Keywords

Introduction

The Department of Veterans Affairs Healthcare (VA) system is the nation’s largest provider of integrated health services, with an FY19 operating budget of more than 76.5 billion dollars for medical care [1]. Mission driven, its goal is to fulfill President Lincoln’s promise “to care for him who shall have borne the battle, and for his widow and his orphan,” by serving and honoring the men and women who are America’s veterans. Many VA employees are veterans themselves or have a veteran in the family and are personally connected to the mission of the VA.

Services for Homeless Veterans Are a Core Component of the VA Healthcare System

Homelessness among military veterans has been reported back as far as the Civil War. Following this war, Congress established the national home for disabled volunteer soldiers, and by 1900, more than 100,000 Union soldiers had received care in federal institutions [2]. VA’s homeless programs, formally initiated in 1987, constitute the largest integrated network of homeless services in the country and are unmatched by private sector programs.

Homeless program and mental health services throughout the VA are defined and regulated by comprehensive guidelines contained in the VHA Homeless Programs Directive (VHA Directive 1501) [3] and the Uniform Mental Health Services Handbook (VHA handbook 1160.01) [4]. These handbooks and directives specify the type of services VA hospitals and clinics are required to offer to veterans and their families. The requirements differ depending on the size and type of VA hospital or clinic but apply across the entire VA system.

Veterans who are homeless or at risk of being homeless frequently have concurrent mental health conditions or substance use disorders, so mental health and homeless services at VA are closely coordinated in VA medical centers and clinics. All facilities are required to provide homeless veterans appropriate mental health treatment and referrals to rehabilitation programs as indicated by their assessed symptoms and needs.

VA clinical care is facilitated by an electronic medical record, the VA computerized patient record system (CPRS). This system supports integrated care by allowing different providers within the system and across the country access to a patient’s healthcare data and facilitates the sharing of clinical care nationwide. This is a unique strength of the system as veterans receive comprehensive healthcare in accordance with their treatment plans no matter where they travel throughout the United States, allowing them to receive care at any VA Medical Center. To facilitate identification and treatment of homeless veterans, VA policy dictates that every veteran must be screened for homelessness upon entry to the VA, both on a yearly basis and as clinically indicated. Results are entered into the computerized patient record system. Positive results prompt in-depth assessment, and when problems are identified, veterans are referred to the appropriate services.

Due to the multifactorial origins of homelessness, VA cannot succeed alone in resolving homelessness. Therefore, VA partners with state and local governments, the US Department of Housing and Urban Development (HUD), the US Department of Labor, the US Interagency Council on Homelessness (USICH), and community partners in its mission to prevent and end veteran homelessness. The 2014–2020 VA strategic plan established ending veteran homelessness as a key priority through the Eliminate Veteran Homelessness Initiative [5]. This initiative is consistent with federal strategic plans to prevent and end homelessness developed in 2010 and the most recent version entitled “Home, Together: The Federal Strategic Plan to Prevent and End Homelessness” [6].

Presently, the current VA strategic plan for FY 2018–2024 identifies homeless services and mental healthcare as top priorities [7]. Priority areas include ending veteran homelessness, reducing the veteran suicide rate, implementing a housing first model for homeless veterans, and leading the nation in caring for veterans with trauma-related mental health conditions.

Given its national scope, VA leverages its considerable resources to deliver many unique and exceptional treatment models for the care of homeless veterans that are not available in the private sector. Drawing on over 100 years of experience and evidence-based research, VA has developed a multitude of programs available to house and treat homeless veterans, designed to help them live as self-sufficiently and independently as possible. VA programs designed for homeless veterans fall into several categories: (1) programs which specifically focus on providing housing to veterans in the VA and the community via a housing first model, (2) outreach programs, (3) biopsychosocial services, (4) targeted mental health treatment programs, (5) vocational programs, and services for justice system-involved veterans.

Housing First Model

Housing First [8] is an effective approach to ending homelessness for the most vulnerable and chronically homeless individuals by prioritizing housing and then assisting veterans with access to healthcare and other supports that promote stable housing and improved quality of life.

Treatment is not required prior to securing housing. Instead, based on veteran choice, treatment and other support services are wrapped around veterans as they obtain and maintain permanent housing. VA offers programs such as the Grant and Per Diem (GPD) and Housing and Urban Development-Veterans Affairs Supported Housing (HUD-VASH) that collaborate with federal and community agencies to provide housing. Specifically, the GPD program awards grants and makes per diem payments to community-based agencies to create transitional housing programs for veterans. HUD-VASH, a collaboration between US Department of Housing and Urban Development and VA, provides rental assistance vouchers to homeless veterans and ongoing case management by VA homeless program staff.

The Grant and Per Diem Program (GPD) is an important component of residential care for homeless veterans. This program offers transitional housing to homeless veterans in both congregate settings and independent housing units. It features five service models from which veterans can choose. For homeless veterans with mental health and substance abuse treatment needs, GPD offers the Clinical Treatment model in about 3000 beds across the nation, representing about one-fourth of all GPD beds [9].

Services are individualized and lengths of stay may vary. The model offers individual and group counseling/therapy and family support groups/family therapy, delivered by licensed and/or credentialed staff. Psychoeducation is also typically offered, which may be delivered by peer recovery specialists or community members representing recovery groups like Alcoholics Anonymous and Narcotics Anonymous.

While clinical treatment is the focus of a veteran’s stay in a GPD Clinical Treatment bed, there is also strong emphasis on planning to obtain permanent housing and attainment of employment. The VA’s National Homeless Program office has performance measures with targets related to permanent housing and employment attainment for veterans who choose the Clinical Treatment model: 65 percent of discharges from Clinical Treatment beds should be directly into community-based permanent housing, and 50 percent of discharges should have obtained competitive employment prior to discharge [10]. In fiscal year 2019, the national averages for both targets were surpassed [11].

Outreach Programs

Though veteran homelessness was reduced by about 50 percent between 2009 and 2019 [9], it is estimated that approximately 37,000 veterans were still homeless at the time of the January 2019 Point-in-Time count [12]. This underscores the continuing importance of outreach activities, whether conducted at community-based sites such as soup kitchens or through VA programs providing outreach to the homeless population. VA has a wide range of outreach programs including Healthcare for Homeless Veterans (HCHV), Community Resource and Referral Centers (CRRCs), the National Call Center for Homeless Veterans (NCCHV) hotline, and programs for Justice-Involved Veterans (VJP). Program highlights are discussed below.

The National Call Center for Homeless Veterans is an important outreach tool, available 24 hours a day, 7 days a week, at 877-424-3838. Veterans who are homeless or at risk of homelessness, as well as family members, friends, and supporters, can call or chat online with trained counselors. Carefully monitored referrals to the nearest homeless program staff at VA Medical Centers are an important outcome for veteran callers to the Center. Highly trained homeless program staff then reach out to the veterans, offering same-day services and referrals. The Center executes “warm hand-offs” to the Veterans Crisis Line (VCL) as appropriate. Federal, state, and local partners such as community agencies can also contact the Center to get information on VA homeless programs, healthcare, and other services in their geographic areas.

The Healthcare for Homeless Veterans (HCHV) program provides outreach in the community in order to connect homeless veterans with healthcare and other services as needed. The program provides prevention and support services such as case management and develops contracts with community-based programs for housing. This program is often the first step in connecting homeless veterans to VA programs and services. In addition to this core mission, HCHV contracts with providers for community-based residential treatment for homeless veterans. Many of the veterans served in HCHV may benefit from mental health and medical treatment but would not seek services without the encouragement of outreach workers.

Community Resource and Referral Centers (CRRCs) provide another first step in connecting homeless veterans to VA programs and services. CRRCs are strategically located in the community, in 31 urban centers across the country. They offer access to an array of services in one location on a walk-in basis for homeless veterans and those who are at risk of becoming homeless. At these facilities, veterans can walk in without appointments and see VA staff—primarily social workers—who assess their needs and address them directly or by referral.

At many CRRCs, services such as showers, laundry facilities, phone and internet services, food or meal tickets, and transportation resources are immediately available. Housing, employment, and income-related referrals (such as referrals to the Veterans Benefits Administration or the Social Security Administration) are provided as needed. Some sites offer life skills and recovery groups facilitated by veteran peer specialists or social workers. Staff from community partner agencies may hold office hours in CRRCs, making it possible for veterans to more easily link to non-VA resources without traveling to multiple locations. Some CRRCs house co-located medical teams (H-PACT) comprised of doctors and nurses who have been specially trained to address health concerns of homeless veterans and the social determinants of health.

Justice-Involved Veterans

Over the years, numerous studies have looked at the prevalence and severity of criminal justice system involvement among homeless veterans. Definitions of homelessness and criminal justice system involvement in these studies were varied, making comparisons and conclusions difficult. However, a large national sample of formerly homeless veterans in VA supportive housing found that 68 percent of male veterans (n = 25,400 of 39,167) had a history of lifetime incarceration [13]. VA has several programs to provide outreach to veterans who are incarcerated, such as the Veterans Justice Outreach (VJO) program and the Health Care for Re-entry Veterans (HCRV) program, further discussed below.

Veterans Justice Outreach (VJO) Program

This program provides services to veterans at the front end of justice system, diverting them into treatment instead of incarceration. In addition to performing outreach at over 1700 jails, Veteran Justice Outreach specialists provide assessment, treatment planning services, and linkages to VA treatment for veterans who participate in Veterans Treatment Courts (VTCs) across the country. VTCs are part of their local jurisdictions’ specialty court systems. Eligibility criteria may differ across locations; however, the process remains similar. Veterans facing criminal charges are evaluated for admission and provided the opportunity to comply with individualized treatment programs under the supervision of VTC judges. VA VJO specialists are key members of the interdisciplinary VTC team [14].

In a September 2019 email from the Veterans Justice Program Office, Jessica Blue-Howells, Deputy Director, Veterans Justice Programs, reported that VJO specialists served over 48,000 veterans in fiscal year 2019. A recent study evaluated data on 7931 veterans who entered VTCs from 2011 to 2015. A prior history of incarceration predicted poor outcomes. However, the veterans in this study spent an average of nearly a year in the program, and at exit, 10 percent more were in their own housing and 12 percent more were receiving VA benefits. Outcomes related to recidivism (14 percent) and employment (1 percent more) were less promising, pointing to the need for substance abuse treatment and employment services for VTC participants [15].

Health Care for Re-entry Veterans (HCRV ) Program

Building upon the previous work of VA outreach teams in the 1990s, the Health Care for Re-entry Veterans Program has been successful for the past 15 years in partnering with state and federal prisons to outreach to veterans who are nearing release. In fiscal year 2019, over 40 Veterans Re-entry Justice Specialists conducted in-person outreach at almost 1000 prisons and served almost 9000 incarcerated veterans [15]. The specialists provide pre-release assessment services; referrals; linkages to medical, psychiatric, and social services, including housing resources and employment services; and post-release short-term case management assistance [14].

While more research is needed to validate evidence-based psychosocial treatments that may help to deter recidivism, promising practices with previously incarcerated homeless veterans include treatment for substance abuse disorders; mental health treatment including trauma-informed care; Moral Reconation Therapy (MRT); and the Domestic Violence/Intimate Partner Violence (DV/IPV) Program [16].

Biopsychosocial Services

VA homeless programs providing comprehensive biopsychosocial support and medical services include the Homeless Patient-Aligned Care Teams (H-PACT), Community Resource and Referral Centers (discussed previously), and specific Mental Health RRTP and vocational programs. These programs provide a coordinated and holistic approach to treating veteran’s medical, mental health, and biopsychosocial needs.

Homeless Patient-Aligned Care Teams (H-PACT)

In 2010, VHA implemented the Patient-Aligned Care Team (PACT), designed to restructure primary care to a team-based, patient-centered model. This model is associated with improved quality of care, increased patient satisfaction, decreased emergency department visits, and decreased costs due to fewer hospital visits and readmissions. Also described as the medical home model, it was expanded in 2012 to include veterans experiencing homelessness, known as H-PACT [17]. It now includes 53 H-PACT teams across the country. H-PACT teams have special expertise in assessing the needs of homeless veterans. In addition to providing primary care, these teams include homeless program staff and other providers who offer case management and referrals to housing assistance and social services.

Medical home primary care models differ from traditional care primary care approaches in several significant ways. The model reduces barriers to care by offering an open-access, care-on-demand model, as well as scheduled appointments. At many sites, the model is co-located with mental health and housing-related services, to create a continuum of care. At VA Medical Centers where H-PACT is located within the CRRCs, veterans may receive primary care and have access to food and clothing assistance, showers, laundry facilities, and other services in one location and during the same visit.

While designed to improve access to care, the H-PACT model also has a critically important mission to address the social determinants of health, by facilitating housing placement for veterans who are homeless or at risk of homelessness. The Centers for Disease Control and Prevention define social determinants of health as “the conditions in the places where people live, learn, work, and play.” Unstable housing, low income, unsafe neighborhoods, substandard education, and poor access to nutritious food are examples of social determinants that can negatively impact physical health [18]. By addressing these determinants within the context of primary care, H-PACT staff achieve a synergistic impact beyond what standard primary care delivers when they connect patients to VA and community-based resources that address veterans’ needs.

A secondary focus of H-PACT teams is to coordinate primary care with mental health and addictions treatment. Studies have shown that veterans identified more positive healthcare experiences when they received their primary care from an H-PACT team [19]. This may lead veterans who receive warm hand-offs from H-PACT to other VA mental health and addictions services to engage more willingly and consistently. Engaging veterans in their care is deemed an important component of the model.

Numerous program evaluations and studies have shown that the H-PACT model reduces use of the emergency department and hospitalizations; generates higher numbers of primary care visits per year than both homeless and non-homeless veterans who receive primary care from regular PACT teams; increases specialty care visits and more social work support; and achieves better rates of new diagnosis of chronic conditions. In addition to these health benefits, one study showed the average H-PACT-enrolled veteran costs over $9000/year less to care for than a homeless veteran enrolled in a non-homeless general PACT clinic [20].

Residential Rehabilitation Treatment Programs (RRTP)

Mental Health Residential Rehabilitation Treatment Programs (MH RRTP) provide a 24/7 therapeutic setting for veterans with a wide range of problems, illnesses, or rehabilitative care needs. These can include mental health, substance use disorder (SUD), post-traumatic stress disorder (PTSD), homelessness, and co-occurring medical concerns. They are dual-accredited, under the Joint Commission’s Behavioral Health Standards Manual as well as the Commission on Accreditation of Rehabilitation Facilities (CARF). They provide rehabilitation, community integration, and evidence-based treatment for mental illness.

During FY 2018, VA operated over 7600 beds with over 2 million bed days of care and over 35,000 admissions. Services are designed to improve veterans’ functional status, sustain treatment and rehabilitation gains, assist with community reintegration, and break the cycle of recidivism. Residential care of this magnitude is unique to VA, as this level of care is not offered in the community sector (with the exception of community residential care for substance use disorder). Although these programs have different treatment modalities and eligibility policies, their clinical policies and clinical practices are set nationally and are uniform [21].

MH RRTP programs are open to any homeless veteran who meets the eligibility criteria. Veterans who are unsheltered or in an unsafe living situation are given priority access for admission. Priority access to an RRTP program requires a time frame of 72 hours from screening to admission. VA policy dictates that veterans may not be discharged from an RRTP program to unsheltered homelessness and only to a shelter if there is no other option or the plan is the veterans’ preference. All MH RRTP models are considered appropriate for the provision of care to homeless veterans.

However, the following programs are highlighted as providing treatment related to the major risk factors identified in veteran homelessness.

  1. 1.

    Domiciliary Care for Homeless Veterans (DCHV ) - DCHVs provide 24/7 structured and supportive residential treatment environment for veterans who are homeless, are at risk of being homeless, lack a stable lifestyle, or are currently in a living arrangement that is not conducive to recovery. Preference for admissions is directed to underserved homeless veterans recently discharged from the military, persons living in shelters and camps, and incarcerated veterans. DCHVs were implemented in 1987, to address the complex needs of the large number of homeless veterans at that time [22]. DCHV programs provide time-limited residential treatment to homeless veterans with significant healthcare and social-vocational deficits. Goals of the program are to improve veterans’ health status, employment performance, and access to basic social and financial resources as well as serving co-occurring disorders and the complex biopsychosocial factors that contribute to homelessness.

    Veterans in these programs have access to medical, psychiatric, and SUD treatment in addition to vocational rehabilitation programs such as the Compensated Work Therapy (CWT) and Supported Employment (SE) programs. New admissions are screened for employment and vocational services, and veterans’ goals are addressed in the treatment plan. All MH RRTP programs must provide access to an employment and vocational services counselor. If a homeless veteran is able and desires to work, a referral to employment and vocational rehabilitation services is completed. If there are barriers to employment due to mental or physical illness, a consultation to Therapeutic Supported Employment Services or Homeless Veterans Community Employment Services is provided.

  2. 2.

    Psychosocial Residential Rehabilitation Treatment Programs (PRRTP ) - while all MH RRTPs have the ability to serve veterans diagnosed with a serious mental illness, the PRRTP programs focus on treating veterans with a diagnosis of serious mental illness (SMI) [23]. Treatment is recovery focused, person centered, and focused on improving functioning and community participation. Evidence-based treatments provided in the PRRTP include programming such as Wellness Recovery Action Planning (WRAP), Illness Management and Recovery, Social Skills Training, and Integrated Dual Diagnosis Treatment. Treatment also includes psychiatric support, family psychoeducation, and pharmacotherapy as indicated. If veterans meet admission criteria for a Psychosocial Rehabilitation and Recovery Center (PRRC) (an intensive outpatient program providing focused services to veterans diagnosed with SMI), they can participate while enrolled in the MH RRTP program. Supported employment services are available to those veterans diagnosed with SMI whose goal is competitive community employment.

  3. 3.

    Domiciliary SA (Dom SA) or Substance Abuse Residential Rehabilitation Treatment Program (SARRTP ) - while all residential programs must have the capacity to provide SUD treatment, the SARRTP provides an in-depth treatment focus on treating addiction. Over 85 percent of veterans admitted to a MH RRTP have a diagnosis of substance use disorder (SUD) [21]. Veterans who are treated for SUD in VA often have significant complicating features, including psychosocial factors such as homelessness, unemployment, and lack of social support for recovery and comorbid mental health disorders such as depression, PTSD, and serious mental illness. They may also experience comorbid medical disorders related to SUD such as alcoholic hepatitis and/or infectious diseases such as viral hepatitis, human immunodeficiency virus (HIV), and acquired immune deficiency syndrome (AIDS). Mental health RRTP programs must have the capacity to provide treatment or treatment referrals for comorbidities. A minimum of two evidence-based psychosocial interventions, such as cognitive behavioral therapy for SUD, are required to be provided to veterans enrolled in SARRTP programs. Addiction-focused pharmacotherapy for alcohol, opioid, and tobacco use disorders must be provided as well. Lastly, veterans must have access to a variety of mutual help groups both on-site and in this community such as Narcotics Anonymous, Alcoholics Anonymous, etc.

Mental Health Treatment for Homeless Veterans

There is strong evidence in the literature that veterans with mental illness are at significant risk for homelessness. Specifically, research has found that serious mental illness such as schizophrenia, bipolar disorder and substance use disorder are strong predictors for homelessness [24, 25]. Alcohol and drug dependence are the most prevalent psychiatric disorders found among homeless populations [26]. In addition, substance use disorders are one of the most significant risk factors for homelessness and are associated with extensive homeless histories [25].

Homelessness itself has been found to be a risk factor for suicide, suicide attempts, and ideation. A recent study examining the association between suicide attempts and homelessness determined that veterans with homeless histories were 7.8 times more likely to have attempted suicide than veterans with no homeless histories. Furthermore, lifetime homelessness was significantly and independently associated with lifetime suicide attempts [26]. Untreated mental illness impacts veterans’ ability to maintain employment, social support, and housing. Therefore, mental health treatment must be a strong component of the clinical services offered to homeless veterans.

Evidence-Based Psychotherapies

VA mental health treatment has increasingly shifted to delivering high-quality, evidence-based treatments for the full range of mental health conditions. VA mental health treatment is guided by scientifically established protocols or clinical practice guidelines as well as by policies delineated in the Uniform Mental Health Services Handbook. Since 1998, VA and Department of Defense (DoD) have partnered together through the Evidence-Based Practice Working Group to develop treatment guidelines.

Clinical practice guidelines (CPG) are based upon a rigorous systematic review of the evidence and explicit processes aligned with the National Academy of Medicine’s articulated set of standards. They are designed to optimize patient care by recommending evidence-based practices, create standard guidelines intended to reduce variations in care, and inform delivery of VA care. VA recognizes CPG guidelines as proven standards for clinical practice and policy. Currently, VA/DOD joint guidelines have been developed for a variety of physical health diagnoses and the following mental health diagnoses: PTSD, substance use disorder, major depressive disorder, and suicide prevention [27].

VA is a national leader in the promotion of evidence-based psychotherapy (EBP). EBPs are specific psychological treatments that have been consistently shown in controlled clinical research to be effective for mental or behavioral health conditions. Examples of specific evidence-based psychotherapies available to veterans in homeless programs include dialectical behavior therapy, moral reconation therapy, motivational interviewing, motivational enhancement therapy, cognitive behavioral therapy, integrated dual disorder treatment, harm reduction, and critical time intervention.

Suicide Prevention

In an effort to address the suicide rate among veterans, then VA Secretary Shulkin prioritized suicide prevention as one of his top five priorities in 2017, and it continues to remain a top priority today. VA conducted an analysis of suicide mortality spanning 2001–2014, examining 55 million records from every state [28]. Results concluded that in 2014, an average of 20 veterans died by suicide each day. Six of these 20 veterans were users of VA health services in 2013 or 2014, and the other 14 were not currently enrolled with VA. The trend shows that veterans who receive their healthcare from VA have a significantly lower rate of suicide than veterans who do not receive VA care.

These findings are particularly important considering that veterans with a history of homelessness are five times more likely to attempt suicide than other veterans [29]. A systematic review of major risk factors of veteran homelessness includes similar risk factors identified in completed suicides, such as substance abuse, mental illness, financial distress, and lack of financial support [25, 30, 31]. Based on research linking veteran homelessness and suicide rates, in June 2018, the Deputy Under Secretary for Health Operations and Management (DUSHOM) issued guidance directing VA mental health and homeless programs to collaborate on enhanced care opportunities for veterans identified as being at high risk for suicide.

VA’s national scope and range of services are the foundation of its comprehensive approach to suicide prevention. There is no equivalent private sector program in the United States that has the range and depth of coordinated, comprehensive suicide prevention programs that the VA delivers. VA suicide prevention initiatives include yearly screening for suicide risk, coordinated suicide prevention care, the Veterans Crisis Line, and REACH VET, a predictive analytics program. Highlights of programs benefitting homeless veterans are discussed below.

Recovery Engagement and Coordination for Health (Reach Vet)

VA’s predictive analytics surveillance program, REACH VET, has been in use since November 2016 [32]. The program is designed to identify the veterans at the highest statistical risk, reach out to assess clinical risk, and proactively provide enhanced care if needed. REACH VET uses a multivariate analysis to identify enrolled patients in the highest-risk category (0.1%), who are at risk of suicide, hospitalization, illness, or other adverse events.

Homelessness and substance use disorder in the past 24 months have been identified as significant variables as well as other mental and physical health diagnoses. This population tends to have multiple comorbidities, frequent mental health and primary care contacts, and high rates of polypharmacy. The analysis is run monthly and distributed to the facility REACH VET Coordinator, who is responsible for evaluating the veteran’s care and notifying the medical team of the risk assessment. The clinicians are asked to contact the identified veterans and collaboratively review their healthcare diagnoses and mental health conditions and ensure appropriate treatment is offered. Homeless program coordinators are required by VHA policy: (1) to facilitate a monthly workgroup comprised of homeless program staff and the local Suicide Prevention and REACH VET Coordinators; (2) to review veterans currently engaged in homeless programs; and (3) to coordinate treatment planning for those identified as high risk.

Suicide Prevention Teams

Each VA Medical Center is required to have a suicide prevention team, led by a Suicide Prevention Coordinator (SPC). The VHA Handbook specifies that the Suicide Prevention Coordinator has a full-time commitment to suicide prevention activities. Each VA medical center establishes a high risk for suicide list and a process to ensure that patients determined to be at high risk are provided with follow-up for all missed mental health and substance abuse appointments. VA mental health and homeless staff are also required to conduct trainings known as SAVE—Signs, Ask, Validate, Encourage, and Expedite. A homeless program staff at each facility is required to become a SAVE trainer to provide these trainings not only to community partners but to veterans participating in VHA homeless programs.

Veterans Crisis Line

VA’s Veterans Crisis Line (VCL) (1-800-273-8255, press 1) was established in 2007. The VCL is available 24/7 and employs trained responders, usually social workers or other mental health professionals, who provide callers with immediate support and refer them to VA mental health services. If the caller is determined to be in imminent danger, the VCL will direct local emergency services to callers. The VCL staff interact regularly with the National Call Center for Homeless Veterans (NCCHV). Currently these two hotlines operate independently but have a warm handoff consultation process to coordinate care for homeless, suicidal callers. In 2018, out of 134,490 total calls to the NCCHV, 923 were transferred to the VCL for assistance [33].

Vocational Services

Mental health disorders have been strongly identified as a major risk factor to veteran homelessness; however, as homelessness is multifactorial, they are not the only risk factors. Low income and associated income-related variables such as low military pay grade, problematic military discharges, and unemployment have also been identified as strong risk factors for homelessness [25]. Matching skills gained in a Military Occupational Specialty (MOS) to the civilian job market may also be a challenge, especially for combat arms MOSs such as infantryman or cannon crewmember. National studies of the general US homeless population have identified low income and unemployment as common precipitating factors for homelessness [24].

Employment may be a preventative factor for veterans at risk of homelessness and may also serve as a key tool to help veterans who are homeless to attain independent housing. At-risk veterans are often coping with stressors such as mental illness, substance abuse disorder, and other disabilities which negatively impact their ability to find and sustain employment. Additional factors such as criminal justice involvement, lack of stable employment history, and poor credit ratings may exacerbate employment-related challenges [34].

Researchers examining homelessness have identified a relationship between unemployment and increased risk for suicide, particularly among men [35, 36]. Suicide risk appears to increase the longer an individual remains unemployed, and research suggests that the risk appears to peak within the first 5 years following job loss [37, 38]. Therefore, no discussion of VA clinical services for the homeless population would be complete without a description of the VA Vocational Rehabilitation and Employment Services available to homeless veterans.

VA vocational rehabilitation services offer a range of programs designed to assist veterans to return to full-time, meaningful employment, enabling each veteran to work and function at their highest potential. These programs provide a variety of recovery-based, therapeutic services integrated into clinical treatment to assist veterans to achieve and maintain meaningful competitive employment. Services are open to veterans living with mental illness, substance use disorders, homelessness, criminal justice involvement, or physical impairment with barriers to employment who want to secure and maintain meaningful community-based competitive employment. Employment plans are individualized and based on veterans’ goals, skills, and abilities and are focused on veteran gaining sustainable employment in the community. Each VA Medical Center is required by the Uniform Mental Health Services Handbook to offer vocational rehabilitation services accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) for veterans experiencing occupational difficulties.

Compensated Work Therapy

Compensated Work Therapy (CWT) offers recovery-oriented, vocational rehabilitation services to support the needs of veterans experiencing employment barriers resulting from mental health and/or physical issues and psychosocial barriers such as homelessness and legal histories. The CWT program offers several vocational rehabilitation models, described in the following paragraphs, to best meet a range of vocational and educational support needs of veterans. This long-standing program began in 1976 when it was authorized by the Veterans Omnibus Healthcare Act (Pub. L 94-581) [39]. Funding was specifically established for the purpose of expanding CWT rehabilitation services, allowing VA to enter into contractual arrangements with private industry or other non-federal sources to provide paid therapeutic work for patients in VA healthcare facilities. The Act was amended in 1990 to allow VA to enter into contractual arrangements with federal agencies and to allow for the development of a CWT transitional residence program (PL 102-54) [40].

All VA work therapy programs provide community-based employment opportunities designed to assist veterans with successful reintegration into the community. Vocational staff match an individual veteran’s vocational skills and interests to employment opportunities with local businesses and industry and then provide ongoing support to the veteran as needed for job retention. Veterans have been successfully employed over the years in a variety of positions including healthcare, information technology, manufacturing, warehousing, construction trades, clerical and office support, retail, and delivery.

Compensated Work Therapy-Transitional Work (CWT-TW)

CWT-TW is a pre-employment vocational program that operates in VA medical centers (VAMC) as well as in community business and industry settings. This program enables veteran participants to gain real-world work experience while engaged in a therapeutic rehabilitation treatment program. This program is designed to prepare participants for community employment by helping them build workplace skills and develop behaviors to sustain competitive employment.

Veteran referrals are screened by program staff and matched to a work assignment at the local VA Medical Center or in the community, as clinically appropriate. Participants are supervised by personnel of the sponsoring site, under the same job expectations experienced by non-CWT workers, and receive base pay determined by federal minimum wage laws. Participants actively engage in job searches while in the program, with the goal of securing competitive employment at discharge. CWT-TW programs maintain close ties with state and local employment agency representatives to assist veterans with job searches. In addition, these programs typically develop close ties with local employment resources such as State Department of Labor, vocational rehabilitation, Veterans Benefits Administration, chambers of commerce, and not-for-profit organizations.

CWT-Supported Employment (CWT-SE)

CWT-SE programs are intended to provide services for veterans with significant barriers to employment due to serious mental illness, such as psychosis, and medical conditions, such as polytrauma and spinal cord injury. Similar to the CWT/TW program, this program assists veterans with securing competitive employment in the community, and it provides job development services, job placement services, and job coaching. CWT-SE staff provide veterans with intensive support needs necessary ongoing support to secure and maintain meaningful, paid, competitive employment. There is no time limitation for the services. Enrolled veterans will receive continuous support as they adjust to competitive employment. Veterans are assessed for discharge only if they request to do so or conditions change, making supported employment services no longer therapeutic or practical.

Compensated Work Therapy-Transitional Residence (CWT-TR)

CWT-TR programs provide transitional housing for the veterans participating in the program allowing them to develop skills for independent living as well as employment skills. The CWT-TR program was originally implemented to address veterans diagnosed with severe SUD and homeless veterans diagnosed with mental health concerns who underutilized VA services. It has now expanded its mission to include veterans diagnosed with PTSD, serious mental illness, and homeless women veterans [23]. CWT-TR programs provide homeless veterans with rehabilitative services focused on transitioning to permanent housing, gaining employment, and continuing their engagement in recovery services. The prerequisite for CWT-TR programs requires that veterans must be able to meet the eligibility requirements for the broader Compensated Work Therapy programs [23].

Homeless Veterans Community Employment Services (HVCES)

In addition to the general VHA vocational rehabilitation services previously discussed, in 2014 the VA established Homeless Veterans Community Employment Services (HVCES), as part of the strategy to end homelessness among veterans. The HVCES program is an integral part of the homeless continuum of care in VA medical centers and is intended to complement existing services by functioning as a connection to employment opportunities and community-based resources. Community Employment Coordinator positions are funded at each VA Medical Center, and some HUD-VASH and HCHV programs receive funding for Employment Specialists.

HVCES staff collaborate with vocational rehabilitation programs; Compensated Work Therapy programs; community, state, and federal partners; and employers to assist homeless veterans in finding and sustaining employment. As a result of these efforts, employment rates for veterans in transitional programs and HUD-VASH have been trending upwards. Over a 5-month period in 2018, HVCES assisted veterans engaged in or exiting VA homeless programs or services in securing over 13 thousand unique instances of employment [41].

One of the most important partners of the HCVES program is the Homeless Veterans’ Reintegration Program (HVRP), funded by the US Department of Labor. Initially authorized in 1987 as part of the Stewart B. McKinney Homeless Assistance Act [42], HVRP is a grant program that served over 16,000 participants in 2016. Community-based grantees perform outreach to veterans, employers, and other partners; assessment; case management utilizing a veteran-centered approach; and training and job placement. Specific categories that have been prioritized to receive HVRP services have included chronically homeless veterans; homeless female veterans and veterans with families; and incarcerated veterans. In program year July 2017 through June 2018, the program achieved a placement rate for program participants of 60 percent, at an average wage of $13.50 [43].

Summary

The Department of Veterans Affairs offers an unparalleled range of programs and treatment within a nationwide, coordinated system of care. Drawing on its size, scope, and mission, VA strives to end veteran homelessness utilizing its wealth of resources. VA’s clinical treatment programs are unmatched by the community as they are delivered within a comprehensive, integrated continuum of care that encompasses many disciplines. VA also leverages its strengths through its critically important partnerships with other federal agencies, state and local governments, and community-based organizations.

Our work continues with strengthening efforts to sustain existing services by engaging in enhanced efforts to enroll homeless veterans in primary care, which is a protective factor against homelessness; effectively addressing co-occurring psychiatric and substance use disorders among homeless veterans; identifying innovative practices to address age-related deficits among homeless veterans, in order to improve their ability to sustain housing; fostering collaborations with other VA services such as caregiver support, women’s and rural health, telehealth, and whole health; and continuing to initiate and nurture vital community partnerships. VA’s progress in ending veteran homelessness has been significant. However, our mission will not be complete until any and all episodes of veteran homelessness are rare, brief, and a one-time experience.