STATEMENT OF
FRANCES M. MURPHY, MD, MPH
ACTING DEPUTY UNDER SECRETARY FOR POLICY AND MANAGEMENT
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS, SUBCOMMITTEE ON HEALTH AND
SUBCOMMITTEE ON BENEFITS
U S HOUSE OF REPRESENTATIVES

March 9, 2000

Mr. Chairmen and Members of the Committees

I appreciate the opportunity to discuss homelessness among veterans and the VA’s efforts to address homeless veterans’ needs. Accompanying me this morning are Ms. Estella Morris, Program Manager of the Comprehensive Homeless Center of the Central Arkansas Veterans Health Care System, Ms. Henrietta Fishman, Manager of the Network 3 Homeless Veterans Treatment Programs Service Line and Mr. Peter Dougherty, Director, Homeless Veterans Programs. Mr. Angel Caban, a formerly homeless veteran, who now serves as a supervisory social worker for the VISN 3 Mental Illness Research, Education and Clinical Center (MIRECC), is also with us today.

VA has developed a wide range of programs and services to address homeless veterans needs. These programs operate in partnership with community-based organizations and service providers and other federally funded programs. With the additional funding made available in the FY 2000 budget we will be significantly expanding our homeless programs this year and we plan to initiate new program evaluation efforts as required by the Millennium Act. While many special programs have been designed to address the special needs of homeless veterans, they do not function in isolation. These programs are integrated with other VA healthcare and benefits services. In addition, VA relies heavily on its federal, state and community based partners to assure a full range of services for homeless veterans.

Homeless Veteran Population

In 1996 the Federal Interagency Council on the Homeless (ICH) designed and the Census Bureau conducted the "National Survey of Homeless Assistance Providers and Clients." The survey was conducted in the 28 largest metropolitan areas, 24 randomly selected small and medium sized areas and 24 randomly selected groups of rural counties. Approximately 12,000 service providers were contacted and 4,200 consumers of homeless services were interviewed. Survey findings and a technical report written by the Urban Institute were released in December 1999. Survey findings related to homeless veterans were as follows:

• 33% of homeless males and 23% of homeless adults are veterans while 31% of adult males and 13% of all adults are veterans;

• 33% of homeless veterans report being stationed in a war zone;

• 28% of homeless veterans report being exposed to combat;

• 67% of homeless veterans reported serving 3 or more years in the military;

• 32% of veterans compared to 17% of non-veterans reported that their last episode of homelessness lasted more than 13 months; and

• 57% of homeless veterans reported using VA health care services at least once.

The Urban Institute issued a press release in February 2000, estimating that between 2.3 million to 3.5 million Americans may have experienced an episode of homelessness during 1996. Extrapolation from this estimate would suggest that between 322,000 – 491,000 veterans might have experienced homelessness during that time period.

Homeless Veterans Served by VA

In FY 1999, staff in VA’s Health Care for Homeless Veterans (HCHV) Program had contacts with over 39,000 homeless veterans. Approximately 29,000 homeless veterans were given formal intake assessments to determine their clinical, housing and income status. Data from these intake assessments provides VA with detailed information about the demographic and clinical characteristics of the homeless veterans served by VA. We would like to share some of these findings with you today:

• Approximately 97% of homeless veterans contacted by program staff are men and 3% are women.

• The mean age of these veterans was 46.

• Approximately 48% of the veterans served in the military during the Viet Nam Era while nearly 4% served during the Persian Gulf era.

• Approximately 50% of these veterans were African Americans and 6% were Hispanic.

• 60% of homeless veterans report part-time, irregular employment or no employment; 73% of homeless veterans report not having worked at all during the 30 days prior to the intake assessment.

• 68% of homeless veterans reported living in emergency shelters or outdoors at the time of the intake assessment.

• 81% of homeless veterans were determined by HCHV clinicians to have a serious psychiatric or substance abuse problem -

- 43% had a serious psychiatric problem,

- 69% were dependent on alcohol and/or drugs,

- 31% were dually diagnosed with psychiatric and substance abuse

disorders.

Programs and Services Provided by VA

VA is the only federal agency that provides substantial hands-on assistance directly to homeless persons. Although limited to veterans, VA's major homeless programs constitute the largest integrated network of homeless assistance programs in the country, offering a wide array of services and initiatives to help veterans recover from homelessness and live as self-sufficiently and independently as possible.

VA, using its resources or in partnerships with others, has secured more than 8,000 transitional and permanent beds for homeless veterans throughout the nation. These include:

• beds in VA’s Domiciliary Care for Homeless Veterans (DCHV) program;
• beds in VA’s Compensated Work Therapy/Transitional Residence (CWT/TR) program;
• beds supported through the Health Care for Homeless Veterans (HCHV) program;
• the VA Supported Housing (VASH) program;
• the joint HUD-VA Supported Housing (HUD-VASH) program; and
• the Homeless Providers Grant and Per Diem Program.

With new initiatives that will be started this year, VA expects to add approximately 9,000 more transitional beds for homeless veterans over the next 4 years.

In addition to these special initiatives, VA provides a wide range of services to homeless veterans through its mainstream health care and benefit assistance programs. To increase this assistance, VA has initiated outreach efforts to connect more homeless veterans to both mainstream and homeless-specific VA programs and benefits. These programs strive to offer a continuum of services including:

• aggressive outreach to veterans living on streets and in shelters who otherwise would not seek assistance;

• clinical assessment and referral to needed medical treatment for physical and psychiatric disorders including substance abuse;

• long-term sheltered transitional assistance, case management and rehabilitation;

• linkage and referrals for employment assistance, linkage with available income supports; and assistance in obtaining housing.

Homeless Veterans-Specific Programs

VA’s FY 2000 budget increased funding for specialized services for homeless veterans by $50 million. Of this increase, $39.6 million was included in the medical care appropriation and the remainder is available to guarantee loans made under the Multifamily Transitional Housing for Homeless Veterans Program. VA expects to spend $143.8 million on specialized programs for homeless veterans this year and is projecting a budget of $150.6 million for these programs in FY 2001. The following provides an overview of the types of programs VA has developed to meet the multiple and varied needs of homeless veterans:

VA's Health Care for Homeless Veterans Program (HCHV) operates at 76 sites where extensive outreach, physical and psychiatric health exams, treatment, referrals, and ongoing case management are provided to homeless veterans with mental health problems, including substance abuse. As appropriate, the HCHV program places homeless veterans needing longer-term treatment into one of its 200 contract community-based facilities. During the last reporting year, this program assessed more than 29,000 veterans, with 4,000 receiving residential treatment in community-based treatment facilities. The average length of stay in community-based residential care is about 70 days and the average cost per day is approximately $39.00. VA is committing $18.8 million to the expansion of the HCHV program in FY 2000. This includes the activation of new sites and expansion of existing programs. When new staff and new programs are fully operational, it is expected that 12,000 additional homeless veterans will be treated. Approximately one third of these veterans will be provided contract residential treatment. In FY 2000, VHA will commit an additional $3 million to establish 10 programs that will be dedicated to homeless women veterans. These programs are expected to serve 1,500 homeless women veterans per year.

VA's Domiciliary Care for Homeless Veterans (DCHV) Program provides medical care and rehabilitation in a residential setting on VA medical center grounds to eligible ambulatory veterans disabled by medical or psychiatric disorders, injury or age and who do not need hospitalization or nursing home care. There are 1,751 operational beds available through the program at 35 VA medical centers in 26 states. The program provided residential treatment to some 5,530 homeless veterans in FY 1998. The domiciliaries conduct outreach and referral; admission screening and assessment; medical and psychiatric evaluation; treatment, vocational counseling and rehabilitation; and post-discharge community support.

Special Outreach and Benefits Assistance is provided through funding from VA's Veterans Health Administration to support 12 veterans benefits counselors from the Veterans Benefits Administration (VBA) as members of VA's Health Care for Homeless Veterans Program and DCHV programs.

Acquired Property Sales for Homeless Providers Program makes available properties VA obtains through foreclosures on VA-insured mortgages. These properties are offered for sale to homeless provider organizations at a discount of 20 to 50%. To date, 116 properties have been sold, and 58 have been leased to nonprofit organizations to provide housing for the homeless.

Drop-In Centers provide homeless veterans who sleep in shelters or on the streets at night with safe, daytime environments. Eleven centers offer therapeutic activities and programs to improve daily living skills, meals, and a place to shower and wash clothes. At these VA-run centers, veterans also participate in other VA programs that provide more extensive assistance, including a variety of therapeutic and rehabilitative activities. Drop-In Center staff also coordinates with other programs to provide veterans with long-term care services.

Compensated Work Therapy (CWT) and CWT/Transitional Residence Programs have had dramatic increases in activity during the past few years. Through its CWT/TR program, VA offers structured therapeutic work opportunities and supervised therapeutic housing for at risk and homeless veterans with physical, psychiatric and substance abuse disorders. VA contracts with private industry and the public sector for work to be done by these veterans, who learn new job skills, re-learn successful work habits and regain a sense of self-esteem and self-worth. The veterans are paid for their work and, in turn, make a monthly payment toward maintenance and upkeep of the residence.

The CWT/TR program includes 49 community-based group home transitional residences with more than 400 beds. Nine program sites with 14 houses exclusively serve homeless veterans. The average length of stay is approximately six months. There currently are more than 100 individual CWT operations connected to VA medical centers nationwide. Nearly 15,000 veterans participated in the programs in 1999, an increase of more than 5,000 over 1996. CWT programs developed contracts with companies and agencies of government valued at a national total of $43.8 million. Increased competitive therapeutic work opportunities are occurring each year. At discharge from the CWT/TR program 44% of the veterans were placed in competitive employment and 7% were placed in training programs. VA has committed $2.3 million to the activation of new CWT programs and other therapeutic employment initiatives for homeless veterans. When these programs are fully operational, it is expected that they will be able to serve an additional 1,600 veterans annually.

Intradepartmental programs also support the CWT programs for homeless veterans. VA's National Cemetery Administration and Veterans Health Administration have formed partnerships at 20 national cemeteries, where more than 100 formerly homeless veterans from the CWT program have received therapeutic work opportunities while providing VA cemeteries with a supplemental work force.

HUD-VA Supported Housing (HUD-VASH) Program, a joint program with the Department of Housing and Urban Development (HUD), provides permanent housing and ongoing treatment services to the harder-to-serve homeless mentally ill veterans and those suffering from substance abuse disorders. HUD's Section 8 Voucher Program continues to renew 1,780 vouchers for $44.5 million, designated over a ten year period, for homeless chronically mentally ill veterans, and VA staff at 35 sites provide outreach, clinical care and case management services. Rigorous evaluation of this program indicates that this approach significantly reduces days of homelessness for veterans who suffer from serious mental illness and substance abuse disorders.

VA's Supported Housing Program is like the HUD-VASH program in that VA staff provides therapeutic support and assistance to help homeless veterans secure low-cost, long-term transitional or permanent housing and provide ongoing clinical case management services to help them remain in housing. It differs from HUD-VASH in that dedicated Section 8 housing vouchers are not available to homeless veterans in the program. As part of VA’s clinical case management services, staff work with private landlords, public housing authorities and nonprofit organizations to find therapeutically appropriate housing arrangements. Veterans service organizations have been instrumental in helping VA establish these housing alternatives nationwide. In 1998, VA staff at 26 Supported Housing Program sites helped 1,700 homeless veterans find transitional or permanent housing in the community.

Joint Social Security Administration (SSA)/VA Pilot Project provides benefits and services to homeless mentally ill veterans at four sites – New York City, Brooklyn, Dallas, and Los Angeles. HCHV and DCHV staff coordinate outreach and benefits certification with SSA staff to locate and assist homeless veterans in obtaining SSA benefits.

Comprehensive Homeless Centers place a variety of VA's homeless programs into an integrated organizational framework to promote coordination of VA resources and non-VA homeless programs. VA currently has eight comprehensive homeless centers connected to medical centers in Anchorage, Brooklyn, Cleveland, Dallas, Little Rock, Pittsburgh, San Francisco, and West Los Angeles.

Stand Downs are 1-3 day safe havens for homeless veterans that provide a variety of services to veterans and opportunity for VA and community-based homeless providers to reach more homeless veterans. Stand downs provide homeless veterans a temporary place of safety and security where they can obtain food, shelter, clothing and a range of community and VA-specific assistance. In many locations, VA provides health screenings, referral and access to long-term treatment, benefits counseling, ID cards and linkage with other programs to meet their immediate needs. VA participated in 136 stand downs run by local coalitions in various cities during 1999. Surveys showed that more than 25,000 veterans and 8,000 members of their family and others in need of assistance attended these events. More than 17,000 volunteers contributed to this effort. The Secretary has identified stand downs as VA’s White House Millennium Project for 2000. In FY 2000, VA is committing $1.5 million to support stand downs. VA expects to participate in 200 stand downs and to provide services to 100,000 homeless veterans at these events.

VA Excess Property for Homeless Veterans Initiative provides for the distribution of federal excess personal property, such as clothing, footwear, socks, sleeping bags, blankets and other items to homeless veterans through VA domiciliaries and other outreach activities. In less than six years, this initiative has been responsible for the distribution of more than $80 million worth of materiel and currently has more than $8

million in inventory. A CWT program providing a therapeutic work experience for formerly homeless veterans has been established at the VA Medical Center in Lyons campus of the VA New Jersey Health Care System, to receive, warehouse and ship these goods to VA homeless programs across the country.

The Homeless Providers Grant and Per Diem Program is a dynamic component of VA's homeless-specific programs. It provides grants and per diem payments to assist public and nonprofit organizations to establish and operate new supportive housing and service centers for homeless veterans. Grant funds may also be used to assist organizations in purchasing vans to conduct outreach or provide transportation for homeless veterans. Since the first year of funding in FY 94, VA has awarded 178 grants to nonprofit organizations, units of state or local governments and Native American tribes in 42 states and the District of Columbia.

Total VA funding for grants has exceeded $41 million. When these projects are completed, approximately 4,000 new community-based beds will be available for homeless veterans. Nearly 1,500 homeless veterans are being cared for through these programs today and supported by VA per diem payments to service providers.

VA is committing $11 million in additional funding for the Grant and Per Diem Program. For the first time VA is providing "Per Diem Only" awards to non-VA organizations that have not received grants. VA announced the availability of $5 million for Per Diem Only awards on February 11, 2000. VA will also announce a new round of grants later this month and has committed $12 million for the seventh round of funding. We estimate that 20,000 homeless veterans will receive services funded through the grant and per diem program in FY 2000.

Project CHALENG (Community Homelessness Assessment, Local Education and Networking Groups) for Veterans is a nationwide initiative. VA medical center and regional office directors work with other federal, state and local agencies and nonprofit organizations. They assess the needs of homeless veterans, develop action plans to meet identified needs, and develop directories that contain local community resources to be used by homeless veterans.

More than 10,000 representatives from non-VA organizations have participated in Project CHALENG initiatives, which include holding conferences at VA medical centers to raise awareness of the needs of homeless veterans, creating new partnerships in the fight against homelessness and developing new strategies for future action. As a result of recent Project CHALENG activities, 19 new homeless coalitions have been formed, 95 new interagency service agreements have been signed and 53 new sites were identified for outreach to homeless veterans.

Loan Guarantee for Multifamily Transitional Housing for Homeless Veterans is currently being implemented as authorized by P. L. 105-368. This program will allow VA to guarantee loans made by lenders to help non-VA organizations develop transitional housing for homeless veterans. VA awarded a contract to Birch and Davis Associates, Inc., and their subcontractors, Century Housing Corporation, to assist with the development of this pilot program. VA plans to guarantee 5 loans in the next two years, with a total of 15 loans guaranteed over the next 5 years. It is expected that 5,000 new transitional beds for homeless programs will be created through this program.

Mainstream VA Programs Assisting Homeless Veterans

The Veterans Benefits Administration (VBA) administers a number of compensation and pension programs: disability compensation, dependency and indemnity compensation, death compensation, death pension and disability pension. Vocational rehabilitation and counseling assist veterans with service-connected disabilities to achieve independence in daily living and to the extent possible become employable and maintain employment. In the Fiduciary or Guardianship Program, the benefits of veterans who are determined to be incapable of managing their funds are managed by fiduciary.

VBA regional offices at 57 locations have designated staffs who serve as coordinators and points of contact for homeless veterans through outreach activities. In FY 1999, VBA staff engaged over 23,000 homeless veterans through outreach activities. These VBA staff made 2,753 shelter visits and 4,721 agency visits.

The Readjustment Counseling Service’s Vet Centers have homeless coordinators who provide outreach, psychological counseling, supportive social services and referrals to other VA and community programs. Each year approximately 140,000 veterans make more than 800,000 visits to VA’s 206 Vet Centers. During the winter months, approximately 10% of Vet Center clients report being homeless.

A substantial number of homeless veterans are served by VHA’s general inpatient and outpatient mental health programs. For the past five years VA at its Northeast Program Evaluation Center (NEPEC), has conducted an End-of-Year Survey of hospitalized homeless veterans in VA health care facilities. On September 30, 1999, 17,258 veterans were being treated in acute medical surgical and psychiatric beds, acute substance abuse beds, psychosocial residential rehabilitation and treatment program (PRRTP) beds and domiciliary beds. A total of 4,811 veterans (27.9%) were homeless at admission. Nearly 20% were living on the streets or in shelters before admission and 8% had no residence and were temporarily residing with family or friends.

A total of 4,376 veterans were being treated in VA mental health beds. Approximately one-third of these veterans were homeless at admission and another 6%, while not homeless when admitted, were at high risk for homelessness if discharged on the day of the survey. The following is a break out of the type of mental health bed section veterans occupied:

• 23.1% of 2,715 veterans in Acute Psychiatry beds were homeless at admission.

• 46.7% of 255 veterans in Acute Substance Abuse beds were homeless at admission.

• 48.5% of 1,406 veterans in PRRTP beds were homeless at admission.

VA has also collected information on homeless veterans seen in outpatient mental health programs. For FY 1999, a total of 664,340 veterans were treated in outpatient mental health programs. Approximately 62,000 (9.3%) of these veterans were identified as homeless on VA encounter forms. Over 70% of homeless veterans were treated in VA’s specialized programs for homeless veterans and the remaining 30% were treated in general mental health outpatient programs.

Homeless Veterans Program Monitoring and Evaluation

VA has the Nation’s most extensive and long-standing program of monitoring and evaluating data concerning homeless individuals and the programs that serve them. In 1987, we initiated a three-fold evaluation strategy for what was then an unprecedented VA community collaborative program – the original HCMI veterans program.

Under this evaluation plan: (1) all veterans evaluated by the program were systematically assessed to assure that program resources were directed to the intended target population (now almost 30,000 under served homeless veterans per year); (2) housing, employment, and clinical outcomes were documented for all veterans admitted to community-based residential treatment, the most expensive component of the program; and (3) a detailed outcome study documented housing and employment outcomes after program termination was initiated.

The VA study showed 30% to 40% improvement in psychiatric and substance abuse outcomes, employment rates doubled, and 64% exited from homelessness at the time of program completion. When these veterans were re-interviewed 7.2 months after program completion, they showed even GREATER improvement. A similar effort was mounted for the Domiciliary Care for Homeless Veterans program with similar long-term post-treatment results. These data have been published by NEPEC in leading medical journals.

After establishing the effectiveness of these standard programs with extensive follow-up studies, VA developed several enhancements to the core program in several areas. These areas include compensated work therapy (CWT), outreach to assure access to Social Security Administration (SSA) benefits, and a collaborative program with HUD that joins VA case management with HUD section 8 housing vouchers. Outcome studies demonstrated the long-term effectiveness of the CWT/TR program at reducing substance abuse and increasing employment. The Joint VA-SSA outreach effort conducted in New York City, Brooklyn, Dallas, and Los Angeles almost doubled the percentage of SSI awards made to veterans from 7.19 % to 12.4 % of the veterans contacted during the outreach effort.

An outcome study showed that, compared to a control group that did not receive benefits, SSA beneficiaries had improved housing and overall satisfaction with life as a result of their receipt of benefits. The outcome of the study also showed no increase in substance abuse, with the exception of tobacco use for SSA recipients. A follow-up study of the HUD-VA supported housing program shows that the benefits of this program, especially housing stability were sustained three years after program entry. This is one of the longest follow-up studies conducted on any homeless population anywhere.

All of our homeless initiatives and programs receive rigorous evaluation. VA uses a consistent set of clinical measures for the Homeless Providers Grant and Per Diem Program as with all other VA homeless veterans programs to assure that valid comparisons can be made. VA performance measures provide consistency in evaluating homeless programs.

In FY 2000, VA is expanding its evaluation of homeless veterans programs to more thoroughly determine the effectiveness of these programs. Sec. 904 of the Veterans Millennium Health Care and Benefits Act (P. L. 106-117) requires VA to conduct evaluations of its homeless veterans programs. This is to include measures to show whether veterans for whom housing or employment is secured through one or more of VA’s programs continue to be housed or employed after six months. The General Accounting Office (GAO) made a similar recommendation in its April 1999 Report entitled, Homeless Veterans: VA Expands Partnerships, but Homeless Program Effectiveness is Unclear. GAO’s single recommendation to VA was to conduct … "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."

Through these ongoing and new program evaluation efforts, VA expects to increase our knowledge about the effectiveness of services that are provided to assist homeless veterans. Information will be used to modify and improve our programs for homeless veterans.

Conclusion

VA health care services and other benefits programs form the core elements for the wide range of medical, work therapy, rehabilitation, transitional housing and benefits programs, VA offers to homeless veterans. With assistance from community-based service providers and veterans service organizations, we are bringing thousands of veterans off the streets and into a continuum of care that offers them the health care and support services they need to resolve their health, housing and vocational problems.

The Department of Veterans Affairs is proud of its past contributions to homeless programs and is committed to enhancing the Nation’s understanding of risk factors which contribute to this problem, to work towards reduction of homelessness among veterans and to providing high quality programs for homeless veterans.

I would be pleased to answer any questions the committees have at this time.