Homeless Veterans: VA Expands Partnerships, but Homeless Program
Effectiveness Is Unclear (Letter Report, 04/01/99, GAO/HEHS-99-53).

Pursuant to a congressional request, GAO reviewed the effectiveness of
efforts to assist homeless veterans, focusing on: (1) describing the
Department of Veterans Affairs (VA) homeless programs; (2) determining
what VA knows about the effectiveness of its homeless programs; and (3)
examining promising approaches aimed at different groups of homeless
veterans.

GAO noted that: (1) VA's homeless assistance and treatment programs
address diverse needs of homeless veterans by providing services such as
case management, employment assistance, and transitional housing; (2) VA
also provides medical, mental health, substance abuse, and social
services to homeless veterans through its hospitals, outpatient clinics,
and other health care facilities; (3) because of resource constraints
and legislative mandates, VA expanded its homeless veterans efforts by
better aligning itself with other federal departments, state and local
government agencies, and community-based organizations; (4) the goal of
this effort is to develop a continuum of care for the homeless--that is,
to identify or create options for addressing the full array of housing,
health, and service needs of this population; (5) VA has little
information about the effectiveness of its homeless programs; (6) VA has
relied on the Northeast Program Evaluation Center (NEPEC) to gather and
report information about its homeless programs; (7) each of VA's
homeless program sites routinely submits extensive data, mostly related
to client characteristics and operations at individual program sites;
(8) these data are used primarily to provide program managers with
information about service delivery and are of limited use in assessing
program effectiveness; (9) to evaluate effectiveness, information must
be gathered about intended program results; (10) the outcome measures
that NEPEC uses focus on housing, employment, and changes in substance
abuse and mental health at the time veterans are discharged from VA's
homeless programs; (11) little is known about whether veterans served by
VA's homeless programs remain housed or employed, or whether they
instead relapse into homelessness; (12) many questions about how to
treat homelessness remain unanswered; and (13) experts agree, however,
that a comprehensive continuum of care for the homeless--such as that
which VA is striving to achieve--should include a range of housing and
service alternatives, with specific approaches at any one site
reflecting local needs and local resources.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-99-53
     TITLE:  Homeless Veterans: VA Expands Partnerships, but Homeless 
             Program Effectiveness Is Unclear
      DATE:  04/01/99
   SUBJECT:  Homelessness
             Redundancy
             Veterans
             Performance measures
             Program evaluation
             Federal aid programs
             Interagency relations
IDENTIFIER:  VA Domiciliary Care for Homeless Veterans Program
             VA Health Care for Homeless Veterans Program
             VA Homeless Chronically Mentally Ill Program
             
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Cover
================================================================ COVER


Report to the Chairman, Committee on Veterans' Affairs, U.S.  Senate

April 1999

HOMELESS VETERANS - VA EXPANDS
PARTNERSHIPS, BUT HOMELESS PROGRAM
EFFECTIVENESS IS UNCLEAR

GAO/HEHS-99-53

Homeless Veterans

(406150)


Abbreviations
=============================================================== ABBREV

  ACT - Assertive Community Treatment
  CHALENG - Community Homeless Assessment, Local Education and
     Networking Groups
  CHC - Comprehensive Homeless Centers
  CTI - Critical Time Intervention
  CWT - Homeless Compensated Work Therapy
  CWT/TR - Homeless Compensated Work Therapy/Transitional Residence
  DCHV - Domiciliary Care for Homeless Veterans
  GPD - Homeless Providers Grant and per Diem
  HCHV - Health Care for Homeless Veterans
  HCMI - Homeless Chronically Mentally Ill
  HHS - Department of Health and Human Services
  HIV - human immunodeficiency virus
  HUD - Department of Housing and Urban Development
  HUD-VASH - Housing and Urban Development-VA Supported Housing
  NEPEC - Northeast Program Evaluation Center
  PTSD - post-traumatic stress disorder
  SH - Supported Housing
  SSA - Social Security Administration
  SSA-VA - Social Security Administration-VA Joint Outreach
     Initiative
  VA - Department of Veterans Affairs
  VBA - Veterans Benefits Administration
  VHA - Veterans Health Administration
  VISN - Veterans Integrated Service Networks
  VVSD - Vietnam Veterans of San Diego

Letter
=============================================================== LETTER


B-280946

April 1, 1999

The Honorable Arlen Specter
Chairman, Committee on Veterans' Affairs
United States Senate

Dear Mr.  Chairman: 

Homelessness in the United States is a complex and difficult problem. 
The exact number of homeless is unknown, but on any given night an
estimated 500,000 to 600,000 homeless people live on the streets or
in shelters.\1 The Department of Veterans Affairs (VA) reports that
approximately one-third of the adult homeless population are
veterans, and these homeless veterans suffer with about the same
relatively high rates of psychiatric and substance abuse disorders as
the general homeless population.  Over the past decade or so, VA
established programs to address the needs of homeless veterans and,
in fiscal year 1997, obligated approximately $84 million on targeted
homeless programs.  Other federal departments and agencies have also
developed programs aimed at assisting the homeless.  In fiscal year
1997, the Departments of Education, Health and Human Services (HHS),
Housing and Urban Development (HUD), Labor, and VA, and the Federal
Emergency Management Agency obligated approximately $1.2 billion on
targeted homeless assistance. 

Despite these programs, homelessness remains a persistent problem,
prompting questions about the effectiveness of efforts to assist the
homeless.  For this reason, you asked us to (1) describe VA's
homeless programs, (2) determine what VA knows about the
effectiveness of its homeless programs, and (3) examine promising
approaches aimed at different groups of homeless veterans. 

To develop this information, we conducted work at VA headquarters and
VA's Northeast Program Evaluation Center (NEPEC) in West Haven, Conn. 
We also reviewed reports from federally funded research and visited
VA and community-based homeless programs that illustrate approaches
to dealing with different homeless populations in Little Rock, Ark.;
Denver, Colo.; Washington, D.C.; West Los Angeles and San Diego,
Calif.; and New York, N.Y.  We performed our work between April 1998
and January 1999 in accordance with generally accepted government
auditing standards.  (App.  I contains a more detailed discussion of
our scope and methodology, and app.  VI contains detailed
descriptions of programs we visited that were designed for different
homeless groups.)


--------------------
\1 Martha R.  Burt, ï¿½Demographics and Geography:  Estimating Needsï¿½
(Paper presented at the National Symposium on Homelessness Research: 
What Works, cosponsored by the Department of Housing and Urban
Development and the Department of Health and Human Services, Oct. 
1998). 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

VA's homeless assistance and treatment programs address diverse needs
of homeless veterans by providing services such as case management,
employment assistance, and transitional housing.  VA also provides
medical, mental health, substance abuse, and social services to
homeless veterans through its hospitals, outpatient clinics, and
other health care facilities.  Because of resource constraints and
legislative mandates, VA expanded its homeless veterans efforts by
better aligning itself with other federal departments, state and
local government agencies, and community-based organizations.  For
example, in 1994, VA implemented a strategy that encourages its
homeless staff to work more closely with community-based homeless
organizations.  The goal of this effort is to develop a continuum of
care for the homeless--that is, to identify or create options for
addressing the full array of housing, health, and service needs of
this population. 

Despite the resources VA has devoted to homeless programs--over $640
million between fiscal years 1987 and 1997--VA has little information
about the effectiveness of its homeless programs.  VA has relied on
NEPEC to gather and report information about its homeless programs. 
Each of VA's homeless program sites routinely submits extensive data,
mostly related to client characteristics and operations at individual
program sites.  These data are used primarily to provide program
managers with information about service delivery and are of limited
use in assessing program effectiveness.  To evaluate effectiveness,
information must be gathered about intended program results.  The
outcome measures that NEPEC uses focus on housing, employment, and
changes in substance abuse and mental health at the time veterans are
discharged from VA's homeless programs.  Little is known about
whether veterans served by VA's homeless programs remain housed or
employed, or whether they instead relapse into homelessness.  For
this reason, we are recommending that VA initiate program evaluation
studies designed to clarify the effectiveness of their homeless
programs. 

Many questions about how to treat homelessness remain unanswered. 
Experts agree, however, that a comprehensive continuum of care for
the homeless--such as that which VA is striving to achieve--should
include a range of housing and service alternatives, with specific
approaches at any one site reflecting local needs and local
resources.  Some promising approaches address the needs of different
groups of the homeless.  For example, some homeless veterans have
medical conditions that, while not serious enough to require
hospitalization, are likely to worsen if the individuals are not in a
stable environment; programs in Washington, D.C., and Los Angeles
address this need for convalescent care.  Seriously mentally ill
homeless persons can be among the most difficult to help; programs in
New York City and San Diego, however, are showing promise.  Projects
like these target the needs of specific components of the homeless
population and vary to include services for medical, mental health,
substance abuse, or other problems depending on the population's
specific needs. 


   BACKGROUND
------------------------------------------------------------ Letter :2

In July 1987, the Congress responded to the problems of homelessness
by enacting several laws addressing different aspects of the problem. 
The most comprehensive of these was the Stewart B.  McKinney Homeless
Assistance Act (P.L.  100-77).  Combined, the more than 20 McKinney
Act grant programs funded activities that provided homeless men,
women, and children with supportive services such as emergency food
and shelter, surplus goods and property, transitional housing,
primary health care services, and mental health care.\2 The remaining
McKinney Act grant programs and authorities are administered by five
different departments--Education, HHS, HUD, Labor, and VA--and one
agency, the Federal Emergency Management Agency.  Since fiscal year
1987, federal funding for targeted homeless assistance has increased
dramatically, from $490 million to more than $1.2 billion in fiscal
year 1997.\3

Veterans constitute about one-third of the homeless adult population
in the United States on any given day.  They form a heterogeneous
group and are likely to have multiple needs.  For example, VA
estimates that approximately one-half of homeless veterans have a
substance abuse problem, approximately one-third have a serious
mental illness (of those, about half also have a substance abuse
problem), and many have other medical problems.  Some homeless
veterans need assistance in obtaining benefits, managing their
finances, resolving legal matters, developing work skills, or
obtaining employment.  Many require some form of transitional housing
before a more permanent housing arrangement can be achieved.  For
some homeless veterans, independent housing and economic self-support
are reasonable goals.  But for others, including many seriously
mentally ill homeless persons, neither full-time work nor independent
housing may be feasible.  Instead, for these individuals, relative
stability in a supportive environment such as a group home may be the
most reasonable outcome.  Thus, efforts to assist the homeless
require a range of housing options (including emergency shelter as
well as transitional and permanent housing); treatment for medical,
mental health, and substance abuse problems; and supportive services
such as transportation and case management.  This spectrum of options
is referred to as the continuum of care. 

Homeless veterans are eligible for health care through the VA by
virtue of their status as veterans, but in addition, VA has
established programs specifically for homeless veterans.  Two major
VA homeless programs, Health Care for Homeless Veterans\4 (HCHV) and
Domiciliary Care for Homeless Veterans (DCHV), were created as a
result of legislative actions taken during 1987 to address the needs
of homeless veterans.  The goal of these programs is to outreach and
identify homeless veterans, assess their needs, and link them with VA
or community-based programs for services, as appropriate. 

The HCHV and DCHV programs are both managed by the Veterans Health
Administration (VHA) but under the auspices of different health care
groups within VHA.  HCHV programs are under the jurisdiction of VHA's
Strategic Health Care Group for Mental Health Services; the DCHV
program is directed by VHA's Geriatrics and Extended Care Strategic
Health Care Group.  VA's annual obligations for its targeted homeless
programs increased from $10 million in fiscal year 1987 to
approximately $84 million in fiscal year 1997.  During this period,
VA has obligated over $640 million for its targeted homeless
programs.  Since the inception of VA's homeless programs, VA has
served over 250,000 veterans. 

VA's NEPEC monitors and evaluates VA's homeless programs using data
it collects and analyzes from program sites.  NEPEC generally issues
annual reports for VA's homeless programs that include some outcome
measures such as whether a veteran is housed or employed upon leaving
a program. 

With the reorganization of VHA into networks in 1995, headquarters
oversight has been decentralized, and control of oversight and
funding of the homeless programs has shifted to the local level. 
Specifically, VA organized its health care system to give greater
authority and control to 22 Veterans Integrated Service Networks
(VISN) and medical center managers.  Headquarters program officials
have now assumed a largely consultative role.  Currently, all 22
VISNs participate in a Council of Network Homeless Coordinators to
advise VA headquarters and VISN directors on issues related to the
delivery and evaluation of homeless services to veterans. 

In its fiscal year 2000 budget request, VA revised its strategic
planning and performance measurement processes under the Government
Performance and Results Act of 1993 by adding performance measures
related to outcomes for veterans served by its homeless programs. 
These outcome measures, which are already monitored by NEPEC, address
the percentage of veterans who have independent living arrangements
and employment upon their discharge from VA or from community-based
contract residential care programs.  Beyond these outcome measures,
VA has three process goals:  to increase (1) the number of community-
based beds for homeless veterans, (2) VA facilities' efforts to
coordinate with other providers of homeless services, and (3) the
number of homeless veterans treated in VA's health care system. 


--------------------
\2 While authority for most McKinney Act programs has expired, some
programs were consolidated and continue to be funded by Congress. 

\3 See Homelessness:  Coordination and Evaluation of Programs Are
Essential (GAO/RCED-99-49, Feb.  26, 1999), for an inventory of
targeted and nontargeted federal programs that assist the homeless. 

\4 When established, this was called the Homeless Chronically
Mentally Ill (HCMI) program.  HCHV is an umbrella term VA uses to (1)
describe the targeted homeless programs and (2) avoid use of the term
ï¿½chronically mentally ill.ï¿½


   VA PROVIDES KEY SERVICES,
   BUILDS CAPACITY THROUGH
   PARTNERSHIPS
------------------------------------------------------------ Letter :3

VA provides services to homeless veterans through targeted homeless
programs across the United States.  VA also provides medical, mental
health, substance abuse, and social services to homeless veterans
through its mainstream health care programs.  VA's homeless efforts
include services such as outreach activities to identify homeless
veterans, residential treatment programs to address clinical
disorders, and job counseling and placement assistance to veterans
seeking work.  However, realizing that it does not have the resources
to address all the needs of homelessness alone, VA is working more
closely with community-based providers and other organizations to
create a continuum of care to improve services for homeless veterans. 


      VA PROVIDES AN ARRAY OF
      HOMELESS SERVICES
---------------------------------------------------------- Letter :3.1

Since establishing its first homeless programs in 1987, VA has
expanded its efforts to provide an array of services to homeless
veterans.  VA initially funded 43 HCHV program sites to contract with
community-based providers for residential treatment and
rehabilitation of mentally ill (including substance abusing)
veterans.  VA currently operates 73 HCHV program sites, 62 of which
offer residential treatment for the homeless chronically mentally ill
(HCMI), generally for less than 6 months.  HCHV staff conduct
outreach at community-based homeless service providers such as
shelters, soup kitchens, and other places frequented by the homeless. 

HCHV staff also serve as case managers for homeless veterans.  Case
management services are provided to maintain continuity of care and
assist veterans in obtaining needed services by referring them to VA
and non-VA sources that can address their needs for medical and
psychiatric treatment, social and work rehabilitation, income
support, housing, and other services.  In addition, HCHV staff are
responsible for monitoring the services provided each veteran
participating in the residential treatment component of the program. 
During fiscal year 1997, the 73 HCHV program sites served 35,059
homeless veterans. 

The HCMI program is the core homeless program under the HCHV
umbrella.  The service delivery arrangements and treatment received
by veterans participating in the HCMI program vary across sites.  VA
headquarters allows each site some flexibility in operating its
program.  Arrangements for using community-based residential
treatment facilities for care and rehabilitation vary, in part, as a
function of the availability of VA and community resources. 
Accordingly, the HCMI per diem rates paid by VA vary across
community-based providers, depending on the type of services and the
geographic location.  In fiscal year 1997, veterans received
treatment for an average of 73 days; the HCMI per diems ranged from
approximately $15 to over $70, and the average daily rate was
$38.58.\5

Unlike the HCMI program, which was designed to rely on
community-based residential treatment facilities, the DCHV program is
primarily housed on the grounds of VA medical centers.  Most DCHV
program sites are located in existing VA domiciliaries.\6 DCHV is a
hospital-based program that uses interdisciplinary treatment to
provide services to homeless veterans with varying medical, substance
abuse, and mental health problems.  The number of DCHV sites has
increased from 20 to 35 in the 12 years since the program's inception
in 1987. 

The DCHV program focuses on rehabilitation.  Basic services provided
by the DCHV program include (1) outreach at some sites to identify
underserved homeless veterans, (2) time-limited residential treatment
that offers medical and psychiatric services, and job counseling and
placement services, and (3) postdischarge community support and
aftercare.  In fiscal year 1997, the DCHV program discharged 4,619
homeless veterans from treatment in its 1,587 beds nationwide. 
Veterans received treatment for an average of about 116 days at a
cost to VA of approximately $70 per day.  The locations of the HCMI
and DCHV sites are shown in figure 1.  (See app.  II for a summary of
HCHV and DCHV program locations.)

   Figure 1:  VA's HCMI and DCHV
   Program Locations

   (See figure in printed
   edition.)



   (See figure in printed
   edition.)

Over time, VA has developed new programs and approaches to complement
the HCMI and DCHV programs and provide services that are more
integrated, longer term, and more intensive (see table 1).  For
example, homeless veterans participating in VA's Supported Housing
program are provided on-going case management services by HCHV staff
for an extended period.  Moreover, these efforts involve partnerships
with other federal agencies to assist homeless veterans in obtaining
housing and other benefits.  (See app.  III for more information
about these homeless assistance and treatment programs and the other
approaches VA uses to assist homeless veterans.)



                          Table 1
          
             Additional HCHV Homeless Programs

------------------  --------------------------------------
HCHV Outreach       The HCHV outreach program is similar
                    to the HCMI program except it does not
                    include the residential treatment
                    component. VA staff identify homeless
                    veterans and help them obtain services
                    that address their needs.

Homeless            CWT provides veterans with therapeutic
Compensated Work    work opportunities to develop or
Therapy (CWT)       improve work habits and job skills,
                    and earn income.

Homeless            In a few locations, VA has purchased
Compensated Work    houses or arranged housing for
Therapy/            homeless veterans participating in
Transitional        CWT.
Residence

Homeless Providers  The GPD program awards funds to local
Grant and per Diem  organizations to develop transitional
(GPD)               housing or other supportive services
                    to homeless veterans.

Housing and Urban   The HUD-VASH initiative combines
Developmentï¿½VA      agency resources to provide
Supported Housing   independent housing for veterans.
(HUD-VASH)          Qualified veterans are issued HUD
                    section 8 housing vouchers; they must
                    agree to VA case manager involvement
                    while they are adjusting to living
                    independently.

Supported Housing   This multifaceted program varies in
(SH)                how it is implemented at HCHV program
                    sites. In general, HCHV staff help
                    homeless veterans reintegrate into
                    local communities.

Social Security     SSA-VA is another example of two
Administration-VA   federal agencies working
Joint Outreach      collaboratively to assist homeless
Initiative (SSA-    veterans. The primary goal of this
VA)                 program is to assist eligible veterans
                    in filing and expediting benefit
                    claims.

Veterans Benefits   The VBA outreach initiative is an
Administration      example of two divisions within VA
Outreach (VBA)      working together to identify and
                    assist homeless veterans who may be
                    eligible for VA pension and other
                    benefits.
----------------------------------------------------------

--------------------
\5 These costs do not include other expenses borne by VA in treating
the homeless such as medical, substance abuse, and mental health
services provided to veterans participating in the HCMI program. 

\6 Domiciliaries provide rehabilitative and long-term health
maintenance care for veterans who require minimal medical care but do
not need the skilled nursing services provided in nursing homes. 


      VA'S ROLE IN PROVIDING
      HEALTH SERVICES
---------------------------------------------------------- Letter :3.2

While VA has expanded its homeless programs and community
partnerships, it continues to be a provider of medical, mental
health, and substance abuse services to homeless veterans through its
general health care programs.  Although VA does not know the extent
to which its annual health care appropriations are spent on medical
care and other treatment services for homeless veterans, recent
estimates suggest that the amount spent on these health care services
far exceeds the approximately $84 million VA used for its targeted
homeless programs.  NEPEC estimated that in fiscal year 1995 VA spent
$404 million on inpatient general psychiatry and substance abuse
services for homeless veterans, representing approximately 26 percent
of all inpatient VA mental health expenditures.  Cost estimates are
unavailable for other health care expenditures, but NEPEC estimated
that homeless veterans occupied 5 percent of the inpatient medical
and surgical beds during fiscal year 1996.  Moreover, these estimates
do not account for primary care and other outpatient medical services
rendered to homeless veterans at VA's 173 hospitals and over 400
outpatient clinics nationwide. 


      VA HOMELESS PROGRAMS EXIST
      AT SELECTED LOCATIONS WITH
      LIMITED CAPACITY
---------------------------------------------------------- Letter :3.3

Although VA has developed a number of programs to assist homeless
veterans, VA acknowledges that it alone cannot meet all their needs. 
These programs are not available in all locations and, where
available, capacity for residential treatment is limited. 

VA's homeless programs are available at selected locations.  HCMI and
DCHV homeless program sites were established on a voluntary basis;
interested medical centers submitted proposals and those ranked
highest by VA headquarters were initially funded.  VA's homeless
programs vary dramatically in terms of the number of sites available
to treat homeless veterans.  For example, VISN 3 is the only network
to have at least one site for each of VA's homeless programs.  As
shown in table 2, the number of sites provided by each of VA's
programs ranges from 4 to 62.\7



                                          Table 2
                          
                            VA's Homeless Program Sites by VISN

                                                                                      Total
                                                                                     progra
                          HUD-                           HCHV (O/     CWT-     SSA-       m
VISN    HCMI\a  DCHV\b  VASH\c    SH\d   CWT\e   VBA\f       R)\g     TR\h     VA\i   sites
------  ------  ------  ------  ------  ------  ------  ---------  -------  -------  ------
1            1       2       2       3       2       1          2        1        0      14
2            5       1       3       2       1       0          0        1        0      13
3            3       3       2       3       1       2          1        1        2      18
4            4       3       0       3       1       1          0        1        0      13
5            3       2       1       0       1       1          0        1        0       9
6            2       1       1       0       0       0          0        0        0       4
7            5       2       1       0       2       0          0        1        0      11
8            2       1       3       1       1       0          0        0        0       8
9            4       1       1       0       0       0          0        0        0       6
10           3       3       2       0       0       1          1        0        0      10
11           2       0       1       2       0       1          2        0        0       8
12           2       2       1       4       2       2          2        0        0      15
13           2       1       0       0       1       1          0        0        0       5
14           0       1       0       0       0       0          0        0        0       1
15           2       2       0       1       0       0          0        0        0       5
16           5       2       3       2       1       0          0        1        0      14
17           2       1       2       0       1       1          0        1        1       9
18           2       1       1       1       0       0          0        0        0       5
19           3       0       2       0       0       0          0        0        0       5
20           4       4       4       3       3       1          2        0        0      21
21           1       1       1       0       1       1          0        1        0       6
22           5       1       4       1       1       2          1        0        1      16
===========================================================================================
Total       62      35      35      26      19      15         11        9        4     216
-------------------------------------------------------------------------------------------
\a Homeless Chronically Mentally Ill. 

\b Domiciliary Care for Homeless Veterans. 

\c Housing and Urban Developmentï¿½VA Supported Housing. 

\d Supported Housing. 

\e Homeless Compensated Work Therapy. 

\f Veterans Benefits Administration Outreach. 

\g Health Care for Homeless Veteransï¿½Outreach. 

\h Homeless Compensated Work Therapyï¿½Transitional Residence. 

\i Social Security Administrationï¿½VA Joint Outreach Initiative. 

In those locations that have an HCMI or DCHV program, residential
capacity is limited.  For example, the HCHV site in Washington,
D.C.--a city with a homeless veteran population ranging from an
estimated 3,300 to 6,700--served 963 homeless veterans during fiscal
year 1997, of whom 31 were treated in the HCMI residential component. 
Of the 30,857 homeless veterans contacted nationwide at the 62 HCHV
sites with an HCMI residential treatment program, only 4,317 were
placed in VA contracted residential treatment during fiscal year
1997--an average of 70 homeless veterans per site. 

Similarly, the DCHV program has limited inpatient capacity.  For
example, VISN 14, which covers parts of five states, including most
of Iowa and Nebraska, has one homeless program:  a homeless
domiciliary at the Des Moines VA hospital with 20 beds that served 56
veterans during fiscal year 1997.  In another instance, VISN 11,
which includes urban cities such as Detroit, Mich., and Indianapolis,
Ind., has no DCHV beds.  In sum, the 35 DCHV program sites operated
1,587 beds and discharged 4,619 veterans from treatment in fiscal
year 1997.  On average, each DCHV site provided residential care to
approximately 132 homeless veterans. 


--------------------
\7 Homeless Providers Grant and per Diem recipients are not included
in this analysis. 


      VA EXPANDS COMMUNITY
      PARTNERSHIPS TO SERVE
      HOMELESS VETERANS
---------------------------------------------------------- Letter :3.4

Over the past 5 years, VA has expanded its commitment to partnering
with community-based organizations.  This commitment to
community-based providers is reflected in VA's long-range strategic
planning.  One such goal under the Results Act is to maximize
participation in Community Homelessness Assessment, Local Education
and Networking Groups (CHALENG) by increasing VA medical facility
participation to 100 percent by fiscal year 2001.  In response to the
requirement to encourage coordination in Veterans' Medical Programs
Amendments of 1992 (P.L.  102-405), VA homeless staff began holding
annual CHALENG meetings to better coordinate with other homeless
providers and organizations.  For example, in 1997, nearly 2,000
service providers attended CHALENG meetings nationwide and completed
surveys about the extent to which specific needs were being met. 
Once local needs are prioritized, VA collaborates with community
providers to resolve any community resource problems.  This
collaborative effort provides a forum for VA to work with its non-VA
partners to assess, plan for, and address the needs of homeless
veterans.  Since the inception of the CHALENG initiative in fiscal
year 1994, most medical centers have participated in the process.  In
fiscal year 1998, VA reported that 88 percent of its medical
facilities conducted their annual CHALENG meetings. 

Also, the Congress authorized VA to establish alternative housing
programs for homeless veterans through partnerships with nonprofit or
local government agencies.\8 As a result, VA created the Homeless
Providers Grant and per Diem (GPD) program to award grants and per
diem payments to public and nonprofit organizations that establish
and operate new supportive housing and services for homeless
veterans.  Between fiscal years 1994 and 1998, 127 grants were
awarded to 103 nonprofit and state or local government agencies,
providing in excess of $26 million.  Grant moneys have been awarded
to recipients in 39 states and the District of Columbia; all 22 VISNs
have at least one GPD recipient in their jurisdiction.  Once grants
awarded during the first 5 years become fully operational, VA
estimates that over 2,700 new community-based transitional housing
beds will be available for homeless veterans. 

Finally, in the Veterans Programs Enhancement Act of 1998, VA
received authority to make $100 million in guaranteed loans over a
3-year period to qualified organizations.  Most loans will be awarded
to construct, rehabilitate, or acquire land for the purpose of
providing multifamily transitional housing projects for homeless
veterans. 


--------------------
\8 The Homeless Veterans Comprehensive Service Programs Act of 1992
(P.L.  102-590). 


   EFFECTIVENESS OF VA HOMELESS
   PROGRAMS IS UNCLEAR
------------------------------------------------------------ Letter :4

Although NEPEC collects extensive data, VA has little information
about the effectiveness of its homeless programs.  Homeless program
sites submit primarily descriptive data about veterans and program
characteristics.  In addition, some outcome data are collected on
program participants at discharge.  (Outcome data are measures of a
veteran's status upon discharge from a homeless program, including
housing, employment, and changes in substance abuse and mental
health.) These data are of limited use in assessing program
effectiveness, however, because no follow-up information is obtained
after a veteran is discharged from a residential or DCHV treatment
program.  As a result, VA does not know whether veterans served by
its homeless programs remain employed or stably housed. 


      PROGRAM DATA FOCUSES ON
      DESCRIPTIVE CHARACTERISTICS,
      STATUS AT DISCHARGE
---------------------------------------------------------- Letter :4.1

NEPEC collects and analyzes extensive descriptive information
regarding program structure, veteran characteristics, program
processes, and status at discharge for specific sites.  Program
managers use this information to monitor and compare program sites. 
For all measures except those involving status at discharge, the HCHV
and DCHV programs use the average performance for all of their
respective sites as the norm for evaluating each site.  To account
for homeless veterans who are particularly difficult to treat, data
regarding status at discharge are adjusted for patient
characteristics that influence treatment results, such as age or
number of medical problems.  Our analyses focused on the DCHV and
HCHV programs because they are the two main components of VA's
homeless programs. 

NEPEC monitors the 62 HCMI sites that contract with community-based
programs to provide residential treatment to homeless veterans. 
NEPEC collects data obtained upon initial contact with homeless
veterans and at the conclusion of a veteran's participation in the
HCMI program.  From these data, 32 indicators have been selected as
"critical monitors" of site performance.  These measures reflect four
different categories of information about sites:  (1) program
structure (for example, the average number of days veterans spend in
residential treatment and the average number of unique veterans
served by each clinical staff member); (2) patient characteristics
(for example, the percentage of veterans served who were not
literally homeless\9 at the time of intake and the percentage of
veterans served who were diagnosed with a serious mental illness or
substance abuse disorder\10 ); (3) program process measures which
indicate how the program operates (for example, percentage of
veterans served who were contacted by outreach and the percentage of
veterans inappropriately placed in residential treatment\11 ); and
(4) status at discharge (for example, percentages of veterans who
report being housed and employed at discharge).  Appendix IV contains
a complete list of the 32 HCHV critical monitors. 

In fiscal year 1997, 35,059 veterans were served through HCHV
programs.  Of the 3,883 veterans discharged from residential
treatment facilities in fiscal year 1997, 52 percent were considered
to have successfully completed the program (that is, the veteran and
clinician agreed that program goals had been met); 39 percent
reported having their own apartment, room, or house at discharge; 43
percent reported having full- or part-time employment at discharge;
73 percent were rated as showing improvement in drug problems; and 74
percent were rated as showing improvement in mental health problems. 
Under most circumstances, NEPEC data regarding status at discharge
are obtained from veterans who have completed residential treatment. 
In some cases, however, HCMI pays for only part of a veteran's
residential treatment program, and the veteran remains in treatment
after discharge from the HCMI program.  In these instances, the
veteran's status upon completion of residential treatment (which may
occur some time later) is not captured in the NEPEC data. 

NEPEC also monitors the performance of the 35 DCHV sites using data
gathered when veterans are admitted to the program and their status
at the time of discharge.  These measures reflect four different
categories of information about the DCHV sites:  (1) program
structure (assessed solely by the annual turnover rate); (2) veteran
characteristics (for example, the percentage of veterans who entered
the program from the community and the percentage of veterans who
were living outdoors or in a shelter prior to admission); (3) program
participation (for example, the average length of stay and the
percentage of veterans who completed the program); and (4) status at
discharge (for example, percentages of veterans who are housed and
employed at discharge).  The 20 DCHV critical monitors are contained
in appendix V. 

In fiscal year 1997, the DCHV program discharged 4,619 veterans after
an average length of stay of about 116 days.  NEPEC reported that 62
percent successfully completed the program, 57 percent were housed at
discharge, 52 percent had full- or part-time employment at discharge,
79 percent were rated as improved in alcohol problems, 79 percent
were rated as improved in drug problems, and 75 percent were rated as
improved in mental health problems. 


--------------------
\9 VA's homeless programs occasionally serve veterans who are not
literally homeless, but are instead at risk of homelessness or are
without secure housing, for example, living temporarily with friends. 

\10 NEPEC classifies psychoses, mood disorders, and post-traumatic
stress disorder (PTSD) as a serious psychiatric problem and
dependency on alcohol or drugs as a substance abuse problem. 

\11 NEPEC classifies veterans with an income of $1,000 or more per
month; who have their own apartment, room, or house; or who are
without serious psychiatric or substance abuse problems as
inappropriate for HCMI placement. 


      LIMITED INFORMATION
      AVAILABLE ABOUT PROGRAM
      EFFECTIVENESS
---------------------------------------------------------- Letter :4.2

Because information is not obtained after veterans leave treatment,
VA cannot determine whether its homeless programs are effective over
the long term.  Moreover, NEPEC has only limited information about
what aspects of its programs are most beneficial for certain
veterans.  Finally, NEPEC has little information about whether its
programs are more beneficial than other strategies for helping the
homeless.  Evaluation research (including follow-up) is difficult and
expensive to conduct on this hard-to-serve population.  However, VA's
fiscal year 2000 budget request contains an additional $50 million to
expand VA's homeless programs and monitoring and evaluation efforts. 

VA has acknowledged the need for program evaluation and now includes
a plan for program evaluation in its strategic plan.  However, NEPEC
officials told us that their primary emphasis is to monitor the
performance of program sites, rather than to evaluate the
effectiveness of treatments or programs.  These monitoring activities
provide information about program operations.  As a result, NEPEC
does not typically examine outcomes in a way that clarifies what
aspects of treatment are associated with positive results for
different clinical groups (for example, those with serious mental
illnesses or those with a substance abuse disorder).  NEPEC officials
periodically supplement their data files with additional information
(for example, about treatment approaches) and then conduct analyses
that distinguish clinical subgroups.  These findings are often
published in academic journals.  For example, one study looked at
outcomes for dually diagnosed veterans (that is, those with both a
serious psychiatric disorder and a substance abuse problem),
comparing those in programs that specialize in substance abuse
treatment with those treated in integrated programs that
simultaneously address both psychiatric and substance abuse problems. 
Although differences between the two types of programs were modest,
results suggested that those in integrated treatment programs were
more likely than those in the substance abuse programs to be
discharged to housing in the community rather than to an
institutional setting. 

Currently, NEPEC does not conduct follow-up of veterans who have left
the DCHV or HCMI programs.  Follow-up is needed to determine whether
veterans are still employed, housed, or successfully dealing with
substance abuse or mental health problems after program completion
and thereby to estimate the duration of any positive effects.  Other
research efforts involving the homeless that have included follow-up
data suggest that positive outcomes observed at discharge are not
necessarily sustained. 

Between 1987 and 1990, in order to evaluate the benefits associated
with program participation, NEPEC conducted pilot follow-up projects
at nine HCMI and three DCHV sites.  NEPEC reported that veterans were
substantially better off 3 months after discharge from DCHV treatment
than when they were admitted to the program.  Improvements were noted
in housing, income, employment, substance abuse, and psychiatric
functioning.  Similarly, veterans who participated in the HCMI study
exhibited improvements on follow-up (assessed from 1 month to 2 years
after intake, with an average of 8.3 months) compared with intake in
housing, employment, psychiatric problems, and substance abuse.  For
example, 73 percent of the veterans reported that they had spent no
days homeless during the 90 days prior to their interview.  The HCMI
study stated that veterans derived substantial benefit from their
participation in this program. 

While these follow-up studies were a major undertaking, NEPEC reports
on these studies cite two major shortcomings.  First, interview data
were not collected from a fully representative sample.  Of veterans
who agreed to participate in these studies, follow-up interviews were
conducted with 67 percent in the DCHV study and 72 percent in the
HCMI study.  Although the status of those veterans who were not
reinterviewed is not known, it cannot be ruled out that the veterans
who were doing the poorest were also the least likely to be
reinterviewed.  As a result, the data from those who were
reinterviewed could suggest more positive outcomes than is true for
the program as a whole.  Second, no control or comparison groups were
studied.  Data from such groups would allow an estimate of the degree
of improvement attributable to the DCHV or HCMI programs.  In other
words, it is possible that some of the improvements noted among those
veterans who were reinterviewed would have occurred in the absence of
DCHV or HCMI treatment.  Research suggests that some improvement over
time is likely among the homeless even in the absence of intensive
treatment.  Without data from an appropriate comparison group of
veterans who were not served through VA's homeless programs, VA
cannot determine how much additional benefit the veterans derived
from those programs. 

NEPEC officials stated that they have not conducted additional
follow-up studies on the HCMI and DCHV programs because such
information is difficult and expensive to obtain on this
hard-to-serve population.\12 A NEPEC official estimated that if they
were to conduct another follow-up study for the HCMI program, the
cost would be about $60,000 per site with an approximate annual total
cost of $600,000. 


--------------------
\12 Veterans who have participated in the Compensated Work
Therapy/Transitional Residence, HUD-VASH, and VA Supported Housing
programs, which are smaller VA homeless programs, are reinterviewed
periodically, and the HUD-VASH program is being compared to case
management and HCMI residential treatment. 


   LIMITED DATA BUT SOME
   APPROACHES FOR DIFFERENT GROUPS
   APPEAR PROMISING
------------------------------------------------------------ Letter :5

Approaches to homelessness vary with the needs (for example, medical,
mental health, substance abuse, or other problems) of the subgroup
being served.  Although many questions about how to help the homeless
remain unanswered, a series of research initiatives launched in 1982
and funded primarily by HHS have begun to shed light on the issues;
and initial findings from a few projects are promising.\13

These efforts suggest that effective interventions for the homeless
involve comprehensive, integrated treatments.  These initiatives also
suggest that a range of housing, treatment, and supportive-service
options need to be included within a continuum of care for the
homeless. 

As early as 1982, but particularly in response to the McKinney Act in
1987, HHS funded several major research initiatives to learn more
about homelessness in general and about treatments for the mentally
ill or substance abusing homeless in particular.  These efforts
involved epidemiological studies to identify the homeless and their
needs, demonstration projects to explore promising strategies for
helping the homeless, and outcome evaluations to assess the
effectiveness of selected programs.  Cross-site analyses addressed
overarching questions; and procedures for sharing information, such
as conferences and an information clearinghouse, were established. 
Many questions remain unanswered, but several broad themes have
emerged from these efforts.  In addition, these research programs
indicate that although it can be difficult to study homeless
populations, such research can be done and can include follow-ups. 

This body of research indicates that effective treatment for the
homeless requires comprehensive, integrated services.  Although
meeting the most basic needs of a homeless person for food, clothing,
and shelter is a first step, it is rarely sufficient to enable a
person to exit homelessness.  Instead, progress in achieving housing
stability requires comprehensive attention to the full range of a
homeless person's needs, addressing basic needs (such as shelter,
food, and clothing), medical and mental health needs (including
dental and eye care), and supportive services (such as
transportation, assistance in obtaining benefits, and child care if
necessary).  Thus, as examples, untreated mental illness may
interfere with a person's ability to retain housing, and lack of
transportation may limit access to medical appointments or job
interviews. 

Moreover, research suggests that positive outcomes are promoted by
integration of services.  Attempts to address the needs of a homeless
person one by one, or in parallel but without coordination, seem less
effective than strategies that involve integrated efforts to address
multiple needs.  For example, homeless persons who have both a mental
illness and a substance abuse problem seem to benefit more from
integrated treatment programs than from programs that approach these
problems separately.  Similarly, the effectiveness of employment and
training programs for the homeless is enhanced by linkage to housing
assistance and supportive services.  The importance of integration is
attributable in part to fragmentation of the homeless
service-delivery system, so that addressing a homeless person's needs
often requires multiple organizations.  Case managers may facilitate
integration by helping the homeless obtain services in ways that
complement rather than conflict with one another.  In addition,
organizations that serve the homeless may collaborate to promote
integrated, comprehensive service provision. 

At least one-third of homeless veterans have a serious mental
illness.  These disorders are more common among the homeless, and
particularly among the episodically and chronically homeless, than
among those who are domiciled.  Disorders such as schizophrenia or
severe depression can have markedly disabling effects on multiple
aspects of a person's life, including employment, housing stability,
interpersonal relationships, and physical health.  Specific
psychiatric symptoms vary across disorders, but these illnesses often
involve impairments in judgment, motivation, and cognitive and social
skills, difficulties that not only contribute to housing instability
but also limit the person's ability to obtain treatment.  Because of
their impairments, the seriously mentally ill homeless may find it
particularly difficult to negotiate the complexities of a fragmented
service delivery system.  Several researchers have focused on
outreach and case management strategies for this homeless subgroup,
finding that the seriously mentally ill homeless can be helped
through such strategies. 

Some seriously mentally ill persons are able to function well,
typically with the aid of psychiatric medication, but others face
recurrent or persisting difficulties even with medication.  Neither
independent housing nor full-time work may be reasonable goals for
some of these persons.  Instead, a successful outcome might involve
increased housing stability (perhaps in a group home), fewer and
shorter psychiatric hospitalizations, and improved daily living
skills.  Thus, homeless services are often targeted to helping the
homeless maximize self-sufficiency, which may or may not mean
achieving economic or housing independence. 

About half of homeless veterans have a substance abuse problem,
whether a cause or consequence of homelessness, which makes
intervention more complicated.  Several studies have suggested that
housing and employment stability are impeded by ongoing substance
use, and many housing options for the homeless require abstinence. 
On the other hand, many homeless substance abusers are initially
unwilling to accept the goal of sobriety, although they may be
willing to accept substance abuse treatment once some of their other
needs are met.  Thus, low-demand alternatives to the street (such as
safe havens) have been advocated as a necessary part of a full
continuum of care for the homeless. 

Although research has not yet determined what specific strategies are
most effective with homeless substance abusers, initial findings
suggest that drop-out rates are often high and the gains made by
those who complete treatment programs are not necessarily maintained. 
Thus, ongoing contact may be necessary for long-term improvement. 
Too new to have been clearly evaluated, New Directions, associated
with the West Los Angeles VA Medical Center, offers substance abuse
treatment and job training/job placement services to medically stable
substance abusers who do not have serious mental illnesses. 

Among the most difficult to treat homeless are those with both a
serious mental illness and a substance abuse problem.  About one-half
of veterans with serious mental illness also have a substance abuse
problem.  Compared with other homeless persons, these dually
diagnosed persons tend to have longer and more frequent episodes of
homelessness, are harder to engage and retain in treatment, and
require more services. 

Nonetheless, early research has indicated some promising approaches
for the dually diagnosed homeless.  For example, results of a
randomized clinical trial of one case management strategy, Critical
Time Intervention (CTI), suggested that homelessness was reduced
among a group of seriously mentally ill men, many of whom were
substance abusers.\14 Compared with a control group of similar
homeless men who received services as usual (for example, referrals),
CTI was associated with a greater reduction in homelessness
throughout a period that included a 9-month intervention phase and a
9-month follow-up phase.  As another example, empirical evaluation of
a program established by Vietnam Veterans of San Diego for substance
abusing veterans, many of whom also suffered from PTSD or depression,
yielded positive housing, employment, and substance abuse outcomes at
a 6-month follow-up.  Some veterans are referred to this program
through the San Diego VA Medical Center.  Long-term follow-up
research with the dually diagnosed homeless suggests that set-backs
are not uncommon, but that increases in residential and psychological
stability are possible. 

Medical problems are also common among the homeless, with rates of
illness and injury estimated at two to six times higher than among
those who are housed.  Typical conditions of homelessness--poor
nutrition and hygiene; fatigue; and exposure to the elements,
violence, and communicable diseases--contribute to poor health and
make recovery from illnesses more difficult.  Physical illnesses
commonly reported among the homeless include respiratory infections,
trauma (for example, lacerations, fractures, and burns),
hypertension, skin disorders, gastrointestinal diseases, peripheral
vascular disease, musculoskeletal problems, and dental and visual
problems.  Rates of tuberculosis and human immunodeficiency virus
(HIV) are higher among the homeless than among the housed.  It has
been reported that the homeless end up using expensive health care
alternatives, including emergency and inpatient services, and
mortality rates among the homeless have been estimated to be three to
four times higher than in the general population. 

Lack of adequate housing can exacerbate illnesses among the homeless. 
To illustrate this issue, persons with homes can typically deal with
acute respiratory infections or chronic disorders such as
hypertension or diabetes through a combination of medications, diet,
and rest.  Those living on the street or in shelters, however, may
lack access to appropriate meals, safe storage facilities for
medications and medical supplies, or the opportunity for adequate
rest.  As a result, health may deteriorate, and resultant long-term
medical complications may further interfere with the person's ability
to exit homelessness.  Convalescent care facilities, such as Christ
House, a residential treatment facility with which the Washington,
D.C., VA Medical Center contracts for services, provide medical care
for homeless persons who do not warrant (and are not being considered
for) inpatient medical treatment, but whose medical conditions are
likely to worsen without proper attention in a stable environment. 
Haven II, affiliated with the West Los Angeles VA Medical Center,
provides short-term housing for veterans who have been discharged
from an inpatient medical unit but are still recuperating.  Once
medically stabilized, homeless persons served by these facilities can
be referred to other housing options. 

For those homeless individuals who are able to work, research on job
training suggests some promising strategies.  Services have been
provided through the Department of Labor's Job Training for the
Homeless Demonstration Program to over 45,000 homeless persons since
1988.  More than a third obtained jobs, and half of those were
employed 13 weeks later.  Results suggest that ongoing case
management, work readiness training, assistance in locating work, and
postplacement support are among the elements that contribute to
obtaining and maintaining employment.  The Welfare-to-Work program at
L.A.  Vets, associated with the West Los Angeles VA Medical Center,
incorporates many of these components. 

Experts agree that the continuum of care for the homeless must
include a range of housing and treatment options, and that
flexibility is needed to match homeless persons to appropriate
services.  Housing options should include emergency shelter,
transitional housing, and permanent housing, all linked to supportive
services.  Housing and residential treatment programs should include
options suitable for mentally ill, substance abusing, dually
diagnosed, and convalescent persons.  Although relatively few
programs for the homeless have been empirically evaluated, the
available research includes some promising approaches.  Experts also
note that attention to the individual's preferences is important, and
that failure to acknowledge those choices may reduce the
effectiveness of intervention.  Because the homeless have diverse
needs and local resources vary, flexibility is needed in serving
individuals and in arranging partnerships among organizations. 


--------------------
\13 All programs we visited except the homeless program in New York,
N.Y., involved services provided by VA or VA in collaboration with
community-based homeless service providers.  The research literature
reviewed regarding the effectiveness of homeless programs was largely
funded through grants from HHS or Labor. 

\14 Assertive Community Treatment (ACT) is another case management
strategy that has yielded promising results for the seriously
mentally ill homeless.  Neither case management strategy is formally
used within the VA system, but VA recently indicated its intention to
develop a pilot implementation of CTI. 


   CONCLUSIONS
------------------------------------------------------------ Letter :6

As VA facilities attempt to develop a continuum of care for homeless
veterans, variations in local needs and resources will result in
different patterns of involvement for VA and its partners.  Because
homeless veterans differ from one another in their needs, no single
treatment program can serve all veterans with equal effectiveness. 
Recent federally funded research projects suggest there are
beneficial long-term effects attributable to certain strategies for
serving mentally ill and substance abusing homeless persons, which VA
could replicate.  Local programs designed to serve these groups are
likely to be important components of any continuum of care for the
homeless. 

To maximize the effectiveness of its homeless dollars, VA should
direct its resources to those programs and partnerships that show the
greatest potential for increasing housing stability and reducing the
risk of reentry into homelessness.  Research on program effectiveness
can provide the information needed to make decisions about how to
direct these resources.  To better understand the effects of VA's
homeless programs and ways to improve or enhance its programs, a
series of program evaluation studies should be conducted to address
long-term effects, processes associated with positive outcomes, and
program impact.  Thus, VA could design follow-up studies to examine
the stability of housing and employment in the year or 2 after
program discharge.  VA could also undertake outcome evaluations
designed to assess program processes to better understand how
desirable outcomes are produced.  Such studies could identify aspects
of treatment that are associated with positive outcomes for veterans
with different conditions.  Finally, VA could estimate how program
outcomes differ from outcomes that would be likely in the absence of
the program.  For example, results observed for a sample of homeless
veterans who received a particular kind of treatment could be
compared to a comparable group who did not receive that treatment. 

In its fiscal year 2000 budget, VA requested an additional $50
million for its homeless programs and indicated its desire to invest
some of those funds in evaluating its homeless programs.  Even though
evaluation research can be difficult and expensive to conduct, such
studies are necessary to ensure that VA directs its resources to
those efforts with the greatest potential for beneficial effects. 


   RECOMMENDATION
------------------------------------------------------------ Letter :7

We recommend that the Secretary of Veterans Affairs direct the Under
Secretary for Health and the Assistant Secretary for Planning and
Analysis to collaborate on conducting a series of program evaluation
studies to clarify the effectiveness of VA's core homeless programs
and provide information about how to improve those programs.  Where
appropriate, VA should make decisions about these studies (including
the type of data needed and the methods to be used) in coordination
with other federal agencies with homeless programs, including HHS,
HUD, and Labor. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :8

In commenting on a draft of this report, VA generally agreed with our
findings and the thrust of our recommendation.  VA suggested,
however, that our recommendation be modified to recognize the role of
the Assistant Secretary for Planning and Analysis in coordinating the
Department's program evaluations under the Results Act.  We made this
change.  VA also identified several recent initiatives and planned
actions to evaluate VA's homeless program efforts, which we
incorporated into the report.  Finally, VA provided other comments
regarding technical aspects of the report, which we incorporated as
appropriate.  (See app.  VII for VA's comments.)


---------------------------------------------------------- Letter :8.1

Copies of this report are being sent to the Honorable Togo West, the
Secretary of Veterans Affairs; Senator John D.  Rockefeller IV,
Ranking Minority Member, Senate Veterans' Affairs Committee; other
interested congressional committees; and interested parties.  Copies
will be made available to others upon request. 

Please contact me on (202) 512-7111 if you have any questions about
this report.  Other GAO contacts and staff acknowledgments are listed
in appendix VIII. 

Sincerely yours,

Stephen P.  Backhus
Director, Veterans' Affairs
 and Military Health Care Issues


SCOPE AND METHODOLOGY
=========================================================== Appendix I

In conducting our review, we interviewed officials at VA
headquarters, Veterans Integrated Service Networks, VA's Northeast
Program Evaluation Center, researchers who study homeless issues, and
representatives of veterans service organizations.  We visited
homeless programs at VA medical centers and community-based providers
with whom they have partnerships; these sites were in Little Rock,
Ark.; Denver, Colo.; Washington, D.C.; Los Angeles, Calif.; and San
Diego, Calif.  We also visited a community-based program in New York,
N.Y., that is not affiliated with VA, and we attended a VA Community
Homeless Assessment, Local Education and Networking Groups meeting. 
We analyzed annual NEPEC reports and other reports and documents
relating to VA's homeless programs. 

To describe the programs and approaches used by VA to assist homeless
veterans, we obtained documents from VA headquarters and NEPEC that
identified and provided detailed information about VA's homeless
efforts. 

To determine what VA knows about the effectiveness of its homeless
programs, we reviewed NEPEC reports issued since the inception of
VA's homeless programs.  NEPEC generally issues annual reports on its
two major homeless programs, the Homeless Chronically Mentally Ill
(HCMI) and Domiciliary Care for Homeless Veterans (DCHV).  We
discussed these reports and program effectiveness issues including
performance indicators and outcome data with NEPEC staff and VA
headquarters officials to better understand how the information is
used to monitor and evaluate VA's homeless programs.  In addition, as
part of our review of NEPEC's reporting system, we evaluated the
reliability of NEPEC's data by testing a random sample of 5 percent
of 1,059 intake and discharge forms collected during our site visits. 
We found, based on our limited reliability testing of the data, an
error rate of less than one percent. 

To identify options or approaches for addressing the needs of
specific groups of homeless veterans that VA might replicate we
conducted a literature review to clarify issues involving
homelessness and identify strategies associated with effective
treatment.  The data bases scanned included PsycINFO and several
bibliographies regarding homelessness (Federally-Sponsored Research
Findings on Homelessness and Mental Illness prepared by the National
Resource Center on Homelessness and Mental Illness, HHS Publications
Related to Homelessness from the Department of Health and Human
Services, the National Institute on Alcohol Abuse and Alcoholism's
ETOH data base, and relevant bibliographies available through Policy
Research Associates, Inc.).  The focus of this literature review was
on federally-funded research into interventions for homelessness.  We
also spoke with experts and visited community-based programs in New
York, Los Angeles, San Diego, and Washington, D.C., that serve
different subgroups of the homeless. 

We reviewed VA's strategic plan for fiscal years 1998 through 2003
and its homeless performance measures in the FY 1997 Performance
Measures for VA Homeless Veterans Treatment & Assistance Programs and
VHA Directive 96-051, Veterans Health Administration Special Emphasis
Programs. 


SUMMARY OF DOMICILIARY CARE FOR
HOMELESS VETERANS AND HEALTH CARE
FOR HOMELESS VETERANS PROGRAM
LOCATIONS AS OF JANUARY 1999
========================================================== Appendix II



   (See figure in printed
   edition.)



   (See figure in printed
   edition.)


VA HOMELESS ASSISTANCE AND
TREATMENT PROGRAMS AND OTHER
HOMELESS APPROACHES
========================================================= Appendix III

VA HOMELESS ASSISTANCE AND
TREATMENT PROGRAMS

HCHV Outreach.  This initiative is similar to the HCMI program,
except that the 11 sites included in this program do not offer the
residential treatment component.  Moreover, these HCHV outreach sites
generally do not provide the array of VA homeless programs typically
found at HCHV locations with the HCMI program.  Under this
initiative, HCHV staff perform outreach activities at locations where
the homeless congregate, conduct initial intake assessments, and link
clients with appropriate and available VA and non-VA homeless service
providers.  In fiscal year 1997, the number of veterans served by
each outreach site varied between 129 and 680.\1

Homeless Compensated Work Therapy (CWT).  CWT, also known as Veterans
Industries, is a work program that provides veterans with job skills
development and a source of income.  Work is used as a therapeutic
tool to help homeless veterans improve their work habits and mental
health.  While participating in this program, veterans may receive
individual or group therapy and follow-up medical care on an
outpatient basis.  Currently, 19 homeless CWT program locations exist
nationwide supported by VA medical centers.\2 In fiscal year 1997,
1,371 homeless veterans were discharged from these programs. 

Homeless Compensated Work Therapy/Transitional Residence (CWT/TR). 
At selected locations, homeless veterans reside in transitional
residences while participating in the CWT work program.  The
transitional residences are community-based group homes; and veterans
are required to use a portion of their income from the CWT work
program to pay rent, utilities, and food costs.  VA owns 15 houses at
9 HCHV program sites which have 142 beds available for homeless
veterans while they participate in the CWT/TR program.  In addition,
VA has contracted with one facility in Washington, D.C., to house 10
veterans.  In fiscal year 1997, 132 homeless veterans were admitted
to the program, and VA obligated about $3.6 million. 

Homeless Providers Grant and per Diem (GPD).  This program offers
grant moneys, through a competitive process, to homeless providers
who construct or renovate facilities for transitional housing or
other supportive services to homeless veterans.  Over a 5-year
period, 127 grants have been awarded, and total VA funding for these
projects exceeds $26 million.  Upon completion of these projects,
over 2,700 new community-based transitional housing beds will be
available for homeless veterans. 

Housing and Urban Development-VA Supported Housing (HUD-VASH).  This
interagency housing program combines the resources of HUD and VA to
provide homeless veterans with permanent, subsidized housing. 
Through local housing authorities nationwide, HUD allocates section 8
vouchers for use by homeless veterans.  Veterans are required to pay
a portion of their income for rent; those without income receive
fully subsidized housing.  In general, veterans who do not exceed the
maximum allowable income can remain in their section 8 housing. 
Prior to accepting section 8 housing, veterans agree to intensive
case management services from VA staff and long-term commitment to
treatment and rehabilitation.  HUD allocated 1,805 vouchers to local
housing authorities; as of September 1998, 1,383 were being used to
house former homeless veterans.  In fiscal year 1997, VA's cost to
support this program was approximately $5 million. 

Social Security Administration-VA Joint Outreach Initiative (SSA-VA). 
This outreach initiative involves the Social Security Administration
and VA:  staff from both agencies work collaboratively to identify
homeless veterans who are eligible for social security benefits but
not receiving them.  Once veterans are identified, SSA and VA staff
take action to expeditiously prepare and process claims so qualified
veterans can obtain their benefits as quickly as possible.  The
SSA-VA initiative currently operates at four HCHV program locations. 
In fiscal year 1997, 372 applications were filed on behalf of
homeless veterans, and 56 awards were received. 

Supported Housing.  This multifaceted program offers a variety of
services that vary among sites.  In general, staff provide case
management services and assist homeless veterans in locating either
affordable permanent or transitional housing.  In addition, staff
offer practical services to homeless veterans to help them relearn
daily living skills such as budgeting, shopping, and cleaning.  They
also assist veterans with job hunting and developing and maintaining
good relationships with family members, neighbors, or others.  These
staff also serve as a link between homeless veterans and VA.  As
such, they facilitate care by ensuring that veterans obtain whatever
services they need to reintegrate into community living.  By the end
of fiscal year 1997, 26 supported housing sites existed, situated at
23 HCHV and 3 DCHV program locations.  During fiscal year 1997, these
26 sites served 1,688 homeless veterans.\3

Veterans Benefits Administration Outreach (VBA).  VBA staff work with
HCHV and DCHV staff to conduct joint outreach, provide counseling,
and offer other activities to homeless veterans, for example, helping
them apply for veterans benefits.  One of the goals of this program
is to expedite the process for benefit claims of homeless veterans. 
In fiscal year 1997, 2,893 contacts with homeless veterans were made,
and as a result of these contacts, 734 were awarded new benefits. 

OTHER HOMELESS APPROACHES

Acquired Property Sales for Homeless Providers.  VA properties that
are obtained through foreclosures on VA-insured mortgages are
available for sale to homeless provider organizations at below fair
market value.  Some of these properties are also available for lease. 
Since the inception of this program, 120 properties have been sold or
leased. 

Comprehensive Homeless Centers (CHC).  This initiative is not a
program that provides direct services but is rather an effort to
develop an integrated and coordinated system of treatment services
for homeless veterans.  Generally, CHC staff seek to (1) organize and
enhance communications and cooperation among the VA homeless
programs; (2) cultivate relationships with community-based homeless
service providers and organizations; and (3) work with other
government entities, including local, state, and federal agencies in
the area.  These actions help VA and non-VA homeless providers work
collaboratively to prevent or eliminate overlap and duplication of
efforts, and to streamline the delivery of services to homeless
veterans. 

Direct Leases With Service Providers on Medical Center Grounds. 
Where underutilized space exists, VA headquarters has encouraged
medical centers to lease property on medical center grounds to
homeless service providers. 

Drop-In Centers.  These daytime centers offer various services in a
safe environment.  Veterans can generally receive food and have
access to showers and washer/dryer facilities.  In addition, veterans
can participate in therapeutic and rehabilitative activities and
receive information about topics such as HIV prevention and good
nutrition.  The drop-in centers also function as a point of entry for
veterans into other VA homeless programs, including those that
provide more intensive services. 

Psychiatric Residential Rehabilitation and Treatment Program.  This
program is a 24-hour-a-day therapeutic setting that provides
professional support and treatment to chronically mentally ill
homeless veterans in need of extended rehabilitation and treatment. 
There is one funded site in Anchorage, Alaska. 

VA Assistance to Stand Downs.  Over the past 3 years, VA staff have
participated in more than 200 community ï¿½stand downsï¿½ that serve the
homeless.  Stand downs are 1- to 3-day events that provide the
homeless a safe and secure place to obtain a variety of services such
as food, clothing, shelter, and other assistance--including VA
provided health care, benefits certification, and linkages with other
programs. 

VA Surplus/Excess Property for Homeless Veterans Initiative.  With
support from the General Services Administration and Department of
Defense, VA searches for and obtains federal property such as hats,
gloves, socks, boots, sleeping bags, furniture, and other items. 
These items are distributed to homeless veterans and programs that
serve the homeless.  Over the past 5 years, this initiative has
distributed $42.6 million worth of surplus goods. 

HCHV Critical Monitors

----------------------------------  ----------------------------------
Structural (quantity or intensity   Length of stay in residential
of services provided)               treatment
                                    1. Mean days in residential
                                    treatment.

                                    Trend in veterans treated
                                    2. Unique veterans served per
                                    clinician.
                                    3. Visits per clinician.

                                    Trend in veterans contacted
                                    4. Difference from previous year
                                    of intakes.

                                    Residence at intake
                                    5. Literally homeless intakes per
                                    clinician.

                                    Supported housing workload
                                    6. Veterans treated per full-time
                                    equivalent employee in supported
                                    housing.

Patient characteristics (key        Residence at intake
characteristics of target           7. Not strictly homeless.
population)
                                    Length of homelessness
                                    8. No time spent as homeless.

                                    Trend in length of homelessness
                                    9. Difference from previous year
                                    of not strictly homeless.
                                    10. Difference from previous year
                                    of homeless less than 1 month.

                                    Medical and psychiatric
                                    indicators
                                    11. Percentage with serious
                                    psychiatric or substance abuse
                                    diagnosis.

                                    Trend in psychiatric indicators
                                    12. Difference from previous year
                                    of serious psychiatric or
                                    substance abuse diagnosis.

                                    Supported housing: Homelessness at
                                    intake
                                    13. Literally homeless veterans.

Process (how the program operates)  How contact was initiated
                                    14. Contact through VA or special
                                    program outreach.

                                    Trend in outreach indicators
                                    15. Difference from previous year
                                    in contact through outreach.

                                    Selection of veterans for
                                    residential treatment
                                    16. Ratio of veterans with no
                                    residence placed in residential
                                    treatment versus those not
                                    placed.
                                    17. Ratio of veterans with serious
                                    psychiatric or substance abuse
                                    problems placed in residential
                                    treatment versus those not
                                    placed.
                                    18. Inappropriate residential
                                    treatment.
                                    19. Veterans in hospital day
                                    before intake assessment to
                                    residential treatment.

                                    Supported housing: Percentage
                                    contacted by outreach
                                    20. VA outreach.

                                    Supported housing: Status of
                                    discharges
                                    21. Mean total days in program.


Outcome (status at discharge from   Deviation from median performance
residential treatment)              22. Successful completion of
                                    residential treatment.
                                    23. Domiciled at discharge.
                                    24. Housed at discharge.
                                    25. Employed at discharge.
                                    26. Improved psychiatric
                                    symptoms.
                                    27. Improved alcohol symptoms.
                                    28. Follow-up planned at
                                    discharge.

                                    Supported housing: Change in
                                    problems at discharge
                                    29. Improved alcohol problems at
                                    discharge.
                                    30. Improved psychiatric problems
                                    at discharge.

                                    Supported housing: Status of
                                    discharges
                                    31. Mutually agreed-on
                                    termination.

                                    Supported housing outcomes
                                    32. Discharge to homeless or
                                    unknown housing.
----------------------------------------------------------------------

--------------------
\1 The costs of operating the HCHV Outreach program are included in
the HCHV program allocation. 

\2 CWT programs serve homeless and non-homeless veterans alike.  Some
staff costs are funded by the HCHV program allocation, but total
program costs for serving homeless veterans are unavailable. 

\3 The costs of operating the Supported Housing program are included
in the HCHV program allocation. 


DCHV CRITICAL MONITORS
=========================================================== Appendix V

==================================  ==================================
Structural                          Turnover rate
                                    1. Annual turnover rate.

Veteran characteristics             Method of program contact
                                    2. Community entry (includes
                                    outreach initiated by VA staff and
                                    referrals by shelter staff or
                                    other non-VA staff).
                                    3. VA inpatient and outpatient
                                    referrals (includes referrals from
                                    the HCHV program).

                                    Usual residence in month prior to
                                    admission to program
                                    4. Outdoors/shelter.
                                    5. Institution (includes health
                                    care facilities and prisons).
                                    6. Own house, room, or apartment.

                                    Length of time homeless
                                    7. At risk for homelessness (HCHV
                                    uses the term "no time
                                    homeless").

                                    Appropriateness for admission
                                    8. No medical/psychiatric
                                    diagnosis.

Program participation               Length of stay
                                    9. Mean length of stay.

                                    Method of discharge
                                    10. Completed program.
                                    11. Asked to leave.
                                    12. Left by choice.

Outcome                             Deviation from median performance
                                    13. Alcohol problems improved.
                                    14. Drug problems improved.
                                    15. Mental health problems
                                    improved.
                                    16. Medical problems improved.
                                    17. Housed at discharge.
                                    18. Homeless at discharge.
                                    19. Competitively employed or in
                                    VA's CWT/TR at discharge.
                                    20. Unemployed at discharge.
----------------------------------------------------------------------

APPROACHES TARGETED TO SPECIFIC
SUBGROUPS OF THE HOMELESS
========================================================== Appendix VI

Specific approaches within the continuum of care for homelessness
vary with the needs of the subgroup being served.  These needs may
involve medical, mental health, substance abuse, or other problems;
and different needs may predominate at different times during an
episode of homelessness.  We visited collaborative programs that
target a range of different groups of the homeless (for example,
homeless with substance abuse problems, homeless with serious mental
illnesses), thus representing different possible elements in a
continuum of care for homeless veterans.  Each of the programs we
reviewed has the potential to be replicated, and we included two
projects that have been empirically evaluated. 

Convalescent Medical Care.  Christ House (Washington, D.C.) and Haven
II (Los Angeles, Calif.) address the need for convalescent medical
care among homeless persons who do not warrant (and are not being
considered for) inpatient medical treatment, but whose medical
conditions are likely to worsen without continued attention in a
stable environment. 

Christ House in Washington, D.C., is a 34-bed medical recovery
facility with a staff that includes nurses, a nurse practitioner, and
doctors.  Care is provided to homeless persons with a variety of
medical problems, such as postsurgical recovery, temporary
instability associated with HIV or diabetes, or sickness from
chemotherapy.  Homeless veterans placed at Christ House through an
HCMI contract may stay for several months, receiving medical
attention, sobriety support, and social service support as necessary. 

Haven II, located on the West Los Angeles VA Medical Center grounds,
is a 35-bed step-down care unit run by the Salvation Army.  The
Medical Center pays a per diem for up to 14 days for ambulatory
veterans who have been discharged from an inpatient medical unit, but
who are still recuperating and have not yet obtained other suitable
housing.  Veterans at Haven II receive their medical and mental
health treatment through the VA Medical Center. 

L.A.  Vets' Westside Residence Hall.  Targeting formerly homeless
veterans who have achieved 90 days of sobriety and who appear ready
to obtain and maintain employment, Westside Residence Hall provides
housing and supportive services to veterans who are judged to be
approaching the transition to permanent housing.  A renovated
dormitory, Westside Residence Hall is divided into suites, each with
several single or double rooms.  Meals are served through a food
reprocessing and redistribution business that also employs and trains
some of the residents, and the facility has an Economic Development
Center, where residents can pursue employment opportunities. 

L.A.  Vets is a joint venture between a for-profit corporation and a
nonprofit one.  Westside Residence Hall, Inc., the for-profit
corporation, owns and manages the building, and is geared to
generating enough cash to be self-sustaining and cover the core
administrative costs of the nonprofit corporation, Los Angeles
Veterans Initiative, Inc. 

To be eligible for Westside Residence Hall, veterans must have been
homeless or precariously housed, be medically and psychiatrically
stable, have achieved 90 days of sobriety, be willing to submit to
random toxicology screening, be actively involved in ongoing sobriety
support (if a history of substance abuse was involved), be judged
able to function independently and to seek employment, and be able to
pay rent.  Current rents range from $255 through $400. 

Westside Residence Hall has two separate programs, a supported
housing program and a welfare-to-work program.  About 250 veterans
are at Westside Residence Hall as part of the West Los Angeles VA
Medical Center's Supported Housing Program.  They receive case
management services through VA staff, who work part time at Westside
Residence Hall.  A VA psychologist also spends time at this facility,
and veterans go to the Medical Center for other needed services. 

Preliminary analyses by the West Los Angeles VA Medical Center staff
suggest that veterans stay at Westside for an average of 6 months and
that placement at Westside Residence Hall may be associated with a
reduced risk of inpatient hospitalization.  This analysis also
suggests that upon leaving, 54 percent report employment and 36
percent report having obtained both housing and employment; about 45
percent have relapsed at the time of exit. 

Westside Residence Hall's welfare-to-work program provides up to 90
days of assistance in obtaining and maintaining employment.  Begun in
1997 and funded in part by VA GPD funds, the program supports 100
beds.  Sober veterans who appear able and motivated to reenter the
job force must actively pursue work while in this program.  They
receive sobriety support, assistance in searching for employment, and
services to help them maintain work once it is found.  Although the
Westside Residence Hall welfare-to-work program is too new to allow
clear evaluation, research suggests that job assistance programs for
the homeless are enhanced by provision of supportive services and
postplacement assistance. 

Westside Residence Hall is thus designed to address needs that may
arise toward the end of an episode of homelessness.  According to
L.A.  Vets, projects such as Westside Residence Hall can be expected
to serve at least 30 percent of homeless or precariously housed
veterans.  They suggest that replication of Westside Residence Hall
is likely to require six conditions:  (1) a large population of
homeless veterans; (2) real estate suitable for adaptive reuse at an
affordable cost; (3) geographic proximity to a VA medical center with
expert staff committed to serving the homeless and the infrastructure
to allow that involvement; (4) ready access to entry-level jobs; (5)
willing for-profit and nonprofit partners, including a nonprofit
service provider capable of planning and coordinating the project and
an entrepreneur to spearhead efforts; and (6) long-term affordable
financing.  L.A.  Vets is currently developing additional similar
projects. 

New Directions.  New Directions offers substance abuse treatment and
job training/job placement services to medically stable substance
abusers who do not have serious mental illnesses and who are not
receiving medications for psychiatric conditions.  In a renovated
building it leases on the grounds of the West Los Angeles VA Medical
Center, New Directions operates a long-term residential treatment
program.  Beginning, if necessary, with medication-free
detoxification, residents enter a highly structured substance-abuse
treatment program, which can take from 3 to 9 months, and then a
vocational program, which can take up to 2 more years. 

Homeless program staff at the West Los Angeles VA Medical Center
reported that as many as a third of their homeless veterans could be
considered for placement at New Directions.  New Directions receives
a per diem rate through an HCMI contract for the first 30 days and
through GPD funds for an additional 60 days.  The facility has 24
detoxification beds, 64 long-term substance abuse treatment beds, and
40 beds for those in the vocational phase.  It also has 24
shelter-plus-care beds, partially funded by HUD, for veterans who
have completed the recovery phase of their treatment but have
multiple disabilities.  Residents with income are expected to pay a
maximum of 25 percent of their income toward rent. 

In operation for just over 1 year, New Directions is too new to
permit clear evaluation of its effectiveness.  New Directions staff
reported that about one-third of their residents are considered to
have successfully completed the program, and about one-third drop out
of treatment within the first 60 days.  Long-term residential
treatment for substance abuse has not been clearly shown by other
research to be any more or less effective than other treatment
approaches, and questions remain about what treatments are most
effective for homeless substance abusers.\1 Among the homeless,
highly structured programs tend to have somewhat higher drop-out
rates than other strategies. 

Veterans Rehabilitation Center, Vietnam Veterans of San Diego (VVSD). 
Empirical evaluation of VVSD's Veterans Rehabilitation Center, which
serves primarily substance abusing veterans with post-traumatic
stress disorder (PTSD) or serious depression, suggested that it was
associated with positive housing, employment, and substance abuse
outcomes on 6-month follow-up.  An 80-bed facility, the Veterans
Rehabilitation Center provides treatment for substance abuse, PTSD,
and other psychological disorders while also addressing preparation
for employment.  Some mental health needs are addressed in
coordination with the VA or local Vet Center. 

If a dually diagnosed veteran is referred to the Veterans
Rehabilitation Center through the San Diego VA Medical Center HCMI
program, a per diem is paid for up to 90 days.  Other veterans are
partially supported by a contract with that medical center's
substance abuse treatment program.  Residents are asked to pay rent
of up to 30 percent of the income they receive during their stay, not
to exceed $250 per month.  The treatment program includes three
phases, each of which typically requires at least 2 months.  During
the first phase, sobriety is emphasized.  During the second phase,
residents prepare for work by developing relevant skills.  In the
third phase, residents actively seek employment and prepare for the
transition back into the community.  The average length of stay is
about 7 months, with a maximum of 1 year.  The treatment program is
described in a manual that could be used to replicate it. 

VVSD's Veterans Rehabilitation Center was one of six promising
treatment programs for homeless persons with co-occurring substance
abuse or mental health problems that was selected for evaluation
through a grant cosponsored by the Center for Substance Abuse
Treatment and the Center for Mental Health Services.  Data collected
3 and 6 months after veterans left the program suggested that program
graduates spent fewer nights homeless and were more likely to be
housed stably and independently, more likely to be employed, and less
likely to be using alcohol or other substances than participants who
left the program prior to completion.  Moreover, data from the
California Employment Development Department suggested that program
participants were not only more likely to be employed, but were
earning better wages than a comparison group of homeless veterans who
did not participate in VVSD's Veterans Rehabilitation Center.  These
results must be interpreted with some caution, as they reflect a
single evaluation of the program with follow-up for only 6 months;
also, participants were not randomly assigned to the VVSD program or
control group.  Nonetheless, this evaluation suggests that the VVSD
Veterans Rehabilitation Center program offers a promising approach to
the treatment of substance abusing veterans with PTSD or depression. 

NEPEC reports that about 10 percent of the homeless veterans served
by the HCHV program have combat-related PTSD (the overall rate of
PTSD among homeless veterans is likely to be higher because
traumatization and victimization are more common among homeless
people than in the general population), about 29 percent have a mood
disorder, and about 72 percent have a substance abuse diagnosis. 
Thus, a substantial proportion of homeless veterans might benefit
from this kind of program. 

Critical Time Intervention (CTI).  Results of a randomized clinical
trial that compared CTI (a case management strategy) to usual
services only for seriously, chronically mentally ill (for example,
schizophrenic) homeless persons indicated that CTI was associated
with a greater reduction in homelessness throughout a period that
included a 9-month intervention phase and a 9-month follow-up phase. 
(ï¿½Usual servicesï¿½ were those that the person would have received
under normal circumstances, such as referrals to community agencies.)
CTI differs from the other specific programs we visited, in that it
is an approach to case management rather than a transitional housing
or residential treatment program.\2

CTI provides continuity of care during a homeless person's transition
from an institution or the street to a more permanent suitable
housing arrangement.  Designed to span 9 months, it aims to ease this
transition and minimize the risk of relapse to homelessness. 
Specific goals include performing an ongoing assessment, forming an
appropriate long-term plan, establishing linkages to community
resources, fostering independent living skills, and ensuring
efficient use of services.  For those with a substance abuse history,
abstinence is a goal rather than a prerequisite.  (Although ongoing
substance abuse makes intervention more difficult, it allows movement
toward a goal of sobriety while other needs are being addressed.)

In a study funded by the Center for Mental Health Services,\3 96 men
with severe mental illness who had been placed in community housing
were recruited for participation.  Half were randomly assigned to
receive CTI for 9 months, to be followed by 9 months of only usual
services; half were randomly assigned to 18 months of usual services. 
Data were obtained from 94 of the 96 participants at the 18-month
point.  Results indicated that those provided with only usual
services spent more nights homeless (91 on average) throughout the
18-month assessment interval than did those provided with CTI (30 on
average).  Moreover, the difference between these groups in the
likelihood of spending a night homeless tended to become greater over
time.  (Research on homeless veterans has more typically indicated
that treatment and comparison groups begin to converge rather than
diverge after a program ends.) Similarly, fewer of those who had
received CTI experienced prolonged periods of homelessness during the
18 months than those who received only usual services. 

These results are based on a single study, but suggest promising
outcomes for seriously mentally ill homeless persons, a particularly
hard-to-serve subgroup.  To date, CTI has been used most extensively
with some of the hardest-to-serve homeless in the New York City
shelter system:  seriously mentally ill (for example, schizophrenic)
persons, many of whom have multiple psychiatric diagnoses, chronic
and heavy substance abuse problems, serious medical problems, and
long histories of homelessness.  NEPEC estimates that about 45
percent of the homeless veterans served by the HCHV program have
serious psychiatric problems.  Moreover, CTI clinicians believe that
their procedures should be appropriate for use with homeless persons
with less severe disorders as well.  VA is not currently using CTI,
although VA officials have indicated their intention to begin a pilot
CTI project.  Materials are available for training in CTI. 



(See figure in printed edition.)Appendix VII

--------------------
\1 Drug Abuse:  Research Shows Treatment Is Effective, but Benefits
May Be Overstated (GAO/HEHS-98-72, Mar.  27, 1998). 

\2 Assertive Community Treatment (ACT) is another case management
strategy that has yielded promising results for the seriously
mentally ill homeless. 

\3 E.  Susser and others, ï¿½Preventing Recurrent Homelessness Among
Mentally Ill Men:  A ï¿½Critical Time' Intervention After Discharge
From a Shelter,ï¿½ American Journal of Public Health, Vol.  87, No.  2
(1997), pp.  256-62. 


COMMENTS FROM THE DEPARTMENT OF
VETERANS AFFAIRS
========================================================== Appendix VI



(See figure in printed edition.)



(See figure in printed edition.)

GAO Contacts and Staff Acknowledgments

GAO CONTACTS

George Poindexter, Assistant Director, (202) 512-7213
Timothy Hall, Evaluator-in-Charge, (202) 512-7192

STAFF ACKNOWLEDGMENTS

In addition to those named above, the following individuals made
important contributions to this report:  Jean Harker reviewed NEPEC's
reporting, monitoring, and evaluation systems for VA's homeless
programs; Kristen Anderson assisted with the NEPEC review and
conducted a literature review of homeless issues focused on
interventions for the homeless; Deborah Edwards assisted with
designing the job and methodological approaches used to perform the
work and acted as an adviser throughout the assignment; Ann McDermott
provided technical support; and Robert DeRoy assisted with the
reliability testing of NEPEC's data. 


*** End of document. ***