VA Cuts Homelessness, SDOH by 55% with Housing First Model

The Veterans Health Administration (VHA) was able to reduce homelessness by 55 percent over a 13-year period, demonstrating the power of integrating social determinants of health interventions into the healthcare setting, researchers wrote in JAMA Network Open.

The intervention, which flagged veteran patients for housing instability, rehoused them, and provided case management and wraparound healthcare, was more effective at reducing homelessness than usual care in the general population, the team added.

These findings come as the entire healthcare industry looks at solutions to a homelessness problem that can exacerbate healthcare access and clinical issues. Homelessness affected some 653,000 individuals on a single night in the US in 2023, according to the Department of Housing and Urban Development. For veterans, that figure was around 35,000, HUD said.

Housing insecurity is a key social determinant of health (SDOH) targeted by healthcare organizations due in part to its impacts on health access and outcomes and the tangible—albeit sometimes out-of-reach—solution to the problem. This latest study assessed a housing insecurity intervention at VHA, noting that pairing a housing-first model with care coordination and wraparound care is effective at addressing the SDOH.

The model in question, titled the Ending Veteran Homelessness initiative, was an iteration of existing VA programming for permanent supportive housing. Hallmarks of the initiative included:

• Outreach and engagement services
• Homelessness prevention
• Emergency and transitional housing
• Expanded and tailored physical, mental, and substance use disorders care
• Access to other SDOH interventions

VHA said it accomplished these initiative keynotes through a housing-first policy and by leveraging partnerships with other federal agencies, state and local governments, community agencies, and community health partners.

Overall, the program was successful.

The researchers looked at how the VHA housing program worked by counting the number of unhoused veterans at the start of the program, the number of housing vouchers handed out in partnership with HUD, the number of community grants awarded by Support Services for Veterans and Families, and total number of veterans housed each year.

In the years during which the VHA housing program was in operation, the number of unhoused veterans decreased by 55.3 percent. This compares to an 8.6 percent decrease in unhoused individuals within the general population.

The researchers credited this decrease to the housing-first agency policy VHA adopted, which reduced barriers to housing, but they noted that improvements were more nuanced than just getting veterans in homes.

“This was shown in comments that housing first was not intended to be housing only and that the availability of wrap-around services provided by VHA medical centers needed to be actively incorporated into the community housing model,” the team wrote in the study’s results section.

“The VA invested substantial resources in the development and expansion of case management support services, substance use disorder treatment, mental health services, and general medical care programming to veterans to provide the wrap-around care and supports needed once housed,” they added in the discussion.

Of course, VHA being a federally funded healthcare system, there were certain enablers that helped the program thrive. For one thing, it can be easier to cultivate enthusiasm around ending veteran homelessness than ending homelessness in the general population. VHA had public perception on its side.

What’s more, VHA is expansive. This means it has the infrastructure to support sophisticated population health management programs, as well as the wraparound care, case management, and social services necessary to support the housing first model.

Despite these unique advantages, the researchers stressed that lessons can be learned from this model in other sectors of the healthcare industry.

“This dynamic is not always present in private sector health systems, which as noted in the literature, can greatly challenge their ability to effectively intervene in a social determinant of health,” they concluded.

“However, these factors should not be construed to suggest that implementation of an initiative addressing homelessness is only possible in a federally funded, integrated health system. Academic health centers and community health systems have also successfully worked in this area.”