Department of Veterans Affairs - Research Paper Example

14 April The Veterans Administration and Its Responsibility in Housing Homeless Veterans Homelessness in the United s began as early as in the colonial era, with the spread of “vagabonds” in urban areas after the Revolutionary War (“War and Homelessness” 1). The post-Civil War era showed a considerable growth in homelessness because of the negative economic effects of the war and the subsequent recession (“War and Homelessness” 1). While World War I saw a decline in homeless veterans, succeeding wars contributed to it, from World War II and the Vietnam War to the Gulf War (Tsai, Mares, and Rosenheck 27). Some homeless veterans suffered from post traumatic stress disorder (PTSD), substance abuse disorders, and psychological and physical disabilities because of combat experiences (Goldstein et al. 312). Because of these problems, they cannot afford to own houses or pay rent. By the end of the 1970s, the concept of modern homelessness rose, wherein the homeless slept in groups in public areas of New York City and other cities. Homelessness should be addressed because of its short-term problems of mortality and morbidity among the homeless and the long-term effects of aggravating the illnesses of the homeless and exerting additional pressure on existing limited public resources. One of the pressing issues of homelessness that affect veterans and non-veterans alike is chronic homelessness. The State of Homelessness in America 2013 of the Homelessness Research Institute (HRI) is a report of homelessness trends between 2011 and 2012 and understands the economic and demographic characteristics of homelessness across time. From 2011 to 2012, the nation’s homeless population dropped by 0.4 percent, a decrease of 2,235 people (HRI 3). On January 2012, 633,782 people experienced homelessness. The chronic homeless and homeless veterans experienced significant decreases, 6.8 percent and 7.2 percent respectively (HRI 3). The State of Homelessness defines chronic homelessness as homelessness that impact people with different disabilities, such as serious mental illness, chronic illnesses, and substance abuse problems (10). Homelessness continues to afflict veterans: “The national rate of homelessness was 20 homeless people per 10,000 people in the general population” (HRI 3). Military veterans have been discovered to have higher risks for homelessness compared to non-veterans (Tsai et al. 27). Chinman, Hannah, and McCarthy, researchers at VISN 4 Mental Illness Research, Education and Clinical Center (MIRECC) at the VA Pittsburgh Healthcare System, used the U.S. Department of Veteran Affairs supplemental report on homeless veterans to assert that on any given night, 76,000 veterans are homeless (210). Chronic homelessness reinforces homelessness because it can severely limit access to public resources, especially for dishonorably discharged soldiers and veterans suffering from various types of mental and/or physical illnesses and substance abuse disorders (Edens et al. 412). The U.S. Department of Veterans Affairs (VA) develops and implements diverse health care and housing services for homeless veterans that have contributed to a decrease in homelessness. It applies a “no-tolerance policy” towards homeless veterans and produced a five-year plan to stop veteran homelessness by 2014. An essential VA program that aims to alleviate homelessness is the HUD-VASH (Housing and Urban Development-Veteran Affairs Supportive Housing). It adopts principles and practices from “evidence-based housing programs,” particularly “Critical Time Intervention, Supportive Housing, and Housing First” (Chinman et al. 210). It also uses Housing Choice Section 8 vouchers to aid homeless veterans with rent payment and to offer VA case management. The VA also executes Supported Employment, an evidence-based vocational program, at VA Centers in different states. Nan Roman, President of the National Alliance to End Homelessness, which wrote The State of Homelessness in America 2013, underscores that homelessness did not increase from 2011 to 2012. She notes that the Alliance relates this to “federal investment in programs and evidence-based strategies designed to combat homelessness.” In 2011, Roman stresses that the homeless benefitted from the Homeless Prevention and Rapid Re-Housing Program, which the federal stimulus supported. It helped 1.3 million households to either escape homelessness faster than they would have on their own, or evade homelessness (Roman). Roman adds that in the same year, increased investments in permanent supportive housing contributed to a 6.8 percent decrease among chronically homeless individuals, who are the “hardest to serve homeless population.” She commends the interagency endeavor between the departments of Veterans Affairs and Housing and Urban Development to give housing for veterans and their families, which resulted in a 7-percent decrease in veteran homelessness (Roman). These efforts helped curb veteran homelessness. The federal government continues to financially support homeless veterans. Roman reports that after the publication of The State of Homelessness report, President Barack Obama expressed his proposed budget. He asserted that the government would allocate $302 million more funds for HUD programs that offer homeless assistance through rapid re-housing for homeless families and permanent supportive housing for chronically homeless individuals (Roman). Essentially, $1.4 billion would finance VA’s homeless assistance programs, including $300 million for rapid re-housing and prevention activities for veterans and their families (Roman). Roman maintains that this federal investment is exactly what the homeless need to attain immediate results. She states its importance to the development of incremental solutions to homelessness: “Without it, homelessness could worsen and the progress we have made during the past several years could be erased” (Roman). Clearly, the federal government and the VA are working together, along with state and local government units, to resolve veteran homelessness. Despite these programs and services, several scholars have criticized the VA for not consistently applying evidence-based practices, which reduced the effectiveness of their programs. Chinman et al. review the literature on VA programs and find discrepancies between evidence-based models and actual VA programs. They note a study of 36 HUD-VASH sites, which discovered that the majority of these programs did not follow evidence-based models (Chinman et al. 210). Instead of emphasizing “rapid placement, sustained intensive case rehabilitation services, and permanent housing,” the process of getting a housing voucher and being housed varied across programs and took a longer time than initially expected (Chinman et al. 210-211). The same study learned that the kinds and intensity of support given to veterans significantly dropped throughout time and did not concentrate on rehabilitation-oriented efforts (Chinman et al. 211). Another two-year evaluation study on the VA’s Supported Employment showed that although important knowledge and skills enhancements were perceived due to rates of competitive employment, 20% of these sites did not attain satisfactory model fidelity (Chinman et al. 211). Employment rate gains were smaller than past research on similar programs too (Chinman et al. 211). Authors recommended more exhaustive onsite training and performance monitoring to boost the evidence-based program adoption and performance of Supported Employment programs (Chinman et al. 211). Because of these problems with VA projects and programs, several organizations and individuals criticized the VA for not using existing funds to provide housing and related services to homeless veterans. The Coalition for the Homeless argues that the VA is the main cause of homeless veterans for not providing disability benefits and other benefits required to give sufficient housing assistance to veterans (2). U.S. History professor at UC and American Civil Liberties Union (ACLU)-Southern California Foundation board member Irvine John Wiener argues that around 400 acres of Veterans Administration land in Brentwood are being misused because they are not converted to housing services for homeless veterans. He reveals that for several decades, the dormitories have been vacant and for a number of years, and the VA leases its parts to various enterprises, namely Enterprise Rent-a-Car for parking spaces, Marriott hotels for laundry spaces, and the UCLA (University of California, Los Angeles) for a baseball field and a dog park. Mark Rosenbaum of the ACLU of Southern California provides a scathing remark on this dilemma: “If [homeless vets] want to spend the night at the VA in Brentwood, [they are] better off as a rental car than a homeless vet,” and if they need access to the VA land, “[they are] better off as a dog” (Wiener). The ACLU-SC already filed a class-action suit to represent homeless veterans in 2011. These criticisms and the aforementioned studies highlight underlying problems with the VA that must be resolved. Since veterans are high-risk groups for homelessness, the VA should be held legally responsible for housing homeless veterans, including those who are chronically homeless, and helping them access related health and social services because this is the immediate and long-term solution to homelessness among veterans. Veterans are at high risk for homelessness because of their unique experiences from wars and high violence levels in their locations and organizations. Researchers Goldstein et al. of the Mental Illness Research Education and Clinical Center and Veterans Affairs Pittsburgh Healthcare System describe homeless veterans as having health conditions that can be divided into four subgroups: “addiction, psychosis, vascular disorders, and generalized medical and psychiatric illness” (312). Using a survey research design and factor analysis, they examined the structure of these subgroup patters. Findings showed that homeless veterans have a multifaceted and varied pattern of health problems that cannot be illustrated through a single rubric (Goldstein et al. 319). Some homeless veterans have chronic illnesses without major psychiatric diseases, several have extensive substance abuse problems, while others suffer from serious mental illness, such as psychosis or severe anxiety disorders, particularly PTSD (Goldstein et al. 319). Moreover, the addiction factor is related to pure addiction and related liver disease without the accompaniment of psychiatric or general medical disorders (Goldstein et al. 319). This study supports the diverse health problems of homeless veterans. In another study, Edens et al., researchers and professors from the New England Mental Illness Research, Education, and Clinical Center at West Haven, Connecticut, the Department of Psychiatry at Yale University, the National Center on Homelessness among Veterans, and the School of Epidemiology and Public Health at Yale University, investigated homelessness risk among VA health services users. Using a case-control study, they utilized VA administrative data of veterans who are accessing VA mental health services, to scrutinize predictors. Findings showed that substance use disorders (predominantly illicit drug use disorders) were the strongest distinct predictors of homelessness (Edens et al. 415). They also determined a strong association between pathological gambling (PG) and homelessness, when other factors are controlled (Edens et al. 416). These studies indicate that many veterans suffer from disorders and mental illnesses that make them vulnerable to homelessness. The homeless, especially those with chronic health conditions, need government support to help them access housing services, without any exemptions. Providing exemptions and other disqualifiers, especially for the most vulnerable with substance abuse and mental disorders, only exacerbates homelessness among these high-risk groups. Schinka et al., members of the American Psychiatric Association, published an article that examined the effect of requiring sobriety at program entry on outcomes of housing services for homeless veterans. The employed data from a transitional housing program to compare client features and effects of programs requiring abstinence at admission and programs that do not require it. Their analysis included 3,188 veteran records, where 1,250 came from programs requiring sobriety at admission and 1,938 from programs without the same requirement. Findings showed that veterans with substance abuse problems had more chaotic histories and shorter program duration, but the sobriety requirement did not significantly improve housing outcomes (Schinka et al. 1329). Restrictions only hamper the fast transition from homelessness to homing services. Instead of restrictions, housing services should be expanded to the most vulnerable homeless veterans. Without any specific government agency that has the primary responsibility and accountability in addressing homelessness among veterans, homeless veterans will rise, especially after thousands of troops have returned from Iraq and suffered from mental/physical disabilities. Wiener reminds the government of the thousands of soldiers returning from Iraq. They are at risk of being homeless if they have mental or physical disabilities. The greatest problem is that there is no government agency that is mandated to help homeless veterans with these disorders. Wiener notes that the VA asserts in court that “it has no legal or other obligation to provide housing for mentally disabled vets.” The government only requires the VA to provide medical resources, but not housing services, even when housing is critical to accessing and maintaining health services (Wiener). Rosanne Haggerty, president of Community Solutions, which helps the 100,000 Homes Campaign, a national movement of communities that seek to end homelessness, asserts the need for a federal agency that is focused on ending homelessness. She stresses that federal housing assistance for homeless veterans must be available and easier to access and use, so that the government can end homelessness (Haggerty). Homeless people with mental illnesses, chronic health conditions, or psychological issues have particular health and welfare issues that the VA must respond to so that the homelessness can be resolved in the long-run. Existing facilities must be converted to or used for housing homeless veterans efficiently so that funds can be maximized. Furthermore, access to and provision of government services to the homeless must be efficient to provide immediate and lasting effects to homelessness. Haggerty argues that the government must cut red tape to attain meaningful homelessness reduction rates. She notes that in numerous places, “the bureaucratic red tape involved in qualifying a single homeless veteran for housing assistance can add as much as a year to the housing process.” Throughout this time, veterans stay homeless instead of being immediately housed. Haggerty recommends innovations that some communities already adopted, where homeless veterans can be qualified in as fast as 30 days, which should be the “national norm.” The VA must be held responsible by law for quality housing, healthcare, education, and employment services to address the varying needs of homeless veterans. O’Toole and other researchers from the Providence VA Medical Center, the Alpert Medical School at Brown University, Providence, RI, and Salve Regina University, Newport, RI assert the importance of care systems for homeless veterans. They used a quasi-experimental pre-post study to investigate four high-risk groups: “homeless veterans, cognitively impaired elderly, women veterans and patients with serious mental illness” (687). Their sampling included 457 patients. Findings showed that 2008 showed significant increase in access of primary care among the high-risk groups compared to 2006 and improvement in chronic disease monitoring and diabetes control (687). O’Toole et al. recommend systems approach to improve access to primary care utilization and to boost chronic disease monitoring and diabetes management (688). These services are critical to the homeless and must be timely provided through the VA. The VA must consider the specific conditions of homeless women veterans too. Tsai et al. studied the lifetime exposure to traumatic events of 581 homeless female veterans, who are recipients of the Homeless Women Veterans Program. They analyzed the connection between traumatic events and housing, clinical outcomes, and psychosocial wellbeing after a 1-year treatment period. Findings showed that almost all participants experienced multiple kinds and numbers of traumatic events, primarily having someone experience a serious illness and being raped. Despite these correlations, these authors asserted that they did not predict outcomes or housing gains. Home and healthcare services helped them deal with their psychological and physical disorders. Having a home with social and healthcare support can help the homeless develop the physical, emotional, and financial readiness they need to have their own homes. Supported housing programs can directly alleviate homelessness. Tsai et al. compared the needs of homeless veterans and non-veterans. They conducted an observational study that compared 162 chronically homeless veterans to 388 non-veterans, who participated in national-supported housing initiative for one year. Findings showed that veterans were older and came from the Vietnam War, and that there were no differences in housing and clinical needs. They stressed the need for supported housing that will help them transition from homelessness to housing services and other services they need to improve the quality of their lives. McGuire, Rosenheck, and Kasprow studied the impact of treatment process and outcomes for three housing programs, VA-staffed domiciliary care, and two kinds of community-based treatment. Findings showed that longer duration of stay and more encouraging social climate were connected with superior outcomes on a number of measures. These studies indicated that access to reliable housing services improved their health and housing gains. Some critics of establishing the responsibility of the VA to homeless veterans will say that the public should not be held responsible for veterans who have substance abuse problems and are severely mentally ill, and so the VA should not be accountable for the latter’s well-being. The veterans have sacrificed their mental and physical health, as well as their social relationships to serve the country. They did what they had, so that the public will have safe and peaceful lives. Because of the nature of their jobs, their occupations have, in many instances, contributed to their illnesses, and the public should help them access the services they need to recuperate and live decent lives. With studies showing that housing and related services are critical to solving homelessness in the long run, the government must then support the provision of these services through legalizing the role of the VA in providing them. Resolving veteran homelessness cannot be attained through finger-pointing. All this paper aims to offer is a balanced perspective on the strengths and weaknesses of the VA. Its programs are designed using evidence-based programs, but do not rigorously follow the latter. If the VA is held responsible for housing and treating all homeless veterans, it can better monitor these programs and enhance their effectiveness. Homelessness can be resolved through a mixture of immediate and long-term processes and goals that the VA can implement, while collaborating with other government and non-profit organizations that can provide needed services. Homelessness is a chronic issue that can only be strongly resolved through the proactive efforts of the VA. Works Cited Chinman, Matthew, Gordon Hannah, and Sharon McCarthy. “Lessons Learned from a Quality Improvement Intervention with Homeless Veteran Services.” Journal of Health Care for the Poor & Underserved 23.3 (2012): 210-24. CINAHL. Web. 6 Apr. 2012. Edens, Ellen L., Wes Kasprow, Jack Tsai, and Robert A. Rosenheck. “Association of Substance Use and VA Service-Connected Disability Benefits with Risk of Homelessness among Veterans.” The American Journal on Addictions 20.5 (2011): 4124-419. Academic Search Complete. Web. 6 Apr. 2012. Goldstein, Gerald, James F. Luther, Gretchen L. Haas, Cathleen J. Appelt, and Adam J. Gordon. “Factor Structure and Risk Factors for the Health Status of Homeless Veterans.” The Psychiatric Quarterly 81.4 (2010): 311-323. MEDLINE. Web. 6 Apr. 2012. Haggerty, Rosanne. “To Cut Homelessness, Cut the Red Tape.” The New York Times, 24 May 2012. Web. 6 Apr. 2012. < http://www.nytimes.com/roomfordebate/2012/05/24/how-should-the-us-support-returning-veterans/to-cut-veteran-homelessness-cut-the-red-tape>. Homelessness Research Institute. The State of Homelessness in America 2013. National Alliance to End Homelessness. Web. 9 Apr. 2012. . McGuire, James, Robert A. Rosenheck, and Wesley J. Kasprow. “Patient and Program Predictors of 12-Month Outcomes for Homeless Veterans following Discharge from Time-Limited Residential Treatment.” Administration and Policy in Mental Health 38.3 (2011): 142-54. MEDLINE. Web. 6 Apr. 2012. O'Toole ,Thomas P., Paul A. Pirraglia, David Dosa, Claire Bourgault, S. Redihan, M. B. O'Toole, and Joseph Blumen. “Building Care Systems to Improve Access for High-Risk and Vulnerable Veteran Populations.” Journal of General Internal Medicine 26.2 (2011): 683-688. MEDLINE. Web. 6 Apr. 2012. Roman, Nan. “Homelessness and the President's Budget: the Good News and the Bad.” Huffington Post, 12 Apr. 2013. Web. 13 Apr. 2012. < http://www.huffingtonpost.com/nan-roman/homelessness-and-the-pres_b_3072006.html>. Schinka, John A., Roger J. Casey, Wesley Kasprow, and Robert A. Rosenheck. “Requiring Sobriety at Program Entry: Impact on Outcomes in Supported Transitional Housing for Homeless Veterans.” Psychiatric Services 62.11 (2011): 1325-30. CINAHL. Web. 6 Apr. 2012. Tsai, Jack, Alvin S. Mares, and Robert A. Rosenheck. “Do Homeless Veterans have the Same Needs and Outcomes as Non-Veterans?” Military Medicine 177.1 (2012): 27-31. MEDLINE. Web. 6 Apr. 2012. Tsai, Jack, Robert A. Rosenheck, Suzanne E. Decker, Rani A. Desai, and Ilan Harpaz-Rotem. “Trauma Experience among Homeless Female Veterans: Correlates and Impact on Housing, Clinical, and Psychosocial Outcomes.” Journal of Traumatic Stress 25.6 (2012): 624-632. Academic Search Complete. Web. 6 Apr. 2012. “War and Homelessness.” Coalition for the Homeless 27 Mar. 2003. Web. 6 Apr. 2012. . Wiener, Jon. “LA's Homeless Vets.” The Nation, 20 Mar. 2013. Web. 6 Apr. 2012. . Read More