Homeless Veterans Programs: Bed Capacity, Service, and Communication Gaps Challenge the Grant and Per Diem Program
Published: 2007-09-27T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: The Subcommittee on Health of the Committee on Veterans' Affairs asked GAO to discuss its recent work on the Department of Veterans Affairs' (VA) Homeless Providers Grant and Per Diem (GPD) program. GAO reported on this subject in September 2006, focusing on (1) VA's estimates of the number of homeless veterans and transitional housing beds, (2) the extent of collaboration involved in the provision of GPD and related services, and (3) VA's assessment of program performance.
section_title: What GAO Found
paragraphs: VA estimates that about 196,000 veterans nationwide were homeless on a given night in 2006, based on its annual survey, and that the number of transitional beds available through VA and other organizations was not sufficient to meet the needs of eligible veterans. The GPD program has quadrupled its capacity to provide transitional housing for homeless veterans since 2000, and additional growth is planned. As the GPD program continues to grow, VA and its providers are also grappling with how to accommodate the needs of the changing homeless veteran population that will include increasing numbers of women and veterans with dependents. The GPD providers we visited collaborated with VA, local service organizations, and other state and federal programs to offer a broad array of services designed to help veterans achieve the three goals of the GPD program--residential stability, increased skills or income, and greater self-determination. However, most GPD providers noted key service and communication gaps that included difficulties obtaining affordable permanent housing and knowing with certainty which veterans were eligible for the program, how long they could stay, and when exceptions were possible. VA data showed that many veterans leaving the GPD program were better off in several ways--over half had successfully arranged independent housing, nearly one-third had jobs, one-quarter were receiving benefits, and significant percentages showed progress with substance abuse, mental health or medical problems or demonstrated greater self-determination in other ways. Some information on how veterans fare after they leave the program was available from a onetime follow-up study of 520 program participants, but such data are not routinely collected. We recommended that VA take steps to ensure that GPD policies and procedures are consistently understood and to explore feasible means of obtaining information about the circumstances of veterans after they leave the GPD program. VA concurred and, following our review, has taken several steps to improve communications and to develop a process to track veterans' progress shortly after they leave the program. However following up at a later point might yield a better indication of success.

section_title: Letter
paragraphs: Thank you for inviting me here today to discuss the Homeless Providers  Grant and Per Diem (GPD) program, the largest program of its kind  administered by the Department of Veterans Affairs (VA). On any given  night in the United States, an estimated 750,000 people, including veterans,  are homeless and may sleep on the streets or in shelters. Veterans  constitute about one-third of the adult homeless population, and many  veterans who are not yet homeless may be at risk. To address the needs of  these homeless veterans, VA officials told us that through the GPD  program they fund over 300 grants to local agencies to house  approximately 15,000 homeless veterans over the course of a year at a cost  of about $95 million. The program is not designed to serve all homeless  veterans—it focuses on transitional housing and supportive services for  veterans who are most in need, including those who have had problems  with mental illness, substance abuse, or both.
My statement draws on GAO’s report on this program issued in September  2006 that reviewed (1) VA’s estimates of the number of homeless veterans  and transitional housing beds, (2) the extent of collaboration involved in  the provision of GPD and related services, and (3) VA’s assessment of  program performance. I have also included information we obtained in  following up on VA’s efforts to implement our recommendations.
In summary, VA reported in 2006 that about 196,000 veterans were  homeless and that not enough transitional beds were available through VA  and other organizations to meet the needs of homeless veterans eligible to  use this assistance. To help meet these needs, the GPD program has  quadrupled its capacity since 2000 to about 8,200 beds, and additional  growth is planned. In addition to increasing transitional bed capacity, VA  and its providers are also grappling with how to accommodate the needs  of the changing homeless veteran population that will include increasing  numbers of women and veterans with dependents. When we met with GPD  providers who operate the program and their local VA liaisons, we found  that they were working collaboratively with other organizations to deliver  supportive services, but most also noted key resource and  communications gaps. Specifically, providers reported difficulties finding  affordable permanent housing for veterans ready to leave the program. In  addition the eligibility rules for the GPD program were not always clear, a  fact that could cause confusion and could keep veterans from obtaining  needed care. VA data showed that many veterans were better off in terms  of housing; employment; receipt of public benefits; and progress with  substance abuse, mental health, or medical problems at the time they left  the program, but VA did not know how they were faring months or years  later.
We recommended that VA take steps to ensure that GPD policies and  procedures are consistently understood and to explore feasible means of  obtaining information about the circumstances of veterans after they leave  the GPD program. VA concurred and, following our review, has taken  several steps to improve communications and to develop a process to  track veterans’ progress shortly after they leave the program. However  following up at a later point might yield a better indication of success.
subsections: section_title: Background
paragraphs: The GPD program is one of six housing programs for homeless veterans  administered by the Veterans Health Administration, which also  undertakes outreach efforts and provides medical treatment for homeless  veterans. VA officials told us in fiscal year 2007 they spent about $95  million on the GPD program to support two basic types of grants—capital  grants to pay for the buildings that house homeless veterans and per diem  grants for the day-to-day operational expenses. Capital grants cover up to  65 percent of housing acquisition, construction, or renovation costs. The  per diem grants pay a fixed dollar amount for each day an authorized bed  is occupied by an eligible veteran up to the maximum number of beds  allowed by the grant—in 2007 the amount cannot exceed $31.30 per  person per day. VA pays providers after they have housed the veteran, on a  cost reimbursement basis. Reimbursement may be lower for providers  whose costs are lower or are offset by funds for the same purpose from  other sources.
Through a network of over 300 local providers, consisting of nonprofit or  public agencies, the GPD program offers beds to homeless veterans in  settings free of drugs and alcohol that are supervised 24 hours a day, 7  days a week. Most GPD providers have 50 or fewer beds available, with  the majority of providers having 25 or fewer. Program rules generally  allow veterans to stay with a single GPD provider for 2 years, but  extensions may be granted when permanent housing has not been located  or the veteran requires additional time to prepare for independent living.  Providers, however, have the flexibility to set shorter time frames. In  addition, veterans are generally limited to a total of three stays in the  program over their lifetime, but local VA liaisons may waive this limitation  under certain circumstances. The program’s goals are to help homeless  veterans achieve residential stability, increase their income or skill levels,  and attain greater self-determination.
To meet VA’s minimum eligibility requirements for the program,  individuals must be veterans and must be homeless. A veteran is an  individual discharged or released from active military service. The GPD  program excludes individuals with a dishonorable discharge, but it may  accept veterans with shorter military service than required of veterans  who seek VA health care. A homeless individual is a person who lacks a  fixed, regular, adequate nighttime residence and instead stays at night in a  shelter, institution, or public or private place not designed for regular  sleeping accommodations. GPD providers determine if potential  participants are homeless, but local VA liaisons determine if potential  participants meet the program’s definition of veteran. VA liaisons are also  responsible for determining whether veterans have exceeded their lifetime  limit of three stays in the GPD program and for issuing a waiver to that  rule when appropriate. Prospective GPD providers may identify additional  eligibility requirements in their grant documents.
While program policies are developed at the national level by VA program  staff, the local VA liaisons designated by VA medical centers have primary  responsibility for communicating with GPD providers in their area. VA  reported that in fiscal year 2007, there were funds to support 122 full-time  liaisons.
section_title: VA Has Expanded GPD Program Capacity to Help Meet Homeless Veterans’ Needs, but Demand Still Exceeds Supply
paragraphs: Since fiscal year 2000, VA has quadrupled the number of available beds  and significantly increased the number of admissions of homeless veterans  to the GPD program in order to address some of the needs identified  through the its annual survey of homeless veterans. In fiscal year 2006, VA  estimated that on a given night, about 196,000 veterans were homeless and  an additional 11,100 transitional beds were needed to meet homeless  veterans’ needs. However, this need was to be met through the combined  efforts of the GPD program and other federal, state, or community  programs that serve the homeless. VA had the capacity to house about  8,200 veterans on any given night in the GPD program. Over the course of  the year, because some veterans completed the program in a matter of  months and others left before completion, VA was able to admit about  15,400 veterans into the program, as shown in figure 1. Despite VA rules  allowing stays of up to 2 years, veterans remained in the GPD program an  average of 3 to 5 months in fiscal year 2006.
The need for transitional housing beds continues to exceed capacity,  according to VA’s annual survey of local areas served by VA medical  centers. The number of transitional beds available nationwide from all  sources increased to 40,600 in fiscal year 2006, but the need for beds  increased as well. As a result, VA estimates that about 11,100 more beds  are needed to serve the homeless, as shown in table 1. VA officials told us  that they expect to increase the bed capacity of the GPD program to  provide some of the needed beds.
Most homeless veterans in the program had struggled with alcohol, drug,  medical or mental health problems before they entered the program. Over  40 percent of homeless veterans seen by VA had served during the Vietnam  era, and most of the remaining homeless veterans served after that war,  including at least 4,000 who served in military or peacekeeping operations  in the Persian Gulf, Afghanistan, Iraq, and other areas since 1990. About 50  percent of homeless veterans were between 45 and 54 years old, with 30  percent older and 20 percent younger. African-Americans were  disproportionately represented at 46 percent, the same percentage as non- Hispanic whites. Almost all homeless veterans were men, and about 76  percent of veterans were either divorced or never married.
An increasing number of homeless women veterans and veterans with  dependents are in need of transitional housing according to VA officials  and GPD providers we visited. The GPD providers told us in 2006 that  women veterans had sought transitional housing; some recent admissions  had dependents; and a few of their beds were occupied by the children of  veterans, for whom VA could not provide reimbursement. VA officials said  that they may have to reconsider the type of housing and services that they  are providing with GPD funds in the future, but currently they provide  additional funding in the form of special needs grants to a few GPD  programs to serve homeless women veterans.
section_title: GPD Providers Collaborate to Offer a Range of Services, but Face Challenges in Helping Veterans
paragraphs: VA’s grant process encourages collaboration between GPD providers and  other service organizations. Addressing homelessness—particularly when  it is compounded by substance abuse and mental illness—is a challenge  involving a broad array of services that must be coordinated. To  encourage collaboration, VA’s grants process awards points to prospective  GPD providers who demonstrate in their grant documents that they have  relationships with groups such as local homeless networks, community  mental health or substance abuse agencies, VA medical centers, and  ancillary programs. The grant documents must also specify how providers  will deliver services to meet the program’s three goals—residential  stability, increased skill level or income, and greater self-determination.
The GPD providers we visited often collaborated with VA, local service  organizations, and other state and federal programs to offer the broad  array of services needed to help veterans achieve the three goals of the  GPD program. Several providers worked with the local homeless networks  to identify permanent housing resources, and others sought federal  housing funds to build single-room occupancy units for temporary use  until more permanent long-term housing could be developed. All  providers we visited tried to help veterans obtain financial benefits or  employment. Some had staff who assessed a veteran’s potential eligibility  for public benefits such as food stamps, Supplemental Security Income, or  Social Security Disability Insurance. Other providers relied on  relationships with local or state officials to provide this assessment, such  as county veterans’ service officers who reviewed veterans’ eligibility for  state and federal benefits or employment representatives who assisted  with job searches, training, and other employment issues. GPD providers  also worked collaboratively to provide health care-related services—such  as mental health and substance abuse treatment, and family and  nutritional counseling. While several programs used their own staff or  their partners’ staff to provide mental health or substance abuse services  and counseling directly, some GPD providers referred veterans off site— typically, to a VA local medical center.
Despite GPD providers’ efforts to collaborate and leverage resources, GPD  providers and VA staff noted gaps in key services and resources,  particularly affordable permanent housing for veterans ready to leave the  GPD program. Providers also identified lack of transportation, legal  assistance, affordable dental care, and immediate access to substance  abuse treatment facilities as obstacles for transitioning veterans out of  homelessness. VA staff in some of the GPD locations we visited told us  that transportation issues made it difficult for veterans to get to medical  appointments or employment-related activities. While one GPD provider  we visited was able to overcome transportation challenges by partnering  with the local transit company to obtain subsidies for homeless veterans,  transportation remained an issue for GPD providers that could not easily  access VA medical centers by public transit. Providers said difficulty in  obtaining legal assistance to resolve issues related to criminal records or  credit problems presented challenges in helping veterans obtain jobs or  permanent housing. In addition, some providers expressed concerns about  obtaining affordable dental care and about wait lists for veterans referred  to VA for substance abuse treatment.
We found that some providers and staff did not fully understand certain  GPD program policies—which in some cases may have affected veterans’  ability to get care. For instance, providers did not always have an accurate  understanding of the eligibility requirements and program stay rules,  despite VA’s efforts to communicate its program rules to GPD providers  and VA liaisons who implement the program. Some providers were told  incorrectly that veterans could not participate in the GPD program unless  they were eligible for VA health care. Several providers understood the  lifetime limit of three GPD stays but may not have known or believed that  VA had the authority to waive this rule. As a consequence, we  recommended that VA take steps to ensure that its policies are understood  by the staff and providers with responsibility for implementing them.
In response to our recommendation that VA take steps to ensure that its  policies are understood by the staff and providers with responsibility for  implementing them, VA took several steps in 2007 to improve  communications with VA liaisons and GPD providers, such as calling new  providers to explain policies and summarizing their regular quarterly  conference calls on a new Web site, along with new or updated manuals.  Language on the number and length of allowable stays in the providers’  guide has not changed, however.
section_title: VA Data Show Many Veterans Have Housing and Jobs on Leaving the Program and Plans Are Under Way for Follow-up
paragraphs: VA assesses performance in two ways—the outcomes for veterans at the  time they leave the program and the performance of individual GPD  providers. VA’s data show that since 2000, a generally steady or increasing  percentage of veterans met each of the program’s three goals at the time  they left the GPD program.
Since 2000, proportionately more veterans are leaving the program with  housing or with a better handle on their substance abuse or health issues.  During 2006, over half of veterans obtained independent housing when  they left the GPD program, and another quarter were in transitional  housing programs, halfway houses, hospitals, nursing homes, or similar  forms of secured housing. Nearly one-third of veterans had jobs, mostly  on a full-time basis, when they left the GPD program. One-quarter were  receiving VA benefits when they left the GPD program, and one-fifth were  receiving other public benefits such as Supplemental Security Income.  Significant percentages also demonstrated progress in handling alcohol,  drug, mental health, or medical problems and overcoming deficits in social  or vocational skills. For example, 67 percent of veterans admitted with  substance problems showed progress in handling these problems by the  time they left. Table 2 indicates the numbers or percentages involved.
VA’s Office of Inspector General (OIG) found when it visited GPD  providers in 2005-2006 that VA officials had not been consistently  monitoring the GPD providers’ annual performance as required. The GPD  program office has since moved to enforce the requirement that VA  liaisons review GPD providers’ performance when the VA team comes on- site each year to inspect the GPD facility.
To assess the veterans’ success, VA has relied chiefly on measures of  veterans’ status at the time they leave the GPD program rather than  obtaining routine information on their status months or years later. In part,  this has been due to concerns about the costs, benefits, and feasibility of  more extensive follow-up. However, VA completed a onetime study in  January 2007 that a VA official told us cost about $1.5 million. The study  looked at the experience of a sample of 520 veterans who participated in  the GPD program in five geographic locations, including 360 who  responded to interviews a year after they had left the program. Generally,  the findings confirm that veterans’ status at the time they leave the  program can be maintained.
We recommended that VA explore feasible and cost-effective ways to  obtain information on how veterans are faring after they leave the  program. We suggested that where possible they could use data from GPD  providers and other VA sources, such as VA’s own follow-up health  assessments and GPD providers’ follow-up information on the  circumstances of veterans 3 to 12 months later. VA concurred and told us  in 2007 that VA’s Northeast Program Evaluation Center is piloting a new  form to be completed electronically by VA liaisons for every veteran  leaving the GPD program. The form asks for the veterans’ employment and  housing status, as well as involvement, if any, in substance abuse  treatment, 1 month after they have left the program. While following up at  1 month is a step in the right direction, additional information at a later  point would yield a better indication of longer-term success.
Mr. Chairman, this concludes my remarks. I would be happy to answer any  questions that you or other members of the subcommittee may have.
section_title: Contact and Acknowledgements
paragraphs: For further information, please contact Daniel Bertoni at (202) 512-7215.  Also contributing to this statement were Shelia Drake, Pat Elston, Lise  Levie, Nyree M. Ryder, and Charles Willson.
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