Homeless Veterans Programs: Bed Capacity, Service, and		 
Communication Gaps Challenge the Grant and Per Diem Program	 
(27-SEP-07, GAO-07-1265T).					 
                                                                 
The Subcommittee on Health of the Committee on Veterans' Affairs 
asked GAO to discuss its recent work on the Department of	 
Veterans Affairs' (VA) Homeless Providers Grant and Per Diem	 
(GPD) program. GAO reported on this subject in September 2006,	 
focusing on (1) VA's estimates of the number of homeless veterans
and transitional housing beds, (2) the extent of collaboration	 
involved in the provision of GPD and related services, and (3)	 
VA's assessment of program performance. 			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-1265T					        
    ACCNO:   A76776						        
  TITLE:     Homeless Veterans Programs: Bed Capacity, Service, and   
Communication Gaps Challenge the Grant and Per Diem Program	 
     DATE:   09/27/2007 
  SUBJECT:   Data collection					 
	     Eligibility determinations 			 
	     Federal/state relations				 
	     Homelessness					 
	     Housing						 
	     Housing programs					 
	     Performance appraisal				 
	     Program evaluation 				 
	     State programs					 
	     Veterans						 
	     Veterans benefits					 
	     Program goals or objectives			 
	     VA Homeless Providers Grant and Per Diem		 
	     Program						 
                                                                 

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GAO-07-1265T

   

     * [1]Background
     * [2]VA Has Expanded GPD Program Capacity to Help Meet Homeless V
     * [3]GPD Providers Collaborate to Offer a Range of Services, but
     * [4]VA Data Show Many Veterans Have Housing and Jobs on Leaving
     * [5]Contact and Acknowledgements
     * [6]GAO's Mission
     * [7]Obtaining Copies of GAO Reports and Testimony

          * [8]Order by Mail or Phone

     * [9]To Report Fraud, Waste, and Abuse in Federal Programs
     * [10]Congressional Relations
     * [11]Public Affairs
     * [12]PDF6-Ordering Information.pdf

          * [13]Order by Mail or Phone

Testimony before the Subcommittee on Health, Committee on Veterans'
Affairs, House of Representatives

United States Government Accountability Office

GAO

For Release on Delivery
Expected at 10:00 a.m. EDT
Thursday, September 27, 2007

HOMELESS VETERANS PROGRAMS

Bed Capacity, Service and Communication Gaps Challenge the Grant and Per
Diem Program

Statement of Daniel Bertoni, Director
Education, Workforce, and Income Security Issues

GAO-07-1265T

Mr. Chairman and Members of the Subcommittee:

Thank you for inviting me here today to discuss the Homeless Providers
Grant and Per Diem (GPD) program, the largest program of its kind
administered by the Department of Veterans Affairs (VA). On any given
night in the United States, an estimated 750,000 people, including
veterans, are homeless and may sleep on the streets or in shelters.
Veterans constitute about one-third of the adult homeless population, and
many veterans who are not yet homeless may be at risk. To address the
needs of these homeless veterans, VA officials told us that through the
GPD program they fund over 300 grants to local agencies to house
approximately 15,000 homeless veterans over the course of a year at a cost
of about $95 million. The program is not designed to serve all homeless
veterans--it focuses on transitional housing and supportive services for
veterans who are most in need, including those who have had problems with
mental illness, substance abuse, or both.

My statement draws on GAO's report on this program issued in September
2006 that reviewed (1) VA's estimates of the number of homeless veterans
and transitional housing beds, (2) the extent of collaboration involved in
the provision of GPD and related services, and (3) VA's assessment of
program performance.^1 I have also included information we obtained in
following up on VA's efforts to implement our recommendations.

In summary, VA reported in 2006 that about 196,000 veterans were homeless
and that not enough transitional beds were available through VA and other
organizations to meet the needs of homeless veterans eligible to use this
assistance. To help meet these needs, the GPD program has quadrupled its
capacity since 2000 to about 8,200 beds, and additional growth is planned.
In addition to increasing transitional bed capacity, VA and its providers
are also grappling with how to accommodate the needs of the changing
homeless veteran population that will include increasing numbers of women
and veterans with dependents. When we met with GPD providers who operate
the program and their local VA liaisons, we found that they were working
collaboratively with other organizations to deliver supportive services,
but most also noted key resource and communications gaps. Specifically,
providers reported difficulties finding affordable permanent housing for
veterans ready to leave the program. In addition the eligibility rules for
the GPD program were not always clear, a fact that could cause confusion
and could keep veterans from obtaining needed care. VA data showed that
many veterans were better off in terms of housing; employment; receipt of
public benefits; and progress with substance abuse, mental health, or
medical problems at the time they left the program, but VA did not know
how they were faring months or years later.

^1 GAO, Homeless Veterans Programs: Improved Communications and Follow-up
Could Further Enhance the Grant and Per Diem Program, [14]GAO-06-859
(Washington, D.C. Sept. 11, 2006).

We recommended that VA take steps to ensure that GPD policies and
procedures are consistently understood and to explore feasible means of
obtaining information about the circumstances of veterans after they leave
the GPD program. VA concurred and, following our review, has taken several
steps to improve communications and to develop a process to track
veterans' progress shortly after they leave the program. However following
up at a later point might yield a better indication of success.

Background

The GPD program is one of six housing programs for homeless veterans
administered by the Veterans Health Administration, which also undertakes
outreach efforts and provides medical treatment for homeless veterans.^2
VA officials told us in fiscal year 2007 they spent about $95 million on
the GPD program to support two basic types of grants--capital grants to
pay for the buildings that house homeless veterans and per diem grants for
the day-to-day operational expenses.^3 Capital grants cover up to 65
percent of housing acquisition, construction, or renovation costs. The per
diem grants pay a fixed dollar amount for each day an authorized bed is
occupied by an eligible veteran up to the maximum number of beds allowed
by the grant--in 2007 the amount cannot exceed $31.30 per person per day.
VA pays providers after they have housed the veteran, on a cost
reimbursement basis. Reimbursement may be lower for providers whose costs
are lower or are offset by funds for the same purpose from other sources.

^2The other five programs are the Contracted Residential Treatment
Program, the Domiciliary Residential Rehabilitation and Treatment Program,
the Compensated Work Therapy/Transitional Residence Program, the Loan
Guarantee for Multifamily Transitional Housing, and the Housing and Urban
Development-VA Supported Housing program.

^3 On a limited basis, special needs grants are available to cover the
additional costs of serving women, frail elderly, terminally ill, or
chronically mentally ill veterans.

Through a network of over 300 local providers, consisting of nonprofit or
public agencies, the GPD program offers beds to homeless veterans in
settings free of drugs and alcohol that are supervised 24 hours a day, 7
days a week. Most GPD providers have 50 or fewer beds available, with the
majority of providers having 25 or fewer. Program rules generally allow
veterans to stay with a single GPD provider for 2 years, but extensions
may be granted when permanent housing has not been located or the veteran
requires additional time to prepare for independent living. Providers,
however, have the flexibility to set shorter time frames. In addition,
veterans are generally limited to a total of three stays in the program
over their lifetime, but local VA liaisons may waive this limitation under
certain circumstances. The program's goals are to help homeless veterans
achieve residential stability, increase their income or skill levels, and
attain greater self-determination.

To meet VA's minimum eligibility requirements for the program, individuals
must be veterans and must be homeless. A veteran is an individual
discharged or released from active military service. The GPD program
excludes individuals with a dishonorable discharge, but it may accept
veterans with shorter military service than required of veterans who seek
VA health care. A homeless individual is a person who lacks a fixed,
regular, adequate nighttime residence and instead stays at night in a
shelter, institution, or public or private place not designed for regular
sleeping accommodations.^4 GPD providers determine if potential
participants are homeless, but local VA liaisons determine if potential
participants meet the program's definition of veteran. VA liaisons are
also responsible for determining whether veterans have exceeded their
lifetime limit of three stays in the GPD program and for issuing a waiver
to that rule when appropriate. Prospective GPD providers may identify
additional eligibility requirements in their grant documents.

While program policies are developed at the national level by VA program
staff, the local VA liaisons designated by VA medical centers have primary
responsibility for communicating with GPD providers in their area. VA
reported that in fiscal year 2007, there were funds to support 122
full-time liaisons.^5

^4The definitions appear at 42 U.S.C. S 11302 and 38 C.F.R. S 61.1.

VA Has Expanded GPD Program Capacity to Help Meet Homeless Veterans' Needs, but
Demand Still Exceeds Supply

Since fiscal year 2000, VA has quadrupled the number of available beds and
significantly increased the number of admissions of homeless veterans to
the GPD program in order to address some of the needs identified through
the its annual survey of homeless veterans. In fiscal year 2006, VA
estimated that on a given night, about 196,000 veterans were homeless and
an additional 11,100 transitional beds were needed to meet homeless
veterans' needs. However, this need was to be met through the combined
efforts of the GPD program and other federal, state, or community programs
that serve the homeless. VA had the capacity to house about 8,200 veterans
on any given night in the GPD program. Over the course of the year,
because some veterans completed the program in a matter of months and
others left before completion, VA was able to admit about 15,400 veterans
into the program, as shown in figure 1. Despite VA rules allowing stays of
up to 2 years, veterans remained in the GPD program an average of 3 to 5
months in fiscal year 2006.

^5 Liaisons told us in 2006 that they experienced large caseloads and
multiple GPD responsibilities--including eligibility determination,
verification of intake and discharge information, case management, fiscal
oversight, monitoring program compliance and inspections of GPD
facilities, among other duties. To address some of these concerns, VA
obtained funding to increase the number of full-time positions to 122.

Figure 1: Numbers of GPD Admissions and Beds in Fiscal Years 2000 and 2006

The need for transitional housing beds continues to exceed capacity,
according to VA's annual survey of local areas served by VA medical
centers. The number of transitional beds available nationwide from all
sources increased to 40,600 in fiscal year 2006, but the need for beds
increased as well. As a result, VA estimates that about 11,100 more beds
are needed to serve the homeless, as shown in table 1. VA officials told
us that they expect to increase the bed capacity of the GPD program to
provide some of the needed beds.

Table 1: Available and Needed Transitional Beds for Homeless Veterans,
Fiscal Year 2006

eds needed                        51,700 
nal beds available, including GPD 40,600 
ds still needed                   11,100 

Source: GAO analysis of VA's annual survey estimates rounded to nearest
100.

Most homeless veterans in the program had struggled with alcohol, drug,
medical or mental health problems before they entered the program. Over 40
percent of homeless veterans seen by VA had served during the Vietnam era,
and most of the remaining homeless veterans served after that war,
including at least 4,000 who served in military or peacekeeping operations
in the Persian Gulf, Afghanistan, Iraq, and other areas since 1990. About
50 percent of homeless veterans were between 45 and 54 years old, with 30
percent older and 20 percent younger. African-Americans were
disproportionately represented at 46 percent, the same percentage as
non-Hispanic whites. Almost all homeless veterans were men, and about 76
percent of veterans were either divorced or never married.

An increasing number of homeless women veterans and veterans with
dependents are in need of transitional housing according to VA officials
and GPD providers we visited. The GPD providers told us in 2006 that women
veterans had sought transitional housing; some recent admissions had
dependents; and a few of their beds were occupied by the children of
veterans, for whom VA could not provide reimbursement. VA officials said
that they may have to reconsider the type of housing and services that
they are providing with GPD funds in the future, but currently they
provide additional funding in the form of special needs grants to a few
GPD programs to serve homeless women veterans.

GPD Providers Collaborate to Offer a Range of Services, but Face Challenges in
Helping Veterans

VA's grant process encourages collaboration between GPD providers and
other service organizations. Addressing homelessness--particularly when it
is compounded by substance abuse and mental illness--is a challenge
involving a broad array of services that must be coordinated. To encourage
collaboration, VA's grants process awards points to prospective GPD
providers who demonstrate in their grant documents that they have
relationships with groups such as local homeless networks, community
mental health or substance abuse agencies, VA medical centers, and
ancillary programs. The grant documents must also specify how providers
will deliver services to meet the program's three goals--residential
stability, increased skill level or income, and greater
self-determination.

The GPD providers we visited often collaborated with VA, local service
organizations, and other state and federal programs to offer the broad
array of services needed to help veterans achieve the three goals of the
GPD program. Several providers worked with the local homeless networks to
identify permanent housing resources, and others sought federal housing
funds to build single-room occupancy units for temporary use until more
permanent long-term housing could be developed.^6 All providers we visited
tried to help veterans obtain financial benefits or employment. Some had
staff who assessed a veteran's potential eligibility for public benefits
such as food stamps, Supplemental Security Income, or Social Security
Disability Insurance. Other providers relied on relationships with local
or state officials to provide this assessment, such as county veterans'
service officers who reviewed veterans' eligibility for state and federal
benefits or employment representatives who assisted with job searches,
training, and other employment issues. GPD providers also worked
collaboratively to provide health care-related services--such as mental
health and substance abuse treatment, and family and nutritional
counseling. While several programs used their own staff or their partners'
staff to provide mental health or substance abuse services and counseling
directly, some GPD providers referred veterans off site--typically, to a
VA local medical center.

Despite GPD providers' efforts to collaborate and leverage resources, GPD
providers and VA staff noted gaps in key services and resources,
particularly affordable permanent housing for veterans ready to leave the
GPD program. Providers also identified lack of transportation, legal
assistance, affordable dental care,^7 and immediate access to substance
abuse treatment facilities as obstacles for transitioning veterans out of
homelessness. VA staff in some of the GPD locations we visited told us
that transportation issues made it difficult for veterans to get to
medical appointments or employment-related activities. While one GPD
provider we visited was able to overcome transportation challenges by
partnering with the local transit company to obtain subsidies for homeless
veterans, transportation remained an issue for GPD providers that could
not easily access VA medical centers by public transit. Providers said
difficulty in obtaining legal assistance to resolve issues related to
criminal records or credit problems presented challenges in helping
veterans obtain jobs or permanent housing. In addition, some providers
expressed concerns about obtaining affordable dental care and about wait
lists for veterans referred to VA for substance abuse treatment.

^6Through the local Continuum of Care networks, the Department of Housing
and Urban Development contracts with public housing agencies for the
rehabilitation of residential properties that provide multiple single-room
dwelling units. These agencies make Section 8 rental assistance payments
generally covering the difference between a portion of the tenant's income
(normally 30 percent) and the unit's rent to participating owners (i.e.,
landlords) on behalf of homeless individuals who rent the rehabilitated
dwellings.

^7 VA issued a directive for a onetime dental care opportunity for
homeless veterans (VHA Directive 2002-080) in line with 38 U.S.C. S 101
note. VA officials told us that funding was provided in 2006 to implement
this directive.

We found that some providers and staff did not fully understand certain
GPD program policies--which in some cases may have affected veterans'
ability to get care. For instance, providers did not always have an
accurate understanding of the eligibility requirements and program stay
rules, despite VA's efforts to communicate its program rules to GPD
providers and VA liaisons who implement the program. Some providers were
told incorrectly that veterans could not participate in the GPD program
unless they were eligible for VA health care. Several providers understood
the lifetime limit of three GPD stays but may not have known or believed
that VA had the authority to waive this rule.^8 As a consequence, we
recommended that VA take steps to ensure that its policies are understood
by the staff and providers with responsibility for implementing them.

In response to our recommendation that VA take steps to ensure that its
policies are understood by the staff and providers with responsibility for
implementing them, VA took several steps in 2007 to improve communications
with VA liaisons and GPD providers, such as calling new providers to
explain policies and summarizing their regular quarterly conference calls
on a new Web site, along with new or updated manuals. Language on the
number and length of allowable stays in the providers' guide has not
changed, however.

^8 VA may waive the lifetime limit on program stays if the services
offered are different from those previously provided and may lead to a
successful outcome. The VA liaisons must review and approve or deny the
waiver based on their best clinical assessment of the individual case.

VA Data Show Many Veterans Have Housing and Jobs on Leaving the Program and
Plans Are Under Way for Follow-up

VA assesses performance in two ways--the outcomes for veterans at the time
they leave the program and the performance of individual GPD providers.
VA's data show that since 2000, a generally steady or increasing
percentage of veterans met each of the program's three goals at the time
they left the GPD program.

Since 2000, proportionately more veterans are leaving the program with
housing or with a better handle on their substance abuse or health issues.
During 2006, over half of veterans obtained independent housing when they
left the GPD program, and another quarter were in transitional housing
programs, halfway houses, hospitals, nursing homes, or similar forms of
secured housing.^9 Nearly one-third of veterans had jobs, mostly on a
full-time basis, when they left the GPD program. One-quarter were
receiving VA benefits when they left the GPD program, and one-fifth were
receiving other public benefits such as Supplemental Security Income.
Significant percentages also demonstrated progress in handling alcohol,
drug, mental health, or medical problems and overcoming deficits in social
or vocational skills. For example, 67 percent of veterans admitted with
substance problems showed progress in handling these problems by the time
they left. Table 2 indicates the numbers or percentages involved.

^9 Independent housing comprises apartments, rooms, or houses. While
independent housing may be a more desirable outcome, for some veterans,
including those with severe disabilities, secured housing may be more
appropriate.

Table 2: Number Served by VA's Health Care for Homeless Veterans and Grant
and Per Diem Program and Veterans' Outcomes, Fiscal years 2000 and 2006

Participants served and outcomes                             2000     2006 
Number of                                                  43,082   60,857 
                                                                              
      o veterans treated by VA's Health Care for              34,206   38,667 
      Homeless Veterans' (HCHV) staff                                         
      o intake assessments of homeless veterans by             4,841   15,433 
      HCHV staff^a                                                            
      o admissions of veterans to GPDs                         4,020 15,037^b 
      o discharges from GPDs                                                  
Days a veteran stays at a GPD, on average                      91    139^c 
Housing stability outcomes:                                 1,163    7,723 
                                                                              
Number of discharges from GPDs with                           991    3,648 
                                                                              
      o independent housing                                                   
      o placement in halfway house or institution such                        
      as hospital, nursing home, or domiciliary                               
Increased income or skills outcomes:                        1,404    4,766 
                                                                              
Number of discharges from GPDs with                 Not Available    3,648 
                                                                              
      o full-time or part-time employment              Not Available    3,001 
      o VA benefits^d                                                         
      o Other public benefits^d                                               
Greater self-determination outcomes:                        38-42    60-67 
                                                                              
Percentage of discharges from GPDs with                     43-46    57-62 
                                                                              
      o improved alcohol, drug, mental health^e                   30       47 
      o improved medical, social/vocational                                   
      condition^e                                                             
      o success in meeting GPD provider requirements                          

Source: GAO analysis of VA data aggregated from individual discharge forms
completed by VA or GPD providers for veterans at the time they leave the
program and compiled in annual reports by VA's evaluation center.

aIntake assessments are completed by HCHV staff when they first encounter
a homeless veteran, unless the contact is casual and no services are
offered or referrals made. After a year, new assessments are required if
VA care or services are provided and VA staff have not been working with
the veteran.

bNumber of discharges with complete data on their status is 14,710 and is
used to calculate all numbers below.

cMean is shown. Median is 81 days.

dNumbers shown here include veterans who receive both types of benefits as
well as those who receive only the designated benefits.

ePercentages are ranges showing the highest and lowest of each of two or
three outcome measures.

VA's Office of Inspector General (OIG) found when it visited GPD providers
in 2005-2006 that VA officials had not been consistently monitoring the
GPD providers' annual performance as required.^10 The GPD program office
has since moved to enforce the requirement that VA liaisons review GPD
providers' performance when the VA team comes on-site each year to inspect
the GPD facility.

To assess the veterans' success, VA has relied chiefly on measures of
veterans' status at the time they leave the GPD program rather than
obtaining routine information on their status months or years later. In
part, this has been due to concerns about the costs, benefits, and
feasibility of more extensive follow-up. However, VA completed a onetime
study in January 2007 that a VA official told us cost about $1.5 million.
The study looked at the experience of a sample of 520 veterans who
participated in the GPD program in five geographic locations, including
360 who responded to interviews a year after they had left the program.
Generally, the findings confirm that veterans' status at the time they
leave the program can be maintained.

We recommended that VA explore feasible and cost-effective ways to obtain
information on how veterans are faring after they leave the program. We
suggested that where possible they could use data from GPD providers and
other VA sources, such as VA's own follow-up health assessments and GPD
providers' follow-up information on the circumstances of veterans 3 to 12
months later. VA concurred and told us in 2007 that VA's Northeast Program
Evaluation Center is piloting a new form to be completed electronically by
VA liaisons for every veteran leaving the GPD program. The form asks for
the veterans' employment and housing status, as well as involvement, if
any, in substance abuse treatment, 1 month after they have left the
program. While following up at 1 month is a step in the right direction,
additional information at a later point would yield a better indication of
longer-term success.

Mr. Chairman, this concludes my remarks. I would be happy to answer any
questions that you or other members of the subcommittee may have.

^10 Veterans Affairs Office of Inspector General, Evaluation of the
Veterans Health Administration Homeless Grant and Per Diem Program, Report
No. 04-00888-215 (Washington, D.C.: Sept. 20, 2006).

Contact and Acknowledgements

For further information, please contact Daniel Bertoni at (202) 512-7215.
Also contributing to this statement were Shelia Drake, Pat Elston, Lise
Levie, Nyree M. Ryder, and Charles Willson.

(130815)

This is a work of the U.S. government and is not subject to copyright
protection in the United States. The published product may be reproduced
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However, because this work may contain copyrighted images or other
material, permission from the copyright holder may be necessary if you
wish to reproduce this material separately.

To view the full product, including the scope
and methodology, click on [15]GAO-07-1265T .

For more information, contact Daniel Bertoni at (202) 512-7215 or
[email protected].

Highlights of [16]GAO-07-1265T , a testimony before the Subcommittee on
Health, Committee on Veterans' Affairs, House of Representatives

September 27, 2007

HOMELESS VETERANS PROGRAMS

Bed Capacity, Service and Communication Gaps Challenge the Grant and Per
Diem Program

The Subcommittee on Health of the Committee on Veterans' Affairs asked GAO
to discuss its recent work on the Department of Veterans Affairs' (VA)
Homeless Providers Grant and Per Diem (GPD) program.

GAO reported on this subject in September 2006, focusing on

(1) VA's estimates of the number of homeless veterans and transitional
housing beds, (2) the extent of collaboration involved in the provision of
GPD and related services, and (3) VA's assessment of program performance.

VA estimates that about 196,000 veterans nationwide were homeless on a
given night in 2006, based on its annual survey, and that the number of
transitional beds available through VA and other organizations was not
sufficient to meet the needs of eligible veterans. The GPD program has
quadrupled its capacity to provide transitional housing for homeless
veterans since 2000, and additional growth is planned. As the GPD program
continues to grow, VA and its providers are also grappling with how to
accommodate the needs of the changing homeless veteran population that
will include increasing numbers of women and veterans with dependents.

The GPD providers we visited collaborated with VA, local service
organizations, and other state and federal programs to offer a broad array
of services designed to help veterans achieve the three goals of the GPD
program--residential stability, increased skills or income, and greater
self-determination. However, most GPD providers noted key service and
communication gaps that included difficulties obtaining affordable
permanent housing and knowing with certainty which veterans were eligible
for the program, how long they could stay, and when exceptions were
possible.

VA data showed that many veterans leaving the GPD program were better off
in several ways--over half had successfully arranged independent housing,
nearly one-third had jobs, one-quarter were receiving benefits, and
significant percentages showed progress with substance abuse, mental
health or medical problems or demonstrated greater self-determination in
other ways. Some information on how veterans fare after they leave the
program was available from a onetime follow-up study of 520 program
participants, but such data are not routinely collected.

We recommended that VA take steps to ensure that GPD policies and
procedures are consistently understood and to explore feasible means of
obtaining information about the circumstances of veterans after they leave
the GPD program. VA concurred and, following our review, has taken several
steps to improve communications and to develop a process to track
veterans' progress shortly after they leave the program. However following
up at a later point might yield a better indication of success.

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