1. Chapter 15 Homelessness Among Veterans

2. Definition of and Possible Reasons for Veteran Homelessness  A homeless veteran is any one or more of the following:  Lacks a fixed, regular, and adequate nighttime residence  Has a supervised shelter as a primary nighttime residence  Has a temporary residence for individuals intended to be institutionalized  Lives in transitional housing  Lives in a hotel or motel paid for by a government entity  Is in imminent danger of losing housing  Possible reasons:  Difficulty with the culture shock of transition from military to civilian life  Limited resources  Traumatic experiences  Substance abuse  Mental health problems  Difficulty reconnecting with social support systems  Lack of self-advocacy skills  A homeless veteran is any one or more of the following:  Lacks a fixed, regular, and adequate nighttime residence  Has a supervised shelter as a primary nighttime residence  Has a temporary residence for individuals intended to be institutionalized  Lives in transitional housing  Lives in a hotel or motel paid for by a government entity  Is in imminent danger of losing housing  Possible reasons:  Difficulty with the culture shock of transition from military to civilian life  Limited resources  Traumatic experiences  Substance abuse  Mental health problems  Difficulty reconnecting with social support systems  Lack of self-advocacy skills

3. Prevalence  Veterans comprise one-fifth of the homeless population (approximately 58 homeless veterans for every 10,000 veterans).  Vietnam vets are at greatest risk.  Current trends show increases in younger vets and in women vets experiencing homelessness.  A small group of homeless veterans are the most vulnerable and occupy a relatively large proportion of shelter capacities, cycling in and out of shelter facilities.  On a single night in 2009 there were an estimated 75,609 homeless veterans in the USA  one in every 168 veterans  one in every 10 who live in poverty  Veterans comprise one-fifth of the homeless population (approximately 58 homeless veterans for every 10,000 veterans).  Vietnam vets are at greatest risk.  Current trends show increases in younger vets and in women vets experiencing homelessness.  A small group of homeless veterans are the most vulnerable and occupy a relatively large proportion of shelter capacities, cycling in and out of shelter facilities.  On a single night in 2009 there were an estimated 75,609 homeless veterans in the USA  one in every 168 veterans  one in every 10 who live in poverty

4. Interventions  Motivational Interviewing (as discussed in Chapter 10)  Housing First: A continuum of care model that:  Has an eligibility requirement of sobriety and medical or psychiatric compliance  Provides supported housing as homeless consumer’s first choice  Utilizes the Assertive Community Treatment (ACT) team approach (see next slide)  Uses motivational interviewing as a treatment model  VA-Sponsored Permanent Housing Program  Housing vouchers  Case management  Treatment plan  Alcohol and drug screenings  Frequent medical and mental health appointments  Assistance with employment and income needs  Resolution of legal and financial issues  Wraparound services, such as crisis counseling and guidance with the benefits process  Motivational Interviewing (as discussed in Chapter 10)  Housing First: A continuum of care model that:  Has an eligibility requirement of sobriety and medical or psychiatric compliance  Provides supported housing as homeless consumer’s first choice  Utilizes the Assertive Community Treatment (ACT) team approach (see next slide)  Uses motivational interviewing as a treatment model  VA-Sponsored Permanent Housing Program  Housing vouchers  Case management  Treatment plan  Alcohol and drug screenings  Frequent medical and mental health appointments  Assistance with employment and income needs  Resolution of legal and financial issues  Wraparound services, such as crisis counseling and guidance with the benefits process

5. Assertive Community Treatment (ACT)  A multidisciplinary team model that provides intensive case management services in the community to persons with serious and chronic mental disabilities.  Main features:  Consumer-driven treatment goals  Multidisciplinary teams with daily case consultations  Shared, not individual, caseloads  Close medication management and monitoring  Assertive outreach  Low client-to-staff ratios, ideally 10:1  24-hour responsibility for client care  A multidisciplinary team model that provides intensive case management services in the community to persons with serious and chronic mental disabilities.  Main features:  Consumer-driven treatment goals  Multidisciplinary teams with daily case consultations  Shared, not individual, caseloads  Close medication management and monitoring  Assertive outreach  Low client-to-staff ratios, ideally 10:1  24-hour responsibility for client care

6. Health Care for Homeless Veterans  Provided to VA-eligible vets by VA Medical Centers.  The VA funds community agencies that provide:  Transitional housing  Case management  Counseling  Benefits  Social service referral  Employment referral  Life skills  Money management and computer skills classes  Teams comprised mainly of nurses and social workers act as liaisons between the VA and the VA-funded community agencies and provide screening, assessment, treatment planning, referral, case monitoring, and crisis management interventions for homeless veterans who are transitionally housed at the community agencies  Provided to VA-eligible vets by VA Medical Centers.  The VA funds community agencies that provide:  Transitional housing  Case management  Counseling  Benefits  Social service referral  Employment referral  Life skills  Money management and computer skills classes  Teams comprised mainly of nurses and social workers act as liaisons between the VA and the VA-funded community agencies and provide screening, assessment, treatment planning, referral, case monitoring, and crisis management interventions for homeless veterans who are transitionally housed at the community agencies

7. Other Programs for Homeless Veterans  Domiciliary care  Homeless Veterans Reintegration Program  Serves homeless veterans ”who may be shunned by other programs and services because of problems such as severe post- traumatic stress disorder (PTSD), long histories of substance abuse, serious psychosocial problems, legal issues, and those who are HIV-positive.”  Provides intensive assessment, specialized job referrals, and more intensive counseling and case management than is possible in other veteran-specific employment programs.  Also fills a gap for many homeless veterans who are not eligible for VA Vocational Rehabilitation by providing funding for career track vocational and junior college programs.  Domiciliary care  Homeless Veterans Reintegration Program  Serves homeless veterans ”who may be shunned by other programs and services because of problems such as severe post- traumatic stress disorder (PTSD), long histories of substance abuse, serious psychosocial problems, legal issues, and those who are HIV-positive.”  Provides intensive assessment, specialized job referrals, and more intensive counseling and case management than is possible in other veteran-specific employment programs.  Also fills a gap for many homeless veterans who are not eligible for VA Vocational Rehabilitation by providing funding for career track vocational and junior college programs.

8. New VA Programs  Veterans Homelessness Prevention Demonstration Project  The National Call Center for Homeless Veterans  Health Care for Re-Entry Veterans (HCRV)  Veterans Justice Outreach (VJO)  Supportive Services for Veteran Families (SSVF) Program  Veterans Homelessness Prevention Demonstration Project  The National Call Center for Homeless Veterans  Health Care for Re-Entry Veterans (HCRV)  Veterans Justice Outreach (VJO)  Supportive Services for Veteran Families (SSVF) Program

9. Medication Compliance  Homeless veterans with higher rates of medication noncompliance have a lower probability of ending their homelessness.  Reasons for medication noncompliance:  Distressing side effects  Mistrust of providers  Denial of medical needs  Perception that little or no benefit is obtained from prescribed medication  High rates of missed appointments  Transportation costs for appointments or medication copayments  Substance abuse (prescribed drugs contraindicated)  Theft  Confiscation of meds by police or groundskeepers  Mental illness  Homeless veterans with higher rates of medication noncompliance have a lower probability of ending their homelessness.  Reasons for medication noncompliance:  Distressing side effects  Mistrust of providers  Denial of medical needs  Perception that little or no benefit is obtained from prescribed medication  High rates of missed appointments  Transportation costs for appointments or medication copayments  Substance abuse (prescribed drugs contraindicated)  Theft  Confiscation of meds by police or groundskeepers  Mental illness

10. Outreach Considerations  Lack of trust is a primary reason that many homeless persons are reluctant to access services.  Often, no family is available for emotional or financial support.  Social disaffiliation generates a need for community outreach and a period of courting between the veteran and provider that can be quite extensive, just to establish a relationship.  Once trust is established, providers are often called upon to assume advocacy roles in an effort to facilitate access to health care and community services  Peer outreach has been a widely used strategy for HIV prevention with drug users and capitalizes on peer influence processes  Lack of trust is a primary reason that many homeless persons are reluctant to access services.  Often, no family is available for emotional or financial support.  Social disaffiliation generates a need for community outreach and a period of courting between the veteran and provider that can be quite extensive, just to establish a relationship.  Once trust is established, providers are often called upon to assume advocacy roles in an effort to facilitate access to health care and community services  Peer outreach has been a widely used strategy for HIV prevention with drug users and capitalizes on peer influence processes

11. Practitioner Issues  Countertransference  Secondary trauma (see Chapter 5)  Self-care and burnout prevention  Social workers should realize that in the combat zone as in the streets anger is beneficial towards survival and success  Social workers should be prepared ahead of time to expect:  Mistrust  Anger/rage  Depression and cynicism  A testing phase (including questioning their motives and their knowledge of military culture)  Countertransference  Secondary trauma (see Chapter 5)  Self-care and burnout prevention  Social workers should realize that in the combat zone as in the streets anger is beneficial towards survival and success  Social workers should be prepared ahead of time to expect:  Mistrust  Anger/rage  Depression and cynicism  A testing phase (including questioning their motives and their knowledge of military culture)