VA-supported housing isn’t just about putting a roof over veterans’ heads; it involves case management by a social worker and referrals for health and social services. As Stefan Kertesz, MD, a primary care physician and homeless health researcher at the Birmingham (Alabama) VA Medical Center (VAMC), points out: “Housing First is a major change of clinical philosophy and a giant logistic change at the same time. The clinical philosophy takes housing and treats it as a human right instead of a reward for doing well. And that can be uncomfortable and difficult. The logistic challenge is that a medical center may have hundreds or thousands of rental vouchers that need to be redeemed in the community as fast as possible. And that necessarily involves dealing with money, geography, and bureaucracy.” In short, VA caseworkers are called upon not only to resolve clinical and psychological issues, but also to solve logistical problems involving real estate, rental contracts, bill payment, clothing, and furniture. Housing First involves intense staffing requirements.

To discover the best practices among VA centers – what factors contribute most to the success of the Housing First approach, given these challenges – Kertesz and colleagues designed a study called Homeless Solutions in a VA Environment (H-SOLVE). To begin with, Kertesz’s group found significant variations in the way the approach was implemented across eight different VAMCs. The group also discovered that providers who had been tasked with finding housing as a first priority often felt their case management duties were being neglected in favor of the logistical problems, and that in some cases this led to turnover and burnout.

H-SOLVE, a study based entirely on interviews with VA personnel, revealed the importance both of frontline providers – who, in the more successful implementations of Housing First, are skilled and assertive in forging new relationships to secure housing, often with outside parties – and VAMC leadership, which Kertesz’s team evaluated using a scientific model known as the Organizational Transformation Model.

Successful integration of the Housing First approach across VA service lines, Kertesz said, usually requires collaborative working groups, with strong support and investment from the center’s senior-most leadership – integration among working groups, and from top to bottom. “It’s not enough,” he said, “for committed social workers in the homeless service program to dedicate themselves to this task. They’re going to require collaboration and assistance from a vehicle fleet, from the information technology people, from the psychology or mental health service, from the emergency department, and others.”

Homeless Veterans Patient Aligned Care Teams (H-PACT): In 2010, the Veterans Health Administration (VHA) began implementing the PACT model of care, a patient-centered, team-based approach to providing and managing primary care over a veteran’s lifetime. A year later, the VA piloted the H-PACT, tailored specifically to meet the needs of homeless veterans by addressing the many barriers to care these patients encounter.

The H-PACT model has proliferated swiftly: There are 60 active sites throughout the United States, and O’Toole and colleagues are launching new studies and tracking results as more are established.

Before he became director of the VA’s National Center on Homelessness among Veterans, Tom O’Toole, MD, directed the H-PACT program, which he said differs from traditional care models in several different ways:

• Open access. Because their circumstances create difficulties in making and keeping appointments, H-PACT patients can take advantage of on-demand care, with walk-in appointments available at participating locations.
• Wrap-around, integrated services. When possible, H-PACTs avoid referrals by offering a suite of services, in addition to medical care, in one place. “Seventy percent of our clinics have food available on-site,” said O’Toole. “Most have clothes pantries. Transportation is made available to and from the clinic. You can walk down the hall and talk to somebody about getting housing, or about getting food stamps.” To the extent possible, H-PACT clinics are one-stop shops.
• Holistic case management. Similarly, H-PACT services focus on outcomes in the community beyond the clinic, in housing and community services.
• A specialized skill set. H-PACT providers need to both understand which services are available and necessary for homeless patients and how to engage veterans in those services.