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o : MITCH MIRKIN: Hello. This is Mitch Mirkin with VA Research Communications. Welcome to Voices of VA Research. Today, Im going to be speaking with Dr. Anne Elizabeth Montgomery on the topic of veteran homelessness. Dr. Montgomery is at the Birmingham VA Medical Center and the University of Alabama at Birmingham. Shes been an investigator with VAs National Center on Homelessness Among Veterans since the start of that program in 2009. Between 2012 and 2016, she was also an investigator with the VA Center for Health Equity Research and Promotion. Prior to her VA career, she had served as a volunteer at a homeless shelter and a domestic violence center and worked at the New York City Department of Homeless Services. Her educational background is in social work, public policy, and public health. She holds degrees from the University of Alabama at Birmingham, Columbia University, and Boston College. Im going to talk with Anne Elizabeth Montgomery about some of her recent work on homelessness among veterans, particularly a study that came out in January 2019 that was titled Veterans Assignment to Single-Site Versus Scattered-Site Permanent Supportive Housing. Anne Elizabeth, welcome to Voices of VA Research.
DR. ANNE ELIZABETH MONTGOMERY: Thanks for having me.
MIRKIN: Nowadays, when we talk about housing, permanent housing for transitioning homeless veterans to some form of permanent housing, I know a big part of that with the veteran population is whats called the HUD-VASH program, and its an acronym that stands for Housing and Urban Development-VA Supported Housing--HUD-VASH. And if you could, just in a nutshell, tell us a little about that program--what it aims to do, how long its been around, and generally whether its regarded as an effective program for this population of veterans.
MONTGOMERY: OK, so HUD-VASH has actually been around since the nineties, but there are very few vouchers then, and its really ramped up since about 2008. So my numbers may not be exact, but theyre probably between 90,000 to 95,000 vouchers that are funded throughout the country. So, basically, what HUD-VASH does is, HUD provides Housing Choice Voucherswhat we used to call Section 8 vouchers. And the VA provides supportive services, case management, and, you know, healthcare--all sorts of other services for veterans. So thats how it becomes permanent supportive housing. So the voucher is permanent, and veterans either can take that voucher and look for private market rental apartment or what we call scattered-site apartments that are just located in the community, and basically they only have to pay 1/3 of their income toward rent. The voucher pays for the rest of it. They also--there are some programs throughout the country that are called project-based programs, where the vouchers actually sort of stay with the unit. So there could be a building that has multiple units, and veterans can choose to move into that unit or move out of that unit. When a veteran moves out, the units then vacant and the vouchers open again and another veteran can move in. So, HUD-VASH is a type of permanent supported housing. Its the largest permanent supportive housing program in the country, and its basically intended for veterans who have experienced homelessness and need additional support maintaining housing. So its really for people who need help to stay in the housing, to access the housing, who may need help with other, you know, medical conditions. Often, sort of in the most strictest sense, permanent support housing is for people with a history of homelessness and a disabling condition. The VA program is a little different because its so large and it also would be a priority for newer veterans or other veterans of more recent conflicts, for families. HUD-VASH is very effective at helping veterans to maintain housing stability. Thebasically--studies that have been done on permanent supportive housing programs, over the years, and not just VA programs, have found about an 85%--that 85% of people who move into these programs are able to maintain their housing for a year or more. So HUD-VASH is right along those lines in terms of veterans being able to maintain housing stability. And then theres other--one other thing I think is important to note is that HUD-VASH takes the Housing First approach to housing. So veterans are not required--if they have substance use issues and they have mental health issues or medical issues, theyre not required to sort of fix those issues before they move into housing. They dont have to be housing-ready. The underlying philosophy is that once someone gets into housing, thats a platform from which they can, you know, sort of live a healthier life, fuller life, they can address their goals. So its really, you know, intended for veterans to, you know, sort of have this platform of housing stability and then be able to sort of address other issues with the support of sort of the VA half of the equation.
MIRKIN: Right. So it sounds like the HUD-VASH program integrates very well with the whole Housing First philosophy and movement.
MONTGOMERY: Yes.
MIRKIN: You mentioned 1-year outcomes as a sort of benchmark. What about longer-term? And before we get into your specific study, just talking about HUD-VASH in general. What about longer-term over 3 years, 5 years? What tends to be the scenario with these folks who do move into these units? Do they tend to stay there well beyond one year? Do they eventually move out of these HUD-VASH units into some type of mainstream housing in the community?
MONTGOMERY: You know, they do both. So when we talk about mainstream housing, the HUD-VASH scattered-site vouchers, which are the majority of the vouchers, it is mainstream housing. Its just a regular old apartment in a community.
MIRKIN: OK.
MONTGOMERY: It just happens to be subsidized. The rent is subsidized. So I dont have right in front of me sort of longer-term outcomes. We did do a pretty extensive study about exits from HUD-VASH. And we found that, you know, the proportion of veterans who stay over time obviously decreases as the time goes by. We found that veterans leave the program for a lot of reasons. Some are really positive. They get a job and their income increases. So theyre no longer eligible for the vouchers, and they can afford their own rent. And they may be able to stay in that same apartment. Theyre just not receiving the voucher. They may reunite with family. But then, you know, theres also reasons why they may leave the program that arent so great. You know, there may be evictions, there may be, you knowa veteran may be incarcerated--just like anyone else entering or exiting a program.
MIRKIN: Sure. And I should ask a similar question about the Housing First approach. In other words, not focusing on the HUD-VASH program, but when we look at the whole Housing First approach, has that been supported by research? In other words, have there been studies showing that when we indeed do take a Housing First approach that these once homeless men and women do, in fact, have more success in recovering from perhaps substance use issues or achieving some better degree of recovery with their mental health issues? Does the Housing First approach, in fact, seem to lead to better outcomes than previous models?
MONTGOMERY: So, there have been both approaches and definitely been studied over maybe 20 years in lots of different programs. And its hard because all programs look a little different. And theres actually a group at the CDC thats doing a really in-depth systematic review of all of this to answer exactly the question that youre asking. I think that consistently studies have found that housing tenure improves with Housing First. We found this in the HUD-VASH program after the transition to Housing First. There were better housing outcomes in terms of mental health outcomes, reintegration into the community, substance use disorder, those sorts of outcomes. Its kind of mixed. In the VA, we have found some promising outcomes related to like accessing acute care, acute healthcare, like emergency departments. So sometimes when veterans have, you know, permanent housing but also supportive services, theyre able to, you know, do more sort of preventive ambulatory care as opposed to accessing emergency departments. But I think the jury may be still out on the other types of outcomes. But I think, you know, at the end of the day it is a housing program and the objective is for people first and foremost to not be homeless, and its good at doing that.
MIRKIN: OK, Id like to talk a little bit about the specific study that you led with a group of folks from VA and some other institutions here. The title of the study was Veterans Assignment to Single-Site Versus Scattered-Site Permanent Supportive Housing. It was in the American Journal of Orthopsychiatry that came out in January online. So the main focus here was looking at that question of which veterans end up living through the HUD-VASH program in single-site housing--in other words, one site where there are multiple veterans living through this program--versus scattered-site housing, where the individuals are scattered throughout the community, one person here, one person there. Theyre not grouped together in a single location. So before you get into your findings, I know as part of the study, you did a literature review, looked at what any past studies had found comparing these two models. So can you briefly summarize in a nutshell what some of the advantages were that you saw in the literature to single-site housing versus scattered-site?
MONTGOMERY: Sure. And just--just to be clear, its called either single-site or project-based, and I referred to it as project-based housing earlier in our conversation. So if I go back and forth, those mean the same thing, but Ill try to call it single-site. But I think some of the advantages to single-site housing is that theres--you know, if you have a case manager who hasyou know, hes working with 30 people, and theyre spread throughout a large city, that takes a lot of time because theres a big focus on having home-based visits. Basically, I think you end up having a little more one-to-one interaction with services providers because they have more time because theyre also just in this one building. There, you know, in terms of--there may be a decrease in social isolation because youre living in a building where people who you may have similar interests with just by being veterans.
MIRKIN: Yeah.
MONTGOMERY: For example, on the other hand, you know, some research has found that it can be isolating in a different way because you may not feel part of the mainstream community. These programs are really supposed to be just like permanent supportive housing, just like if you were in a scattered-site unit but just grouped together. So it shouldnt feel like an institution oryou know, its supposed to be independent living. I think what we found isnt necessarily from the literature review, but just sometimes people with greater needs may do better there because theyre, you know, typically if not 24/7 staff present at least-- definitely staff more present than would be in your own apartment.
MIRKIN: Right.
MONTGOMERY: So I think theres a number of pros and cons.
MIRKIN: Yeah, and as part of the study, you did focus groups with professionals who provide services with VA at 10 of these single-site programs in 10 different cities. And Im just curious what you heard in those focus groups from these professionals. Did it basically mesh with what the literature had reported? Did you hear anything surprising that didnt seem to jive with what previous studies had found in terms of the potential benefits and downsides of single-site?
MONTGOMERY: I mean, what we heard was pretty consistent, and we also spoke with veterans, but we didnt publish that data.
MIRKIN: OK.
MONTGOMERY: But weahem--we heard a lot about single-site programs are really useful for veterans who may have a history of eviction or history of a felony offense and just cant find anywhere else to rent a place. No other landlord is willing to rent them because they seem like a high-risk tenant. We also heard about--really these are sort of pros, I think, from the program perspective about single-site housing. We heard that there are--we visited some really expensive communities. And the only way you can--you almost cant even use a housing choice voucher anywhere in the city. So the only way you can really live in the city is in one of these programs. We also heard about the utility of these programs as sort of a stepping stone to something more independent. So, for example, if a veteran really wants an apartment in a certain neighborhood but there are none at the moment that he or she can afford or that are willing to take a housing choice voucher, they may move into, you know, the project single-site program and then sort of get a different type of voucher later and move in to other types of housing. So it can be kind of like a stepping stone to the type of housing that they would like. And then the final thing that we really heard about sort of the utility of these programs is for veterans who are aging or who may be sick and need--and dont need to be in a nursing home but just need a little bit more support than they would get just living in a single--a scattered-site unit that these programs are really useful for that demographic.
MIRKIN: So are these typically in neighborhoods and cities that are considered, you know, quiet, safe neighborhoods, not typically neighborhoods where you would see homeless folks living on the street, or do they tend to be in more sort of urban areas where youre in proximity to some of the same areas where these folks mightve been living homeless?
MONTGOMERY: Yeah, so thats a great question. So the answer is both. And, you know, we heard a lot about programs where if the programs located on skid row, its very--theres interesting challenges that come with that. There can be issues around drug dealing, prostitution, that kind of stuff. So the street sort of moves into the building to some degree. Theres also--we visited a program that was not quite suburban, but you know, wasnt in the downtown, wasnt where all these resources were. So I think theres pros and cons of both because if someone has been living in, lets say, the core downtown area and theyre kind of moved up to the suburbs where they dont know anyone, theyre far from their doctor, you know
MIRKIN: Could be a problem.
MONTGOMERY: It could be a problem, you know, if they dont drive. At the same time, you know, if youre wanting to get into permanent housing, work on, for example, like substance abuse issues and your old drug dealer is down the block, that also can be a problem, too.
MIRKIN: Right.
MONTGOMERY: So I think having the program in different--in sort of a nice, White neighborhood is useful. Having them downtown is useful. I think it just depends on what the veteran preference is. But I would say--and even in some neighborhoods, you know, they were in kind of transitioning neighborhoods, where that was where the agency was able to get a building 5 or 10 years ago, and now, you know, its sort of an up-and-coming area. So theres just really a lot of variety.
MIRKIN: Interesting. So, and the buildings that you mentioned that are constructed specifically to serve this purpose, are they built by the--by the HUD program, or are they built by the local government? How is that
MONTGOMERY: That is really, really complicated. And Imall I can tell you is that a lot of people and a lot of time goes into there, because, you know, youre dealing with your local public Housing Authority who gets the vouchers from the Federal Government. You have to have some sort of developer. So its kind of
MIRKIN: Sort of a mix of public and private
MONTGOMERY: Exactly. In a lot of places, theyll try to get tax abatements, so its kind of mix of public and private and also local, state, and federal funding. And there are--weve met some people who say--who, basically, thats become their job.
MIRKIN: So I want to get a little into the question of this social bonding that might occur among these veterans. Lets say you have a property, and there are, I dont know how many--typically 5, 10, 20 veterans living there in a single-site, all with their vouchers, all coming together to live under the same big roof, each in his or her own units. So what have you learned about the type of bonding that goes on? Now keeping in mind, that these are folks who have had their share of challenges. Theyre coming to the situation with a history very often of substance use, mental illness. So how does the social piece come together for them as they live together in the site?
MONTGOMERY: So, we heard about this sort of anecdotally through staff, and veterans talked about it a little bit, but there are some veterans who really want to be with other veterans. They feel like they have you know just have an important common understanding. So for some people, thats really a positive aspect of these single-site programs. But then we heard also from staff that like, for example, we discussed How often do you see the veterans during the program? How often do you meet with them? They would give us examples about how veterans would sort of take care of each other. The younger veterans kind of help out the older veterans. So, you know, I dont have necessarily specific examples of it, but just--and I think particularly in these mission-driven programs, where its a program for veterans, thats kind of the message that theyre gettingyou know, that like, Were here for you. Were here together.
MIRKIN: And does it seem to work out fine when its a mixed population at a single-site in terms of the issues that theyve been coping with? So lets say you have together a few veterans who may have schizophrenia. Theres people there who may be perfectly fine from a mental health standpoint but have really struggled with unemployment or what have you. Does it matter that they all kind of come together, each with their own issues? Or is there any potential benefit, do you think, to separating people based on the types of issues theyre dealing with?
MONTGOMERY: I dont think that theres a benefit of separating people based on the issues that they deal with. We did hear that there could be some really disruptive tenants. The one thing that we did hear about, and I mentioned it before is, you know, if theres someone who is really hoping to--you know, has a history of substance use disorder, is really hoping to stay clean and sober but there are other people actively using, which although you may not be able-- allowed to use in your unit, you can use outside and you can come home because its a Housing First approach. So its not absent. You know, you dont have to abstain from drugs. So that can be really problematic for some people. It can be really triggering if youre, you know, trying to stay clean and you can smell someone smoking crack next door. And thats kind of what we heard most frequently as sort of being an issue.
MIRKIN: So that could be one possible downside of the single-site model.
MONTGOMERY: Mm-hmm.Yeah.
MIRKIN: Interesting. And Im curious about the way VA provides services at these locations. So are there typically some common area where a VA staff member might set up shop and have a table or even a desk? Is that like a permanent fixture there? Would perhaps VA have a designated room within a building where they have the support staff, or the VA professionals go into the individual apartments to meet with the tenants?
MONTGOMERY: So it varies. My answer for everything.
MIRKIN: Right. Ha ha.
MONTGOMERY: So in the programs that are--that were set up to be HUD-VASH single-site programs, they typically have offices and meeting space in programs where, you know, lets say theres 100 units and theres 20 HUD-VASH units. There may be meeting space, but they can definitely meet in the veterans unit. A home visit is kind of a big piece of Housing First and permanent supported housing anyway. Thats reasonable. So in most programs that we would do, either there was space, or if there wasnt, they just, you know, met with the veteran in his or her unit.
MIRKIN: OK. But its definitely--you didnt see any barriers to care being delivered because of a lack of appropriate meeting spaces?
MONTGOMERY: No. I mean if there were barriers, maybe to exactly the kind of care that they ideally in a perfect world would deliver because of meeting space, but thats, you know, thats always the case. And then theres the tension between how many services you bring into the building, because its supposed to be someones home, not a
MIRKIN: Right. A clinic.
MONTGOMERY: Or a clinic. Exactly. So theres a little tension around that issue anyway.
MIRKIN: OK. Now there is something called domiciliary care. And that term maybe is not used much anymore. Now theres something called within VA the Mental Health Residential Rehabilitation and Treatment Programs. And Im curious about what the difference would be. Who would go into HUD-VASH, into some kind of supported housing, whether single-site or scattered-site, versus those who might go into these Mental Health Residential Rehab and Treatment programs?
MONTGOMERY: Mm-hmm. So these treatment programs are for that, are for treatment, and permanent supportive housing in HUD-VASH Housing First is for housing. You can access treatment if you need it, and it needs to be made available to you. And you have choice about, you know, any treatment that you decide to access, but treatment is not the ultimate goal. The ultimate goal is to end homelessness. The other issue is that permanent supportive housing is permanent. So even if youre in one of these single-site buildings, you get this voucher and as long as youre eligible for the voucher, as long as you meet your income eligibility, you continue to be a good neighbor, you can stay there. These other programs are time-limited. So theyre not--if youre homeless and you go into a domiciliary program, or youre homeless and you go into a residential treatment program, youre still homeless. When you go into HUD-VASH, youre housed.
MIRKIN: So there might be some overlap in terms of the population served, but each program has its own specific goals and structure.
MONTGOMERY: Mm-hmm, yeah, and I think theres probably quite a bit of overlap. You know, Ive met veterans or people who work at these programs who say, you know, a veteran may leave the program for a bit to go into one of these programs, but they feel like they need intensive, more intensive treatment.
MIRKIN: I see.
MONTGOMERY: So, yeah. So there can be kind of a back-and-forth depending on what the veteran needs.
MIRKIN: OK. But HUD-VASH--a success in HUD-VASH might be that the veteran stays there and basically just ages in place. And that veteran could be living in that apartment building or that house for many years, decades even, basically until he--for the rest of his life in some cases, I imagine.
MONTGOMERY: Yeah.
MIRKIN: Thats good. And is there any research yet on the outcomes of single- site versus scattered-site permanent housing? I know your study that was just published did not look yet at the outcomes. Is that something thats underway? Are you planning to do a follow-up study that would actually get into how the outcomes compare between the two models?
MONTGOMERY: We--yeah. So we actually just finished-- it came out last week, and I can send it to you--a research brief about homelessness among veterans. And what we did is we matched the veterans who were in single-site with veterans who are in scattered-site programs using administrative data. We matched them based on sort of the of their health needs, their mental health substance abuse to kind of likeyou know, here are veterans who are have a lot of needs. When they get into this program, what do their outcomes look like? And we actually found that veterans--there really were not very many differences in outcomes. We found that veterans in the single-site housing tended to more frequently leave the housing before they had been there for a year, which was not really surprising given that a lot of veterans use that housing as a stepping stone to sort of view other options and also that its a higher-need population. We also found that when they go into single-site housing, their use of primary care increases, which we see as sort of a positive outcome. We just--you know, based on the data that we have, just looking at medical record data, we didnt--we didnt see a lot of difference in outcomes. Granted, were very limited in the outcomes we could look at. We basically just looked at housing tenure and services used.
MIRKIN: Right. Now, in terms of tenure, you said that theres some trend toward leaving before the year with single-site. Correct? Is that a good thing or a bad thing? I guess it depends where theyre going to and why theyre leaving?
MONTGOMERY: Yeah. Yeah. And we werent able to access where they were going, but I kind of see it I think on the whole--I mean, obviously it depends for each individual veteran--on the whole, I get that didnt strike me as necessarily a bad thing. And just given, you know, what I learned by talking to people that it may be that veterans just found other options.
MIRKIN: Right.
MONTGOMERY: So, yeah, I think, like you said, we have to know where they went to really know.
MIRKIN: Right. So perhaps some follow-up research could dig down deeper and tease that out
MONTGOMERY: Right.
MIRKIN: OK, Anne Elizabeth, I want to thank you very much for having a conversation with us today about this very important issue of ending veteran homelessness and your group study on Single-Site Versus Scattered-Site Permanent Supportive Housing. So thanks for being here on Voices of VA Research.
MONTGOMERY: Yeah, well, thanks again for having me, and thank you for your interest in this topic.
MIRKIN: Youve been listening to Voices of VA Research. To learn more about VA research, visit HYPERLINK "http://www.research.va.gov" www.research.va.gov
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