Homelessness Among Veterans of Recent Conflicts:

A Webinar

April 18, 2013

• This training is supported by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the U.S. Department of Health and Human Services (DHHS).

• The contents of this presentation do not necessarily

reflect the views or policies of SAMHSA or DHHS. The training should not be considered a substitute for individualized client care and treatment decisions.

Slide 3

Participants

• Moderator A. Kathryn Power, M.Ed., SAMHSA • Stephen Metraux, Ph.D., National Center for

Homelessness Among Veterans • Stephen Peck, M.S.W., U.S. Veterans Initiative • Susan Angell, Ph.D., U.S. Department of

Veterans Affairs

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Learning Objectives

Participants will gain a better understanding of: • The differences between this generation of Veterans

and those from earlier conflicts; • The risk factors for Veteran homelessness; • The scope of the issue; • Some of the practices that are working well for these

Veterans; and • The role of the U.S. Department of Veterans Affairs

in effective solutions.

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Veterans of Recent Conflicts

• An estimated 62,619 Veterans are homeless in the U.S. on a given night.

• About half of the Veterans experiencing homelessness have some sort of disability.

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Veterans of Recent Conflicts

• Veterans of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New Dawn (OND) have high rates of PTSD and TBI.

• The impact on families can be enormous. Slide 7

Veterans of Recent Conflicts

• Half of homeless Veterans have been involved with the legal system;

• 9.3 percent of people in jail are Veterans; and

• Approximately 20 percent of jailed Veterans are homeless prior to incarceration.

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Today’s Discussion

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Risk Factors for Homelessness Among Veterans of the Iraq

(OIF) and Afghanistan (OEF) Era

Stephen Metraux, Ph.D. s.metraux@usciences.edu

Slide 10

1. Media/Advocates 2. Research 3. Findings from the National Center

on Homelessness Among Veterans (NCHAV),Veterans Affairs Office of the Inspector General (VA OIG)

11

Risk Factors

Slide 11

Swords to Plowshares

• After Vietnam, it generally took 9 to 12 years for Veterans’ circumstances to deteriorate to the point of homelessness.

• OIF/OEF Veterans are already seeking housing services, some just months after returning from Iraq. They stand at the precipice of chronic homelessness unless there is a concerted effort to address their needs.

• Approximately 600 Iraq Veterans have sought homeless healthcare services from the VA. The high incidence of PTSD and traumatic brain injury will contribute to increased chronic homelessness unless proactive measures are taken to mitigate the trend… Veteran service providers and advocates are struggling to improve access to benefits and services, but the conditions of the Iraq war, coupled with limited capacity and resources, present considerable challenges. (Fairweather, 2006)

Iraq Veteran Project

Slide 12

Surge Seen in Number of Homeless Veterans Erik Eckholm (November 8, 2007)

… “Experts who work with Veterans say it often takes several years after

leaving military service for Veterans’ accumulating problems to push them into the streets. But some aid workers say the Iraq and Afghanistan Veterans appear to be turning up sooner than the Vietnam Veterans did.”

… “With more women serving in combat zones, the current wars are already resulting in a higher share of homeless women as well.”…

… “Special traits of the current wars may contribute to homelessness,

including high rates of post-traumatic stress disorder, or PTSD, and traumatic brain injury, which can cause unstable behavior and substance abuse, and the long and repeated tours of duty, which can make the reintegration into families and work all the harder.”…

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Iraq and Afghanistan Veterans of America

“As the national housing crisis deepens, these numbers may be just the beginning. Iraq and Afghanistan Veterans are already turning up on the streets much faster than other generations of Veterans, often within 18 months of coming home. And over time, the signature wounds of the current conflicts—psychological wounds and traumatic brain injuries—may contribute to higher rates of homelessness.”

(Williamson & Mulhall, 2009)

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Rosenheck and Colleagues

• No strong links between combat exposure (including PTSD) and Veteran (all eras) homelessness

• “It appears that the personal risk of homelessness among Veterans was due primarily to the same factors as homelessness among other Americans—poverty, joblessness, mental illness, and substance abuse.”

Slide 15

Blackstock and Colleagues

• 1.8 percent of 445,000 Veterans in OEF/OIF roster file had a record of VA homeless services use.

• Factors associated with elevated risk for homeless services use included: o A range of socioeconomic and demographic

factors (lower educational attainment, black race, Hispanic ethnicity, unmarried, enlisted rank, urban location); and

o A disability rating and range of behavioral health diagnoses, including PTSD.

Slide 16

Edens and Colleagues

• 10 percent of 1.1 million Veterans from all eras who received VA mental health services in 2009 were identified as “homeless” based upon VA records. —Only 4 percent of the OEF/OIF Veterans in this group were so identified.

• This study found significant, protective associations with having a service-connected disability rating and PTSD diagnosis.

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http://www.va.gov/oig/pubs/VAOIG-11-03428-173.pdf

For Further Reading

Slide 18

LC Database

A population of all (half million) service members discharged from active military service between July 1, 2005 – September 30, 2006

• Details from 10/1/2001 to 9/30/2010 • Over 50 files from DoD and VA sources • Continued longitudinal follow-up

10/1/2001 7/1/2005 9/30/2006 9/30/2010

Separation from military DoD/VA info VA/DoD info

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• 5,694 of 310,685 Veterans - records of homelessness

• 1.8 percent of Veterans • 5-year incidence rate of 3.7 percent

20

Incidence of Homelessness

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TBI and Behavioral Health Diagnoses

Total Homeless Hazard Ratio

N 310,685 5,574 Traumatic Brain Injury 1.0% 3.0% 1.30** Any Behavioral Health Disorder 17.8% 43.8% PTSD 2.4% 9.3% 1.13* Adjustment disorders (not PTSD) 5.2% 17.2% 1.52*** Anxiety disorders 3.6% 11.1% 1.12* Mood disorders 5.9% 20.0% 1.61*** Major depression 2.3% 8.5% non-sig. Personality disorders 1.6% 7.5% 1.37*** Psychotic disorders 0.3% 2.9% 2.13*** Substance-related disorders 3.3% 17.7% 1.94***

21 Slide 21

Gender and Military Service Characteristics

Total Homeless Hazard Ratio

N 310,685 5,574

Female 15.2% 15.4% non-sig.

OEF/OIF Deployment 55.1% 65.0% 1.34***

Military Pay Grade E1-E4 44.1% 72.4% reference

E5–E9 43.4% 25.5% 0.37***

O1–O3 5.2% 1.1% 0.18***

O4–O10 6.0% 0.7% 0.10***

Character of Discharge

Honorable 90.6% 90.1% reference

BC/Dishonorable 0.5% 3.3% 4.52***

Other than Honorable 0.0% 0.2% 2.95***

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Key Findings

• OEF/OIF deployment associated with a higher risk for subsequent homelessness (OR=1.3)

• PTSD associated with higher risk for homelessness only in OEF/OIF deployed Veterans • (OR=1.2 [males] and OR=1.6 [females])

• Pay grade had strongest association with homelessness (44 percent in lowest pay grade accounted for 72 percent of homeless)

• No risk differential associated with gender • Mixed evidence of TBI as a risk factor • 18 percent diagnosed with some type of behavioral health

disorder, comprising 44 percent of homeless Slide 23

Implications

• OEF/OIF and PTSD-related risks a modest but important finding

• Prototype of procedure to identify Veterans at homelessness risk at separation

• Starting points for prevention targeting Veterans in lowest pay grades and behavioral health diagnoses

• “Upstream” factors and more precise and extensive data can hone these factors

• Combination of data-based assessments with homeless screener

24 Slide 24

Veterans of Recent Conflicts

Stephen Peck, M.S.W. United States Veterans Initiative (U.S. VETS) Slide 25

Emerging Issues, OIF/OEF Vets

• More than 2 million men and women have served in Iraq and Afghanistan.

• As many as 30 percent have returned with TBI, PTSD, and other emotional wounds that threaten to disrupt their lives.

• More than half of all Afghanistan and Iraq war Veterans treated by the VA received care for mental health problems.

Slide 26

Emerging Issues, OIF/OEF Vets

• More than 35 percent of post-9/11 Veterans in L.A. County, where we are headquartered, have employment that provides less than a sustainable income level.

• The poverty rate for the youngest Veterans, the 18-24 year olds, is 21.3 percent.

• 25 percent of L.A. County’s post 9/11 Veterans are rent-burdened, which means they spend 30-50 percent of their incomes on rent. Another 12 percent are severely rent-burdened, spending more than half their income on rent.

Slide 27

Emerging Issues, OIF/OEF Vets

• The divorce rate among enlisted female soldiers is triple than that of their male counterparts, which is at 9.4 percent.

• With the war winding down, hundreds of thousands of service members will be returning and looking for work in an already weak civilian economy.

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Homelessness Among Veterans of Recent Conflicts

• 158 Veterans of the wars in Afghanistan and Iraq entered U.S.VETS’ transitional programs during FY2012. This total represents 10 percent of new program entries.

• 91 female Veterans entered U.S.VETS’ transitional programs during FY2012. This total represents 6 percent of new program entries.

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U.S.VETS Response to Need

1. ADVANCE Program for Female Veterans 2. Veterans Reentry Project 3. Outside the Wire 4. Career Development Initiative 5. Support Services for Veterans Families

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ADVANCE Program

Five tracks for women:

1. Substance abuse treatment 2. Career development 3. Life skills 4. Renew - sexual trauma treatment , in

partnership with the Long Beach VA Medical Center

5. Women with Children Slide 31

Veterans Re-entry Project

100 percent have PTSD, which has contributed their homelessness. Three distinct programs to address their specific needs: • Skill Building Track • Education Track • Work Track

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Homeless Prevention

Outside the Wire • Early-intervention and prevention program • Confidential individual and group counseling • Other OIF/OEF vets used for outreach to gain their trust • Partnerships with six community colleges, VRCs • Inclusion of families and children linkage to housing and

employment resources • Education to faculty and staff about military life • Partnership with USC

Forthcoming article: Community-based outreach and early intervention with returning Veterans - InterSections in Practice, NASW– Todd Adamson, Psy.D.; Jan Nissly, Ph.D., LCSW

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Homeless Prevention

Career Development Initiative • Works closely with Outside the Wire • Receives support from Corporate America • Partners with the National Guard in CA • Offers virtual employment assistance - placements at

all 11 sites

Supportive Services for Veteran Families • Homeless Prevention and Rapid Rehousing • Rental assistance, employment assistance,

counseling, childcare, transportation • Affordable Housing

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U.S. Department of Veterans Affairs

Dr. Susan Angell, Executive Director Homeless Veterans Initiative Office

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Agenda: Where are We Now?

• VA Programs o Grant and Per Diem (GPD)/Domiciliary

Care for Homeless Veterans (DCHV) o Housing and Urban Development/VA

Supportive Housing (HUD/VASH) o Supportive Services for Veteran Families

(SSVF) • VA Outreach

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Where are We Now?

Committed to ending Veteran homelessness by the end of 2015

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The 2012 Annual Homeless Assessment Report Point in Time count estimated there were 62,619 homeless Veterans in the U.S. on a single night in January 2012.

• 7.2 percent decline since 2011

• 17.2 percent decrease since 2009

• Number of sheltered homeless Veterans decreased by 12.2 percent from 2011 to 2012

• Count of unsheltered homeless Veterans in the U.S. remained virtually unchanged

Where are We Now?

Slide 38

Veterans Served Through VA Programs

VETERANS HEALTH ADMINISTRATION HOMELESS VETERAN PROGRAM DATA FY11 FY12 FY13 Q1

TOTAL # SERVED IN SPECIALIZED HOMELESS OR AT-RISK PROGRAMS (Includes VBA and other programs that code homeless Veterans) 198,932 228,047 147,347TOTAL # SERVED IN SPECIALIZED HOMELESS OR AT-RISK PROGRAMS 157,202 189,146 123,172# SERVED NEW TO VA SERVICES IN THE PAST 2 YEARS 107,031 118,369 41,077# CONTACTED THROUGH OUTREACH (Uniques) 98,094 111,221 52,411# HOMELESS VETERANS ASSESSED 66,270 87,495 24,333# OF CHRONICALLY HOMELESS VETERANS ASSESSED 22,355 30,265 7,581% OF VETERANS ASSESSED WHO WERE CHRONICALLY HOMELESS 34% 34% 31%HOMELESS STATUS AT TIME OF ASSESSMENT % LITERALLY HOMELESS 61% 62% 62% % IMMINENT RISK FOR HOMELESSNESS 9% 10% 10% % UNSTABLY HOUSED 13% 12% 12% % STABLY HOUSED 13% 14% 14% % NOT ANSWERED 4% 2% 2%PREVENTION * TREATMENT * HOUSING Slide 39

Grant and Per Diem(GPD) and Domiciliary Care for Homeless Veterans (DCHV)

GPD: Grants to community-based agencies to create transitional housing programs • 600 funded projects and over 14,000 beds nationwide • In fiscal year 2012, 12,232 Veterans housed through GPD programs

DCHV: Rehabilitation in a residential setting on VA medical center grounds or in the community • Eligible Veterans who have a wide range of problems, illnesses, or

rehabilitative care needs, which can be helped by medical, psychiatric, vocational, educational, or social services

• More than 2,300 beds at 44 sites • Residential treatment to over 8,000 Veterans who

are homeless each year

Transitional solutions and residential rehabilitation

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Grant and Per Diem (GPD) and Domiciliary Care for Homeless Veterans (DCHV)

Slide 41

FY13 Veterans Discharged from GPD and DCHV to Independent Housing Arrangement

Discharged Discharged to Housing October 2,165 1,382 November 2,018 1,300 December 1,738 1,150 January 1,681 1,023 February 1,741 1,089 FY 13 YTD 9,343 5,944

HUD/VASH

• This is a joint effort between the Department of Housing and Urban Development.

• The program provides permanent housing with dedicated case management.

• In FY 2012, 11 percent of Veterans receiving HUD–VASH assistance were women.

• In FY 2012, 14 percent of HUD–VASH vouchers were provided to homeless Veterans with children.

HUD-VA Supportive Housing (VASH) Program

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HUD/VASH

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Date

Total Active

Vouchers Allocated by HUD

Current Veterans

Under Lease

(Actual)

REMAINING VOUCHERS Veterans Provided

Vouchers and in Process of

Securing Housing

Veterans referred to

PHA but not yet issued a voucher

Vouchers Currently

in Use

Vouchers Available for Use

30-Oct-12 47,987 38,514 4,780 1,059 44,353 3,636 28-Nov-12 48,089 39,233 4,519 1,061 44,808 3,279 26-Dec-12 48,089 40,034 4,033 994 45,056 3,033 30-Jan-13 48,089 40,730 3,729 1,072 45,526 2,563 27-Feb-13 48,101 41,366 3,563 1,010 45,905 2,196

• SSVF was authorized by Public Law 110-387 Section 604 of the Veterans’ Mental Health and Other Care Improvements Act of 2008.

• The VA awards grants to non-profit organizations and consumer cooperatives that can provide supportive services to very low-income Veteran families living in or transitioning to permanent housing.

• Priority is given to Veteran families with significant barriers to housing, such as having an income below 30 percent of the area median income (AMI), which was 75 percent of all households served.

Available SSVF resources: FY 2012, $60 million; FY 2013, $100 million; FY 2014, $300 million

SSVF: Supportive Services for Veteran Families

Slide 44

• Prevention: assists those at imminent risk for homeless to maintain their housing.

• Rapid Rehousing: assists those who are homeless or exiting temporary or transitional housing rapidly reconnect to permanent housing.

• Services are flexible but must include case management and capacity to provide:

• Grantees may also provide time-limited payments to third parties (e.g.,

landlords, utility companies, moving companies, and licensed child care providers) if these payments help Veteran families stay in or acquire permanent housing on a sustainable basis.

Two Critical Foci of SSVF

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SSVF Results

• The first year served approximately 21,000 Veterans and a total of 35,363 participants.

• 8,826 children were assisted. • Of the 21,393 Veteran participants, 3,285 are women (15.4

percent of Veterans served). • 3,335 Veteran participants are Operation Enduring

Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) (15.6 percent of Veterans served).

• Approximately 85 percent of those discharged from SSVF exited into permanent housing.

• An additional 9.4 percent (1,952 participants) are off the streets in temporary or institutional settings.

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Outreach Materials

http://www.va.gov/homeless/materials_center.asp Slide 47

Outreach Results

Slide 48

• In its first year of operation, the call center received roughly 10,000 calls; today it receives nearly 10,000 per month.

• Between fiscal 2011 and 2012, total calls increased by 123 percent—from 36,090 to 80,558.

• Calls from Veterans at risk of becoming homeless increased by 128 percent. • Referrals to VA programs increased by 133 percent. • In the first quarter of fiscal 2013, calls are up 83 percent from last year.

36,090

8,683

20,750 21,763

80,558

14,386

47,231 50,608

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

90,000

Total Calls Calls from VeteransWho Are Homeless

Calls from Veterans AtRisk of Homelessness

Calls YieldingReferrals to VA

Programs

FY11

FY12

Increased calls to the National Call Center for Homeless Veterans (NCCHV)

How to Help: We all have a role to play

• Anyone can help. If you know a homeless person, “Make the Call.” Help them call the National Veterans Hotline (1-877-4AID VET).

• Refer an eligible war-time Veteran to a VetCenter. o Program – Provides a broad range of counseling,

outreach, and referral services to eligible Veterans in order to help them make a satisfying post-war readjustment to civilian life.

o Eligibility – War zone Veterans of all eras and their families

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PTSD 101: http://www.ptsd.va.gov/professional/ptsd101/course-modules/traumatic-brain-injury.asp

Examines the functional anatomy of emotion, memory, and behavior circuits, using graphics and figures. The author discusses types of injuries and common functioning deficits, as well as prevalence rates of TBI in OEF/OIF Veterans. A discussion of PTSD and TBI is also provided, as well as an overview of assessment and treatment.

Learn more about VA programs at http://www.va.gov/homeless.

How to Help: We all have a role to play

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Discussion

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Presenter Contact Information

Kathryn Power • Kathryn.Power@samhsa.hhs.gov Stephen Metraux, Ph.D. • S.Metraux@usciences.edu Stephen Peck, M.S.W. • SJPeck@usvetsinc.org Dr. Susan Angell • Susan.Angell@VA.gov

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