNs (Veterans Integrated Service Networks) across the country. Critical Time Intervention (CTI) is a time-limited case management practice that coordinates care and mobilizes support among Veterans with homeless experiences who are undergoing housing transitions. In partnership with the VA Grant and Per Diem Program (GPD) office, Housing Transitions QUERI is providing nine months of CTI training, technical assistance, and implementation support to these grantees, which are community agencies that partner with VA to deliver time-limited case management for homeless-experienced Veterans undergoing housing transitions.

The Housing Transitions QUERI team is utilizing Replicating Effective Programs (REP) to support the implementation of CTI, which has been delivered to 256 homeless-experienced Veterans, to date, and has received strong support from providers and other frontline staff that serve Veterans.

“We’ve been successful [using CTI in our program]. Veterans are graduating and keeping their housing.”  
-Case Manager

To support further scale-up, spread, and sustainment of CTI, the Housing Transitions QUERI team is developing an implementation playbook with CTI training and technical assistance materials, leadership briefs, and implementation support resources. They also will provide a business case analysis for implementing CTI in the aftercare program.

For more information, see the Critical Time Intervention Toolkit or contact the project team at VHAWLAHousingTransitionsQUERI@va.gov.

Housing Transitions QUERI ADIL Initiative: Improving Workforce Wellbeing to Enhance Care for Homeless-Experienced Veterans

Improving workforce recruitment, onboarding, and retention of VA employees and reducing burnout is a top VA priority. To help address this priority, a recent QUERI Advancing Diversity in Leadership (ADIL) awardee, Dr. Taylor Harris, is expanding on the work of the Housing Transitions QUERI and examining workforce wellbeing among community-based homeless service providers implementing Critical Time Intervention (CTI) for homeless-experienced Veterans undergoing housing transitions.

Community-based homeless service providers’ workforce wellbeing deficits are well-established, with burnout estimates upwards of 40% and turnover rates averaging 50% annually. Dr. Harris is examining how CTI implementation affects workforce wellbeing. Specifically, her ADIL goals are to:

• Identify workforce wellbeing factors that are prevalent prior to the implementation of CTI;
• Determine if workforce wellbeing changes following CTI implementation;
• Identify the impacts of two implementation strategies on providers’ wellbeing; and
• Disseminate information with other frontline homeless service providers.

To learn more, please contact VHAWLAHousingTransitionsQUERI@va.gov.

Housing Transitions QUERI ADIL Initiative: Addressing Health Disparities and Promoting Health Equity

Homeless-experienced Veterans face profound health disparities compared to their housed peers, and successful linkages and coordination of health and social services are critical to addressing these disparities. To help improve service use and coordination for homeless-experienced Veterans, ADIL awardee, Talia Panadero, MPH, is tailoring strategies that support the implementation of CTI to reflect homeless-experienced Veteran perspectives, care experiences, and resultant barriers to service engagement and coordination. Specifically, Ms. Panadero is:

• Characterizing Veteran factors (e.g., health attitudes, discrimination/stigma) and care experiences that may impact CTI implementation; and
• Developing case manager training and external facilitation resources that respond to Veteran factors and care experiences.

To learn more, please contact VHAWLAHousingTransitionsQUERI@va.gov.

Homeless Overdose Prevention Expansion

Led by Drs. Keith McInnes, Rani Elwy, Amanda Midboe, and David Smelson, the Bridging the Care Continuum for Vulnerable Veterans across VA and Community (Bridge) QUERI Program strives to expand access to prevention, treatment, and support services for underserved, marginalized, and at-risk Veterans. In partnership with four VA Program Offices and six VISNs, Bridge QUERI is implementing three effective practices – 1) Homeless Overdose Prevention Expansion (HOPE), 2) Maintaining Independence and Sobriety through Systems Integration, Outreach and Networking-Criminal Justice (MISSION-CJ), and 3) Post-Incarceration Engagement (PIE). These practices support frontline providers and staff in delivering high-quality services to Veterans who are experiencing homelessness, in addition to Veteran Treatment Court participants and Veterans recently released from incarceration.

Homeless Overdose Prevention Expansion involves implementing opioid overdose education and naloxone distribution (OEND) to reduce opioid-related overdoses and death among homeless, unstably housed Veterans. Naloxone is an overdose prevention medication. OEND is important because “Veterans who are homeless or unstably housed are at increased risk for opioid-related morbidity and mortality” (Midboe, et al., 2019). Dr. Midboe and her team have completed implementation at four HUD-VASH (Housing and Urban Development-VA Supportive Housing) programs in VISN 21 (VA Sierra Pacific Network). To date, 790 Veterans have been offered OEND through HOPE.

One of our Vets was working at a shelter and it was nighttime, and he was watching a video of the outside parking lot area when he saw a shelter person go down. He went outside to respond, and he went and got his Narcan and revived the guy. —HUD-VASH Supervisor

In addition, Sarah Javier, PhD, was awarded an ADIL to assess disparities in OEND among Veterans experiencing homelessness. She conducted a retrospective cohort quantitative analysis, and her ADIL evaluation results suggest that there are racial/ethnic gaps in OEND receipt across HUD-VASH programs.

For more information, please contact Ketih McInnes, ScD, MSc, at Keith.McInnes@va.gov.

Addressing the Unmet Legal Needs of Veterans Experiencing or at Risk for Homelessness

Addressing Veterans’ legal needs positively impacts their housing and psychosocial outcomes, yet many Veterans’ legal needs remain unmet. It is estimated that 1.8 million Veterans are in need of legal services, including counsel regarding eviction prevention. In 2021, Public Laws 116-283 and 116-315 were enacted to authorize VA to fund legal services for Veterans by awarding grants to community organizations to deliver these services. Drs. Bo Kim and Keith McInnes are partnering with VA’s Homeless Programs Office (HPO) to support the scale-up, spread, and sustainment of this Legal Services for Veterans (LSV) initiative across diverse Veteran populations and settings.

Initially a Rapid Response Team project to help HPO consider approaches for evaluating LSV, this partnership has evolved into a three-year QUERI Partnered Evaluation Initiative (PEI) to comprehensively assess the outcomes, barriers and enablers, and costs of LSV implementation. The evaluation will use a prospective mixed-methods observational study with a repeated measures design. Given the varying types of grantee organizations and processes through which LSV will be operationalized, the evaluation will consider the outcomes of LSV implementation. Investigators will also examine how and why certain outcomes were reached or not reached.

In its first year, LSV plans to award grants to 75 organizations to deliver core legal services – including housing, family law, income support, criminal defense, and discharge upgrades – to approximately 12,000 Veterans. These organizations could include Veterans Service Organizations (VSOs), legal services organizations, bar associations, and other nonprofits and are intended to represent diverse geographic regions and communities.

For more information, please contact Bo Kim, PhD, at Bo.Kim@va.gov .