Question: What do you see as the unique challenges of providing housing and supportive services for veterans experiencing homelessness?
Answer: On the local level, the biggest challenge to providing housing and support services for veterans experiencing homelessness is identification of and engagement of the vet who is eligible for VA services. This isn’t due to any lack of commitment by the VA, as much as from other issues for the vet. Often times, I hear stories of eligible vets entering local homeless shelters and not identifying themselves as someone with a military history, so the identification immediately is impeded. I also hear that some vets, who are homeless, living on the land in camps, are mistrustful of outsiders and government. So the VA outreach workers must spend considerable time building rapport and trust with the person before even being able to establish if the person qualifies for assistance. Luckily, the Veterans Affairs’ offices are making major leaps in expanding their local partnerships with homeless and housing providers, so word is spreading on the streets that the VA is there more now than ever to help a Vet and his or her family.
On the macro-level, formerly, the biggest challenge was the lack of resources to create housing and services. However, the current administration and the US Department of Veterans Affairs Secretary Shinseki’s commitment to end veteran homelessness in five years has done much to overcome that obstacle, committing federal dollars to make a total of 40,000 units of veterans supportive housing available through the HUD-VASH program, and $50 million for a new homeless prevention program for veterans and veteran families. With an estimated 136,000 veterans experiencing homelessness and more than 75,000 on any given night, more resources are clearly needed, but the Federal Government is on the right track.
In addition to a national commitment with resources, the U.S. Department of Veterans Affairs is clearly sending a strong message to local offices and their medical centers to not go it alone in solving this problem. State and local partnerships are growing stronger each year. This is paramount for success. In Ohio and across the country, I have brokered relationships between our criminal justice system and the VA so that identification of vets who are homeless, involved in the courts and who are incarcerated are linked to VA services so they can be successful with reentry. The Veteran’s Justice Outreach Initiative is the outgrowth of that relationship building with new partnerships between the VA and the courts.
The remaining challenges for providing housing and supportive services for homeless veterans have to do with the unique housing and service needs faced by veterans themselves as well as the current way that public systems operate and offer help to veterans. Veterans experiencing homelessness have high rates (76 percent) of addiction and substance abuse and/or mental health disorders. Coupled with these problems, veterans who are homeless often experience traumatic and psychological distress from combat, along with other medical and physical challenges. Together, the multiplicity of challenges facing veterans places them at high-risk of involvement in institutions like psychiatric hospitals, substance abuse treatment programs, and most notably, the criminal justice system. Federal reports indicate that there are more than 200,000 veterans in prisons and jails. Many of these individuals may be caught on a cycle of homelessness, incarceration, and institutionalization.
In Columbus/Franklin County, Ohio for example, the Corporation for Supportive Housing (CSH) chaired a joint committee analyzing the cross between homelessness and incarceration. The joint committee found that although veterans make up about 12 percent of the general homeless population in this community, there was a higher concentration of vets in the smaller population cycling between homelessness, incarceration, and crisis behavioral health care. Identifying and engaging these vets who are frequently using public systems but not getting better needs to be a priority.
For veterans from the Vietnam Era, this cycle may have been persisting for decades. It is tragic that we are only now finding ways to break this cycle for homeless veterans through solutions like supportive housing. More disturbing, however, is the fact that we are allowing a new generation of veterans to become homeless and caught on the same cycle. Veterans returning from Operation Iraqi Freedom and Operation Enduring Freedom are facing high unemployment rates and few affordable housing opportunities. According to a 2007 GAO study, “In 2005, an estimated 2.3 million veteran renter households had low incomes. The proportion of veteran renter households that were low income varied by state but did not fall below 41 percent. Further, an estimated 1.3 million, or about 56 percent of these low-income veteran households nationwide, had housing affordability problems—that is, rental costs exceeding 30 percent of household income.”
Coupled with this are high rates of combat-related post-traumatic stress, and untreated and under-diagnosed mental health and substance abuse issues; it is no wonder that they are entering the ranks of the homeless at unprecedented rates. The recent study by HUD and the VA found that as many as 11,300 homeless veterans are younger, 18 to 30 years old. Another disturbing trend is the growing rate of homelessness among female veterans. While female veterans who are homeless still remain a small minority (roughly 6,500), their risk of homelessness is four times greater than their male counterparts and their numbers have doubled in the past ten years. Many of these female veterans are mothers, and their entry into homelessness means the entry of more children into homelessness.
The needs of veterans experiencing homelessness are so complex, and because of this we need a collaborative approach that brings together the VA with the mainstream health, mental health, substance abuse, employment, housing, the courts, local safety forces, jails, and prisons. Fortunately, this kind of interagency collaboration is taking place both at the Federal, State, and local level. Increasing these collaborations, targeting the highest-need veterans, and sharing more lessons learned across the disciplines would be helpful.
In Ohio, the VA has partnered with several local communities and nonprofit supportive housing providers to develop and operate supportive housing for veterans who are long term homeless and suffering from chronic health conditions. In Cleveland, Liberty Place at St Clair and in Dayton, Ohio, Ohio Avenue Commons are examples of supportive housing with successful outcomes for these veterans. And the joint committee in Columbus/Franklin County that I mentioned earlier has the commitment of the local VA medical center, the Corporation for Supportive Housing, the Franklin County Reentry Task Force and the local homeless Continuum of Care to implement a supportive housing program aimed at the veterans frequently using the public systems.
Programs like HUD-VASH are a good example of what can be achieved when local housing authorities work together with the local VA medical centers to provide both affordable housing and wrap-around services to help veterans permanently exit homelessness. We still have a long way to go, however. Efforts to end veteran homelessness should not be pursued separately from but in partnership with the efforts to end homelessness overall and the efforts to deal with the swelling numbers of incarcerated persons returning to their local communities. Pooling this knowledge, resources, and influence can result in a better job of removing the walls between funding and programs, between data collection and sharing, to create a system where veterans experiencing or at-risk of homelessness can be more easily identified, engaged, and then can access the right kind of help no matter what system he or she enters.
Question: What about unique challenges for veterans with substance use and mental health disorders?
Answer: Co-occurring substance use and mental health disorders are all too common among veterans experiencing homelessness, perhaps even more prevalent than among the general homeless population. The recent report from the VA and HUD states that about 53 percent of homeless veterans are disabled as opposed to 41 percent for non-veteran homeless individuals. Having these co-occurring disorders often means that veterans are unable to work, become poor, lose their housing, and often lose their relationships with family and friends. Facing social marginalization, they wind up hospitalized in psychiatric hospitals or due to physical health problems, or incarcerated in jails or prisons.
Veterans with both substance use and mental health disorders are in need of dual disorder services that not only attend to their addiction and mental health conditions at once and in the same setting, but also attend to all of the challenges that come with having both conditions—obtaining and retaining housing, barriers to employment, family counseling, help with activities of daily living and life skills training, and relationship management. Moreover, all of these offers of help need to take into consideration the feelings of isolation and mistrust of services that these individuals may have accumulated over time. Services therefore need to be assertive but flexible, highly motivational, patient, and most of all, respectful.
Supportive housing, which offers help with all of these under one affordable roof and usually with a respectful, assertive and highly motivational approach, is probably the most viable option for veterans experiencing homelessness with co-occurring disorders. Supportive housing provides a safe and stable foundation for homeless veterans to access the treatment and care they need to begin their path towards recovery and wellness.
Question: How has the Health Reform Act impacted individuals who are homeless and are involved in the criminal justice system?
Answer: The Patient Protection and Affordable Care Act (ACA) creates unprecedented opportunities for people who are homeless and who are involved in the criminal justice system. We know that many people are involved in the criminal justice system not because they pose a real threat to public safety, but rather because they exhibit behaviors associated with their lack of housing, mental health, and addiction issues—disorderly conduct, trespassing, minor drug possession, public intoxication, etc. Looking at the 9 million people we have in jails alone, studies report that between 63 percent of men and 75 percent of women in jail exhibit mental health symptoms, and between 6 percent of men and 15 percent of women having serious mental illnesses. Eighty-five percent of jail detainees reported having substance abuse problems. In terms of chronic health conditions, 53 percent of women and 35 percent of men report having a current medical problem.
We also know that due to a veteran’s homelessness and chronic health conditions, he or she is likely to be poor. Perhaps he or she is eligible, or was at one time eligible, for Medicaid. Yet, when the vet is jailed for the quality of life crimes we frequently see they commit, they lose their Medicaid status. Through my efforts with the prior administrations of the State of Ohio and the collaborative work of the Supreme Court of Ohio’s Advisory Committee on Mental Illness and the Courts (ACMIC), which I chair, Ohio is now suspending Medicaid status for eligible populations when incarcerated instead of dropping them entirely from the Medicaid roles. A pilot project is underway in Ohio to quickly reinstate eligible veterans and others to Medicaid coverage prior to release so health care can continue with reentry.
We also know that if these individuals were provided with housing connected with supportive services and access to quality health and behavioral health care, we could end their homelessness and prevent their returns to the criminal justice system. The Corporation for Supportive Housing has compiled research and evaluation that shows that placing individuals with mental health and addiction issues into supportive housing has reduced their returns to homeless shelters by more than 90 percent, their hospitalizations by between 27 and 77 percent, and reduced their jail involvement by between 42 and 76 percent. However, at this time, people who are homeless and who are involved in the criminal justice system have limited access to supportive housing as well as to health coverage and services. The ACA could change all of that.
The ACA’s extension of Medicaid coverage to all Americans below 133 percent of the poverty level will mean that many homeless people involved in the justice system, who were previously uninsured, will become eligible for Medicaid by 2014. For some individuals, having medical coverage alone can open up many possibilities. For instance, individuals with mental health issues who were started on a medication regimen while in jail or prison for mental illness will now be able to continue to have a means to pay for their needed medications.
For others, having health coverage alone may not help prevent homelessness or recidivism. Individuals should also have access to housing, quality mental health and substance abuse treatment, and “wrap-around” case management supports that help them navigate these services. Individuals must keep their housing, engage in pro-social behaviors, and avoid high-risk behaviors. The expansion of Medicaid coverage under ACA, along with the movement towards parity for primary and behavioral health services under Medicaid, encourages States and jurisdictions to increase the availability of these needed behavioral health and wrap-around services. States like Ohio can, for example, enact changes in their State Medicaid plan to make housing-based case management services eligible for Medicaid reimbursement for justice-involved people with behavioral health problems. Enacting these changes could ultimately generate savings to the State by preventing avoidable (and costly) hospitalizations and incarceration.
Needless to say, these changes will not happen unless States and jurisdictions make the kinds of policy decisions to create ways to facilitate Medicaid enrollment to justice-involved homeless people and to improve access to behavioral health and flexible case management services to these populations. With the work of ACMIC and our pilot in Ohio, I am confident that Ohio will be a leader in this work.
Question: Have you seen changes in the age, race...of citizens who may be homeless because of the current economic climate?
Answer: The economic recession has had a big impact on the number of families that have entered the homeless shelter system. Many of these families already had very low incomes and were more vulnerable to the impact of a job loss or decreases in work hours or wages. The National Alliance to End Homelessness (NAEH) found that between 2008 and 2009, the largest percentage increase in homelessness occurred among family households–a 4 percent increase that represents 3,200 additional homeless families. The 2009 Annual Homeless Assessment Report to Congress shows an increase in the number of adult men in homeless families due in part to an increase in homelessness among two-parent families, a demographic that has more protection from homelessness during better economic conditions. The Federal Housing and Urban Development (HUD) program, Homeless Prevention and Rapid-Rehousing Program (HPRP), which provides emergency assistance to families that are at risk of losing their housing, has undoubtedly prevented homelessness for many of these vulnerable families, but communities will no longer have access to HPRP funding in 2012. We are likely to continue to see increases in family homelessness as families that are currently doubled-up with extended family and friends become homeless when these temporary situations are no longer viable, unless the economy makes a rebound.
Another recent demographic trend that is not related to the economic downturn, but may be exacerbated by it, is the aging of the single adult homeless population. The elderly have historically been underrepresented among the homeless because of the strong social safety net created by Social Security and Medicare. However, according to a recent report by the NAEH, as the Baby Boomer generation is aging and the rate of deep poverty among the elderly remains constant, the number of elderly homeless individuals is rising and will continue to increase over the next decade. This suggests that State and local governments should be prepared to meet the needs of this group and have services connected to housing that address their health care and end-of-life issues.
A supportive housing project in Columbus, Ohio–The Commons at Buckingham–is preparing for that demographic shift. The provider, National Church Residences (NCR), operates health care services for the elderly in their other housing and nursing home settings. NCR is utilizing their health care expertise in this new supportive housing project by providing health care assistance for the elderly tenants who were once homeless. Also interesting about this project, there are a number of veterans who were long-term homeless now housed at this supportive housing project and receiving VA services. This is a great example of partnerships, sharing of resources, and working together to meet several community needs.
Question: Have you or the Ohio court system made any additional changes in how you/it deals with homeless individuals?
Answer: Through the staff of our Specialized Docket Section, the Ohio Supreme Court has supported the more than 140 specialized dockets (drug courts, mental health courts, reentry courts, veterans treatment courts) operating in Ohio. These dockets are therapeutically-oriented judicial approaches to providing court supervision and appropriate treatment for offenders. Working with families and community providers to ensure that participants in these programs have suitable living environments is one of the keys to success.
In learning about treatment and other services through our trainings, judges have become aware of the studies that indicate that it is much easier for an offender to maintain medication compliance or to follow a treatment regime when they have stable housing. As part of their engagement with the offenders, judges are encouraged to ask participants about their living situation and will challenge community partners to provide housing assistance. Often a judge will work to ensure that an individual in custody or residential treatment is not being released into homelessness.
Engaging with an offender enables the courts to understand the individuals’ needs and to make better connections with available services, such as the services provided through the Veteran’s Justice Outreach Initiative. Each VA medical center has been asked to designate a staff person as a Veterans’ Justice Outreach Specialist, who is responsible for direct outreach, assessment, and case management for justice-involved veterans in local courts and jails, and to liaison with local justice system partners.
As part of my Ohio Veterans WrapAround Project, I have been speaking with judges and others in the legal community to “connect the dots” to encourage the development of veterans treatment courts and the network all the programming available to veterans so each court is aware of and can provide the most productive assistance to its veterans who stand before them. Since they have given so much for our country and our safety, we need to wrap our arms around our veterans and help them in their time of need. The first step is just to ask the question, “Do you have military experience?” (I learned that many say “no” if only asked if they are a “veteran.”) This should be part of all intakes so the process of connecting the veteran to benefits and treatment can begin.
As I mentioned earlier, due to the efforts of six state agency directors and the Supreme Court’s Advisory Committee on Mental Illness and the Courts (ACMIC), several initiatives have been created to address the needs of persons who are homeless in the court system.
The Reinstatement of Medicaid for Public Institution Recipients (RoMPIR) is the project to expedite the reinstatement of Medicaid benefits for former State prisoners reentering their communities. The Governor’s office has been chairing this multi-state agency endeavor. It became an equality issue for the State to spearhead this – the State saw the need to offer all citizens equal opportunity for reinstatement if the person lost coverage under a one year span of time. Ohio has about 3,000 people that had Medicaid before going into state prison and who were doing less than one year. It was taking anywhere from 1 to 500 days for them to get reinstated to Medicaid after release with 51 days the average. The 14-day supply of medications provided to ex-offenders with a behavioral health diagnosis upon release was obviously not meeting the former offender’s health needs. As we know, this was a recipe for relapse, potential homelessness and possible re-arrest. RoMPIR is still in its beginning stages of implementation and the Governor’s office is continuing to look for process improvements and how to replicate its use in local jails.
Another major project is the Returning Home Ohio, reentry supportive housing pilot. In 2007, the Ohio Department of Rehabilitation and Correction and the CSH Ohio office began collaboration on an innovative pilot focused on reducing recidivism and preventing homelessness among a small, but significantly challenged population of offenders. Returning Home Ohio is a permanent supportive housing project that targets offenders who are identified as homeless prior to incarceration or are likely to become homeless upon release and who have a disability, such as mental illness, chronic substance abuse, or a chronic health condition. The project works with eight nonprofits in five Ohio cities and has successfully housed more than 150 former offenders. To date, the majority have remained stabilized housed with services or moved on to more independent housing. Returning Home Ohio is being formally evaluated by the Urban Institute who is under contract with CSH-Ohio. We anticipate a full evaluation report to be published on Returning Home Ohio by mid-2012.
Across Ohio, there are a number of local reentry task forces who have identified the lack of housing and services to be an issue for returning former offenders. There is growing collaboration of these task forces with local Continuum of Care for homeless services. What’s important to these collaborations is the shared learning on evidence based practices in criminal justice and in homelessness.
Question: During your tenure, how has your role/insights changed regarding individuals who are homeless?
Answer: After working for a couple of years to encourage local collaborations to support mental health courts, it became apparent to me that one of the critical resources lacking in many of our communities was housing. Judges were sharing with me that their efforts were least effective among those who were homeless. However, there were too few beds available in most communities to meet the existing needs. I began to see how the stability of safe and secure housing was interconnected with other supports that enabled individuals to successfully complete treatment and stay on the medications that they were receiving. I realized that supportive housing became a far more important resource.
In looking into the housing issue, I met Sally Luken, the local director of the Ohio office of the Corporation for Supportive Housing, a national organization that helps communities create permanent housing connected with supportive services to prevent and end homelessness. After touring a supportive housing facility, I knew that this type of resource was critical to meeting the needs of many of the people who enter into our mental health and drug courts. Due to resource restrictions, I learned that support for maintaining a separate CSH office in Ohio was weakening. Working with other State and community partners, we were able to strengthen the commitment for the Ohio office. As a result, several State agencies began to contract for consultative services with Sally to coordinate housing issues for persons leaving state institutions. For my part, I was asked to join and have served for several years now on the national board of directors for CSH.
For me personally, I have come to understand the complexity of the issue of homelessness, especially for those who have been caught up in our criminal justice system or the other institutions maintained by our State agencies. For those individuals who have received stable, supportive housing, I have seen a transformation from hopelessness to that of empowerment. Many of those individuals have regained a sense of self-worth and have been aided in their recovery with other problems. If nothing else, I have realized that no one really wants to be homeless and that talk of choosing to be homeless is just a myth that helps to maintain the stigma affecting this population.
Question: The Substance Abuse and Mental Health Services Administration (SAMHSA) has identified "Military Families - Active, Guard, Reserve, and Veteran" as one of its strategic initiatives. What do you feel is one of the most critical steps the court systems and SAMHSA can take to address this initiative?
Answer: SAMHSA can play a key role in supplementing and enhancing the resources and programs already being offered by the VA and HUD. The truth is that while HUD-VASH has done much to pair housing subsidies with case management for veterans and their families, there are still many veterans whose service needs are so high and complex that they are often unable to take advantage of HUD-VASH or the new Supportive Services for Veteran Families Program. These high-need veterans are those that typically have long histories of addiction and substance use, more severe mental illnesses, and criminal histories that make landlords unwilling to rent to them. SAMHSA can help to make programs like HUD-VASH more accessible to these individuals by providing the resources that enable VAs and community-based partners to enhance the supportive services offered with housing for these high-need veterans.
An example of this is the effort in Columbus/Franklin County to identify, engage and then provide supportive housing for the frequent users of public services that are veterans. The local VA is committed to creating an ACT/IDDT (Assertive Community Treatment/Integrated Dual Disorder Treatment) team to provide the intensive, cross-disciplinary services the veterans will need along with HUD-VASH vouchers. This is a new venture for the local VA to create this particular team, to obtain the specific training and to undergo monitoring to ensure fidelity to the ACT/IDDT model. SAMSHA should help the VA understand this evidenced based practice and how the model should be incorporated in more HUD-VASH initiatives.
In addition, according to data drawn from the Veterans for Common Sense in a 2009 report, “Of the Iraq and Afghanistan war veterans treated by VA, nearly 178,000 were diagnosed with a mental health condition, including 105,000 diagnosed with Post Traumatic Stress Disorder (PTSD). The percentage of recent war veterans returning home with a mental health condition continues to climb steeply, from 14 percent in 2004 to 45 percent in 2008.” These figures are sobering reminders of the implications of having our military not receive appropriate mental health screening post deployment. The current military is largely made up of reservists who are not as well-connected to services post-deployment. SAMHSA is well positioned to implement increased training on Post Traumatic Stress Counseling and focusing on family reunification with training around family trauma associated with military service. The court systems can play just as large of a role through programs such as the Veterans Justice Outreach Initiative or Veterans Treatment Courts. These points of entry can work to find more appropriate diversionary methods of intercepting the veteran such as offering supportive housing. This type of intervention could provide the veteran and veteran family with the support they need to more holistically integrate back in to their communities.