Veteran Homelessness: VA and HUD Are Working to Improve Data on Supportive Housing Program
Released: 2012-06-26T00:00:00

Letter

Background

HUD and VA established HUD-VASH in 1992 to target veterans with severe psychiatric or substance use disorders. From fiscal years 1992 through 1994, the program provided approximately 1,753 housing After the initial voucher distributions, no vouchers to homeless veterans.new vouchers were made available to homeless veterans until fiscal year 2008. From fiscal years 2008 through 2011, the program received funding for about 37,000 new HUD-VASH vouchers. As of fiscal year 2008, program participants are no longer required to have chronic mental illnesses or chronic substance use disorders with required treatment. However, a significant number of veterans with those issues are expected to be helped within the program’s target population of veterans experiencing chronic homelessness.

Program Funding

Obligations for new HUD-VASH vouchers and supportive services increased from $78 million in fiscal year 2008 to $172 million in fiscal year 2011 (see fig. 1).

As of April 2012, more than 140 VA facilities were participating in HUD- VASH. In addition, according to HUD, more than 360 PHAs had partnered with VA facilities to administer HUD-VASH nationwide since fiscal year 2008. The allocation process for HUD-VASH vouchers is a collaborative approach that relies on three sets of data to determine geographic need: HUD point-in-time data on homeless veterans needing services in the area, VAMC data on the number of contacts with homeless veterans, and performance data from PHAs and VAMCs. Based on this analysis of geographic need (adjusted by the number of vouchers received in previous years’ allocations), HUD and VA identify communities that should receive VASH vouchers. The agencies then determine the exact number to allocate in proportion with each community’s level of need. VA then identifies VAMCs from these communities to participate in HUD-VASH, taking into account VA’s case management resources. HUD considers a PHA’s administrative performance and in consultation with VA identifies PHAs located in the jurisdiction of the VAMCs and invites them to apply for HUD-VASH vouchers. The selected VAMCs and PHAs in a given community must partner to administer the program. Under certain terms, HUD allows PHAs to make a portion of their HUD-VASH vouchers project-based (that is, tied to a specific housing unit and not to a tenant). PHAs can request that a portion of their allocation of HUD-VASH vouchers be project-based as long as funding for those vouchers, when added to the funding for vouchers from the PHA’s regular voucher program that have been project-based, does not exceed 20 percent of the PHA’s overall voucher budget authority and the partnering VAMC supports the project.

The Veterans Health Administration within VA issues a HUD-VASH handbook, which establishes procedures and responsibilities for administering HUD-VASH. VA also has released a HUD-VASH Resource Guide that was developed in conjunction with other federal and community partners. It includes additional HUD-VASH guidance and provides technical assistance on clinical issues pertaining to individuals in permanent supportive housing programs.

HUD’s policies and procedures for HUD-VASH, including PHA responsibilities, are defined in a Federal Register notice, the most recent of which dates to March 2012. Figure 2 illustrates the processes and activities for which VA and HUD (through PHAs in compliance with HUD regulations) are responsible when providing HUD-VASH assistance. For example, VA screens veterans to help ensure the following.

That they are homeless based on the McKinney-Vento Homeless Assistance Act definition; that is generally, a person who lacks regular, adequate housing or will imminently lose housing and lacks resources to obtain other permanent housing.

That they are eligible for VA health care.

That they are willing to participate in case management services that are intended to promote housing stability and link the veteran to needed clinical services. According to VA, many veterans experiencing homelessness have physical, emotional, or other problems that make the goal of living independently challenging.

VAMCs refer veterans who meet VA requirements to PHAs, which determine eligibility based on HUD’s income requirements for section 8. To be eligible for assistance, households generally must have very low incomes—not exceeding 50 percent of the area median income, as determined by HUD.offers several waivers to the regular section 8 voucher requirements. Specifically, under HUD-VASH, PHAs cannot deny assistance to potentially eligible households for past section 8 violations, such as previous nonpayment, or for criminal history. However, no members of Except for a sex offender provision, HUD-VASH the veteran household can be subject to a lifetime registration requirement under a state registration program for sex offenders. Once the veteran meets HUD’s requirements for the program, the PHA can issue the voucher for participation in HUD-VASH.

Data Collection, Analysis, Reporting, and Systems

According to VA, the agency has assumed primary responsibility for collecting and reporting HUD-VASH data, which it does for internal performance purposes, monthly congressional reporting, and compliance with Office of Management and Budget (OMB) reporting. VA and HUD officials told us that VA also provides HUD with program data, which HUD uses for internal performance purposes and for OMB reporting.

More than one VA office shares responsibilities for HUD-VASH data collection and analysis. VA’s National Center for Homelessness among Veterans (national center), which falls under the National Homeless Program Office, undertakes development and evaluation of care options and research and methodology related to VA’s homeless programs. Additionally, VA’s Northeast Program Evaluation Center supports and oversees data collection for VA’s mental health programs. According to a VA official, this center provides sites with day-to-day support on technical aspects of data collection, and the national center provides specific feedback on the data collection process and analysis, among other activities.

VA currently uses two systems to collect HUD-VASH program information. According to VA, in 2008, it implemented a HUD-VASH database, referred to as the Dashboard, to collect monthly program status updates from HUD-VASH sites. VAMC staff submit Dashboard reports to their respective Veterans Integrated Service Networks (VISN), which in VA officials told turn submit facility-level reports to the national center.us that VA implemented a new data collection system, the Homeless Operations Management and Evaluation System (HOMES), in April 2011, and VA is in the process of fully implementing reporting mechanisms required to generate reports based on HOMES data.information for several of VA’s homeless programs, including HUD-VASH. It is designed to track and maintain data on individual veterans as they move through VA’s system of care, including HUD-VASH participation. For example, VA’s HOMES user manual states that a HUD-VASH clinician who is familiar with the veteran should complete and submit a HUD-VASH monthly status report form for veterans currently enrolled in the program. The report is intended to capture various information on the veteran for the past 30-day period, including the number of contacts the veteran had for case management, the veteran’s housing arrangement, amount and source of any income, visits to the emergency room or other hospitalizations (including those for mental health conditions), use of alcohol or illegal drugs, and satisfaction (including with their current accommodations, safety of living, and leisure activities).

According to HUD officials, as part of its section 8 program, HUD collects voucher utilization and household information using two information systems, the Voucher Management System (VMS) and Public and Indian Housing Information Center (PIC). PHAs are responsible for submitting VMS and PIC data to HUD. HUD uses VMS as a centralized system to monitor and manage PHAs’ use of vouchers. VMS data include PHAs’ monthly leasing and expenses for HUD-VASH vouchers, which HUD uses to obligate and disburse PHA funding. PHAs enter voucher totals in VMS rather than individual records of HUD-VASH voucher activity. HUD uses PIC as a centralized system to track information on households assisted and lease activity. PIC data fields include PHA identification, assistance program type (such as HUD-VASH), and household demographic information. PIC data fields also include information on income sources and amounts, assets, rent, housing type, and whether the subsidy is tenant-based or project-based.

HUD-VASH Eligibility Is Determined at the Local Level

According to VA and HUD, the departments rely on VAMCs and PHAs to make determinations on veteran eligibility for the HUD-VASH program. Based on our meetings with staff at 10 VAMCs and 10 PHAs nationwide, VAMCs and PHAs generally followed the same procedures to determine that veterans met statutory requirements.

Initial Screening Determines Whether Veterans Meet VA Requirements

VAMC staff that we contacted described how they screened veterans to determine whether they met requirements for HUD-VASH.

Homeless status: To verify that a veteran met the McKinney-Vento definition of “homeless,” VAMC staff told us that they interviewed the veteran. This included, for example, discussing the veteran’s current housing situation (homeless, precariously housed, doubled up, in own housing but facing housing loss/eviction, or stably housed), and history or pattern of housing stability/instability. Some VAMC staff also told us that community organizations referring veterans into the HUD- VASH program may provide documentation supporting the veteran’s homeless status.

VA health care: To verify that a veteran is eligible for VA health care, VAMC staff in several locations told us that they determined if the individual had an existing record in VA’s electronic patient record system. VA determines VA health care eligibility based on whether the individual meets the definition of veteran, has a minimum period of active duty service, and is enrolled in the VA health care system. A dishonorable discharge generally disqualifies an individual from receiving VA benefits.

Case management: According to VAMC staff, a psychosocial assessment, which evaluates the veteran’s clinical and service needs, helps them to determine an appropriate level of case management for each veteran. This involves considering whether the veteran has (1) complex service needs or health conditions, such as serious mental illness or substance use disorder; (2) nonchronic service needs that could be overcome or managed with treatment; or (3) few or minor service needs and is employable. Prior to enrollment in HUD-VASH, each veteran must agree to participate in case management. According to VA guidance, case managers must document the veteran’s HUD-VASH enrollment using a HOMES form. For veterans who do not enter the program, the form lists reasons the veteran did not enter, including the veteran’s refusal to agree with the terms of the program (case management). In Los Angeles, New York, Washington, D.C., and Wyoming, VAMC staff explained that they required veterans to sign a case management agreement. VA officials told us that this was a local management practice rather than a requirement based on the HUD-VASH handbook. Following enrollment, the case manager and the veteran work together to develop an individualized treatment plan with goals that are revisited over the course of the veteran’s participation in HUD-VASH. VA views case management as a key component of HUD-VASH and its case management services are intended to help improve the veteran’s physical and mental health and enhance the veteran’s housing stability. Additionally, VA’s case management aims to support recoveries from physical and mental illness and substance use disorders. According to VA, HUD-VASH does not require veterans to be sober prior to program enrollment; however, the veteran’s treatment plan is recovery-focused and incorporates his or her recovery goals. In addition to monitoring the veteran’s treatment plan, the role of the case manager involves helping the veteran to access other medical and behavioral treatment resources as needed.

VA regards failure to participate in case management as grounds for termination or denial of program participation. However, several VAMC staff told us that VA makes every effort to re-engage veterans in case management before proceeding with termination for nonparticipation. If VA determines that the veteran no longer requires case management services, the veteran may continue to receive the HUD-VASH housing subsidy. In such cases, the VA case manager should notify the PHA that case management is no longer required but that the veteran’s eligibility for a housing voucher remains unchanged. If the PHA has a voucher available in its regular section 8 program, the PHA can offer that voucher to the veteran and make the HUD-VASH voucher available to another homeless veteran.

As previously noted, VA refers veterans who meet its requirements for HUD-VASH to PHAs, subject to voucher availability. The HUD-VASH handbook requires that if there are no available case management openings or vouchers, HUD-VASH program staff place the veteran on an interest list. According to VA, this list consists of all individuals who have been in contact with HUD-VASH staff and expressed interest in the program. These persons are subsequently screened for eligibility and a determination is made regarding acceptance. If a veteran is not eligible but vouchers are available, staff would make a referral to other VA or community resources. If a veteran is eligible but no vouchers are available, program staff must document the reason for denial in HOMES as lack of voucher availability. As of March 28, 2012, VA data show that an estimated 1,689 or 4 percent of the HUD-VASH vouchers authorized nationwide were available for use. Of the 10 VAMCs we contacted, 6 had vouchers available for use as of March 28, 2012, including the Bronx (New York) VAMC with an estimated 63 vouchers available for use and the Seattle VAMC with an estimated 32 vouchers available for use. The other four VAMCs had fewer than five remaining vouchers as of the same date. Regarding interest lists, staff at the Washington, D.C. VAMC told us that there were about 1,000 veterans on their facility’s interest list. The staff also told us that they had developed a screening tool to help make acceptance decisions and prioritize remaining vouchers for veterans on their interest list. According to VA, in addition to targeting chronically homeless veterans, consideration for HUD-VASH enrollment also may be given to women, families with children, disabled veterans, and those who served in Operations Iraqi Freedom and New Dawn in Iraq and Operation Enduring Freedom in Afghanistan.

VAMC staff we contacted generally told us that they routinely directed veterans screened for HUD-VASH to other suitable VA programs, including VA’s Grant and Per Diem and Domiciliary Care for Homeless Veterans programs. For example, the staff explained that they might refer veterans to other VA programs pending HUD-VASH acceptance if another program was more immediately appropriate for the veteran or if the veteran needed services not available under HUD-VASH (such as dental care). Some VAMC staff also mentioned local resources as another referral option.

PHAs Conduct Additional Screening on Income and Other Requirements

PHA staff that we contacted described how they screened veterans to determine whether they met income and other requirements after receiving a referral from the VAMC.

Income: PHA staff told us that they generally relied on third-party sources, such as the Social Security or Veterans Benefits administrations, to verify the reported income of HUD-VASH applicants. HUD requires PHAs to include certain sources of household income in determining income eligibility, including earned and benefits-related income. The HUD-VASH voucher subsidizes recipients’ rental payments and applicants must provide proof that their income level qualifies for this assistance.

State sex offender registry status: PHA staff told us that they checked the sex offender registry for all members of the veteran household who were at least 18. In New York, the PHA staff informed us that they checked for all household members over 16 in compliance with the age limit for that state. If the veteran was subject to lifetime registration under a state registration program for sex offenders, the PHA would refuse the voucher application. If a family member who intended to occupy the assisted unit was subject to lifetime registration under such a program, the application would proceed only if that individual was removed permanently from the household.

To familiarize veterans approved for a HUD-VASH voucher with the PHA’s requirements for HUD-VASH, staff at some PHAs we contacted told us that they conducted briefings with veterans. In several locations, PHAs held such briefings in a group format. Staff at PHAs with a smaller number of HUD-VASH vouchers sometimes met one-on-one with veterans.

Once the veteran is in housing, PHAs reverify income and complete a housing unit inspection, typically on an annual basis. Some PHAs may conduct recertification procedures less frequently. One of the PHAs in our sample was in this category and conducted recipient renewals annually or biannually on a case-by-case basis. The PHA can terminate assistance when a veteran has been evicted from a unit or for serious and repeated lease violations. However, prior to terminating any section 8 participant, PHAs must provide the opportunity for an informal hearing. According to HUD officials, as part of HUD’s routine review of PHA records (such as to determine the accuracy of family income and rent calculations), HUD may review HUD-VASH tenant files if the files are included in a larger sample, but such reviews are not specific to the HUD- VASH program.

Both VA and HUD Have Been Taking Steps to Address Data Reliability

VA Provides the Primary Data for HUD-VASH Reporting

Both VA and HUD report on HUD-VASH using information from VA’s Dashboard database. VA uses the Dashboard to collect summary count information from VAMCs and provides monthly Dashboard-based reports to HUD and Congress. Those reports typically include several data elements or measures on voucher utilization, including the number of veterans issued a voucher and looking for housing and the number of veterans housed (under lease). See table 1 for additional Dashboard data elements.

In addition to the Dashboard, VA uses HOMES to collect data on veterans. HOMES data reflect a series of electronic forms that case managers must complete from the time a veteran is screened for the program to the time a veteran leaves the program. Although HOMES data could be used to create the information captured in the Dashboard database, VA has not yet completed development and testing of report- generating mechanisms necessary to release reports based on HOMES data, according to VA officials. VA officials also told us that they intended to begin using HOMES data for congressional reporting purposes by July 2012 and eventually discontinue the Dashboard reporting mechanism.

VA Has Taken a Number of Steps to Help Ensure Data Reliability

VA has taken a number of steps to help ensure the reliability of HUD- VASH data reported though the Dashboard database. We compared VA’s processes against standards for internal control, including, among other things, having processes and procedures that provide reasonable assurance of the reliability of reports for internal and external use by establishing and supporting a control environment with clearly defined monitoring performance measures and indicators.areas of responsibility and appropriate lines of reporting, incorporating controls over information processing, and HUD-VASH reporting responsibilities, as identified in VA’s guidance, appeared to be consistent with HUD-VASH program responsibilities. For instance, case managers collect and submit HUD-VASH evaluation data on veterans. HUD-VASH program coordinators are responsible for conducting appropriate audits of performance measures. VAMC facility directors are responsible for verifying that staff provide timely reporting of veteran activity. Finally, the VISN’s homeless coordinators are responsible for helping ensure that data are submitted in a timely manner and the VISN directors are responsible for helping ensure the accuracy of these data.

According to VA officials, the national center reviews individual weekly Dashboard reports from VISNs for reasonableness by comparing submissions with prior week reports. Questions or concerns are addressed to the respective VISN and the national center corrects weekly reports accordingly.

As discussed previously, Dashboard reports include a number of program performance measures, including a specific measure for the program’s goal of moving veterans out of homelessness (the number of veterans under lease). In addition to providing data for external reporting, VA officials told us that the Dashboard database serves as a program management tool. According to VA officials, the national center uses the Dashboard reports to monitor program status at individual sites and also compares program performance across sites.

VA also has taken a number of steps to help ensure the reliability of HUD- VASH data collected through HOMES. Consistent with standards for internal control, HOMES reporting responsibilities are clearly defined in VA guidance and, according to VA officials, HOMES data are collected for individual veterans as opposed to the Dashboard’s facility-level counts that did not identify individuals. HOMES includes a number of additional controls. For example, electronic data checks incorporated into HOMES improve data validity and reduce the risk of errors. Authorized program service providers enter program and veteran information into HOMES but, where appropriate, certain data fields automatically limit responses to predefined data ranges to reduce data entry errors. According to VA officials, the system is capable of flagging records for review based on approximate matches of name or Social Security number. Furthermore, only certain authorized users may edit records after data are submitted.

VA and HUD Have Been Taking Steps to Reduce Data Discrepancies

Although counts of voucher use generated from HUD’s and VA’s information systems produce different totals, a proposed information- sharing agreement between HUD and VA is intended to facilitate data sharing and identify and resolve discrepancies. HUD has compared VA data with its VMS and PIC data for the purpose of validating HUD-VASH data. Validating data (in this case, Dashboard data) with an independent data source (such as HUD data) is an additional standard for internal control. HUD collects some HUD-VASH data, including the number of veterans receiving housing assistance (veterans under lease) through its VMS and PIC systems, but generally does not use these data for HUD- VASH reporting purposes. According to HUD and VA officials, both departments consistently use Dashboard data for reporting purposes.

HUD provided its analysis of VA, VMS, and PIC data comparisons of vouchers under lease. For November 2011, HUD’s analysis listed three totals for vouchers under lease: 27,159 vouchers according to VMS, 24,768 vouchers according to PIC, and 27,285 vouchers according to VA data. The totals also differed when HUD compared voucher counts at individual PHAs for the same month. HUD noted three totals for vouchers under lease at the Harrisburg Housing Authority: 19 vouchers according to VMS, 33 according to PIC, and 34 according to VA data. In another example, HUD noted three totals for vouchers under lease at the Housing Authority of Waco: 116 vouchers according to VMS, 13 according to PIC, and 119 according to VA data.

According to HUD officials, data discrepancies between VA and HUD data may have been due to one or more factors, assuming VA data provided at that time were accurate.

First, PHAs may have incorrectly or inaccurately entered PIC or VMS data that relate to HUD-VASH participation counts.

Second, PIC and VMS use different methodologies for assigning HUD-VASH voucher counts when veterans move across PHA jurisdictions, which could affect comparisons of participation data at the facility level. Under the HUD-VASH program, a veteran may use a HUD-VASH voucher in a jurisdiction outside of the PHA that initially awarded the voucher. VMS voucher counts are associated with the initial voucher allocation site, regardless of the participating veteran’s current location. PIC counts veteran households assisted and associates those counts with the veteran’s current location.

Third, in comparison with VA reporting, HUD has taken longer to make data available for analysis. For example, up to 80 days may elapse from the time a PHA must submit VMS data to the time that VMS information is available for analysis. According to VA, the agency typically has provided Dashboard data to Congress within 50 days after the end of each reporting month.

HUD’s VMS and VA’s Dashboard data are comparable when veteran participation is categorized by location; however, these respective data sources are not tied to personally identifying information. Therefore, the agencies have a difficult time identifying the specific source of data discrepancies.

A proposed information-sharing agreement between HUD and VA is intended to facilitate record-level data sharing between the agencies and allow them to precisely identify and resolve data discrepancies between HUD’s PIC data and VA’s HOMES data. According to VA officials, once VA fully implements new reporting mechanisms, HOMES data will enable VA to provide summary status reports and identify information for veteran records used to create the summary totals. Further, they said that the agreement will allow VA to provide HUD with HUD-VASH data including the participating VAMC and PHA, and personally identifying information for each veteran. According to HUD officials, HUD intends to compare these records with PIC data (which include personally identifying information) and then the agencies plan to coordinate with field offices to resolve discrepancies. As of June 2012, the information-sharing agreement was under review. The agencies expected to complete final revisions to the agreement by June 25, 2012 and execute the agreement by August 2012. If VA fully implements HOMES as a data source for reporting purposes and the agencies execute the agreement as planned, it would allow the agencies to match case records in the event of data discrepancies. Although the agreement is not expected to affect VA’s monthly report submissions to Congress, according to the agencies, the information-sharing agreement should further improve their ability to validate HUD-VASH data on an ongoing basis.

HUD-VASH Data Show the Program Has Moved Veterans into Housing

HUD-VASH Performance

Information VA reports for the HUD-VASH program has focused on voucher utilization (such as the number of veterans housed), but HOMES is supposed to provide VA with additional data on veteran outcomes. VA currently reports a number of measures (or various data) related to voucher utilization in monthly reports to Congress (see table 2).

These measures show that HUD-VASH has moved veterans out of homelessness. Nearly 31,200 veterans lived in HUD-VASH-supported housing as of March 28, 2012; veterans in housing represented about 83 percent of the vouchers authorized under the program. In addition, PHAs issued 4,046 vouchers to veterans who were actively seeking a lease and VAMCs reserved 620 vouchers for veterans undergoing PHA validation as of the same date. According to VA, the department’s goal is for veterans in housing to represent at least 88 percent of authorized HUD- VASH vouchers by September 30, 2012. As figure 3 shows, several states had achieved or nearly achieved this goal as of March 2012, including the four states with the largest number of vouchers authorized— California, Florida, New York, and Texas.

For the 10 VAMCs we contacted, the percentage of veterans in housing varied, ranging from 70 percent to 95 percent as of March 28, 2012. For VAMCs further from the goal, such as the Sheridan VAMC in Wyoming (70 percent in housing), challenges with getting veterans placed in housing may be related to local housing markets. For example, Sheridan VAMC staff told us that there was a lack of affordable housing in the area. Similarly, staff at Greater Los Angeles Health Care System (79 percent in housing) told us that suitable housing stock (meeting program requirements for cost and housing quality) was limited, particularly in the West Los Angeles area where the VAMC facility is located. VA data show that both VAMCs had assigned 100 percent of their authorized vouchers to a veteran as of March 2012. However, nearly 30 percent of the Sheridan VAMC’s vouchers and 21 percent of the Greater Los Angeles Health Care System’s vouchers were assigned to veterans actively seeking housing at that time. We discuss challenges with getting veterans placed in housing in greater detail later in this report.

In October 2011, VA submitted a report to Congress that provides additional descriptive and performance-related information on HUD-VASH for June 2008 through September 2010. Summary information from the report includes average number of days at each stage of the admission and housing characteristics of veterans admitted to the program; process; veterans’ typical 90-day housing situation within 3, 6, and 12 months of beginning case management; and reasons for ending case management.

For example, according to VA, for veterans who completed the housing process, the time frame from initial referral to HUD-VASH to the move into permanent housing averaged 130 days.

VA has plans to report additional information, such as measures of the time it took to complete various processes within the program (see table 3). In December 2011, VA issued guidance to its service networks outlining several outcome measures and related targets for which the department planned to start collecting data in fiscal year 2012.

VA also recently began conducting research (although not always nationwide) related to (1) the Housing First approach to supportive housing; (2) positive and negative outcomes for veterans who leave the HUD-VASH program; and (3) various case management approaches for treating veterans for substance abuse.intend to use the results of these studies to assess operations and update policies and procedures accordingly, and to offer guidance on innovative practices to VAMCs. In June 2012, VA officials provided us with updates on these studies: VA officials told us that they

Based on piloting the Housing First approach in Washington, D.C.’s HUD-VASH program in fiscal year 2009, VA determined that Housing First yielded several positive outcomes. The study compared results for 105 HUD-VASH vouchers set aside for Housing First and 70 vouchers that followed VA’s usual treatment process. VA found that, under Housing First, veteran placement into housing took, on average, 35 days from admission, compared with 223 days under the usual treatment process. Additionally, under Housing First, a reduced proportion of veterans had used emergency room and inpatient mental health services, and the housing retention rate was 98 percent after 1 year, compared with 86 percent under the usual treatment process. The pilot was expanded to 13 additional sites in fiscal year 2012, with VA and HUD monitoring for 3 years. Each site had 50 vouchers set aside for Housing First.

Based on program data available at the end of June 2011, VA analyzed veterans who were already housed and left HUD-VASH for reasons categorized as positive (such as accomplishing goals or no longer needing program supports), negative (such as failing to comply with program requirements or being evicted), and neutral (such as death, illness, or transferring to another program site). According to VA, within the sample, 37 percent of exits were positive, 23 percent were negative, 30 percent were neutral, and there were insufficient data for 10 percent of exits. VA officials told us that VA and HUD will work together to conduct a more in-depth study of veterans leaving the program for adverse reasons to identify the major factors involved. The officials informed us that as of March 2012, the departments were in the process of obtaining OMB approval to follow up with veterans who had left HUD-VASH.

VA has launched a 3-site research study comparing the effectiveness of four different intervention methods for veterans with substance use disorders and mental health problems. Methods tested will include standard case management, intensive case management, tele- coaching, and electronic interactive practices. As of June 2012, VA officials told us that they had begun interviewing veterans to participate in the study. VA did not expect results to be available until 2013.

HUD-VASH case managers have started to complete a monthly status form in HOMES that includes data on outcomes. For example, case managers must record (1) changes in the veteran’s community adjustment and social contacts; (2) hospitalizations for unscheduled medical conditions or mental health conditions; (3) employment status and other sources of income or benefits; and (4) use of alcohol or illegal drugs, using a clinical rating scale. In addition to the monthly status form, case managers are required to complete in HOMES a HUD-VASH exit form for each veteran who is discharged from the program. The exit form includes some of the indicators in the monthly report, the veteran’s status upon discharge, and the reason for exit.

Housing stability for veterans participating in HUD-VASH is a component of the program’s primary goal, along with moving those veterans out of homelessness and into housing. VA’s case management efforts play an integral role in helping veterans to achieve housing stability. VA’s current monthly reports, which show the number of veterans housed under the program, do not address housing stability. However, VA’s October 2011 report to Congress gave some indication of general voucher turnover and housing tenure. More specifically, the report showed the number and percentage of veterans leaving the program for positive and negative reasons at various stages of the housing process. It also showed veterans’ typical housing situation over the previous 90 days after 3, 6, and 12 months of participation. Beginning in April 2011, VA told us that case managers began using HOMES to record information on HUD- VASH participants. This would include entering information on each veteran’s housing situation upon enrollment, every 30 days following enrollment, and upon exit from the program. While not enough time has passed to assess the reporting related to HOMES data, VA expects it to provide a range of useful data for site monitoring and program management. Along with other data expected to be collected in HOMES, detailed information on veterans’ housing situation every 30 days should provide VA with an opportunity to assess program performance in helping veterans to achieve housing stability.

HUD Has Disseminated Strategies to Address Some Program Challenges

Based on our interviews at 10 VAMCs and partnering PHAs, staff frequently cited four challenges relating to program administration or processes that they perceived as negatively affecting the goal of housing homeless veterans and helping them maintain housing stability.

Delayed VAMC referrals to the PHA. As previously noted, for fiscal year 2012, VA’s goal is for VAMCs to refer veterans accepted into HUD-VASH to the PHA within 15 days of acceptance into the program. However, PHA staff discussed challenges associated with receiving timely HUD-VASH referrals from the partnering VAMC, particularly at the beginning of a new allocation year. In 9 of the 10 locations, PHA staff told us that delayed referrals from VA slowed the voucher utilization process. While PHAs generally can begin accepting referrals once HUD awards the vouchers, delayed referrals from VA extended the time frame between a PHA receiving the vouchers and getting the voucher holder into housing. Staff at King County Housing Authority in Seattle suggested that VA’s initial delay in making HUD-VASH referrals was related to VA needing to hire and assign case managers, while HUD could move quickly to pass funding on to the PHAs to issue vouchers. Staff at two VAMCs acknowledged the challenge in making initial referrals to the PHA. In one location, the staff explained that to provide an adequate number of case managers, they would need to know how many new vouchers had been added and, therefore, how many new HUD-VASH veterans they would need to serve. Moreover, once new case managers were hired, they had to undergo training and orientation, resulting in additional delays. Staff in several PHA locations noted that VAMC referral time frames had been improving.

HUD-VASH case manager workload. VA’s goal is to have a ratio of 1 case manager to 25 veterans. However, when we contacted VAMCs in January and February 2012, several VAMC staff told us that some case managers had 40 or more cases, as the following examples illustrate: In South Dakota, staff at the Meade County Housing and Redevelopment Commission expressed general concern that the workload for the case manager serving their area may have been unreasonable or otherwise impractical. According to staff at Black Hills Health Care System, which partners with the housing authority, the case manager assigned to Meade County and other locations managed 51 cases in total.

Similarly, case managers at James A. Haley VAMC in Tampa had between 45 and 50 cases. Staff at the Tampa Housing Authority told us that more intensive case management could reduce or eliminate veteran terminations from HUD-VASH due to nonpayment or other violations of the housing agreement.

Staff at Greater Los Angeles Health Care System told us that efforts were under way to reduce their average caseload of 45 per case manager. The facility was accepting applications for additional case managers and also planning to contract with an external entity to supplement case management services.

VA has made efforts to address staffing at its VAMCs, and when we later contacted two of the VAMCs identified with challenges, the staff told us that hiring additional case managers had reduced their caseloads significantly. Additionally, VA provided us with a report on HUD-VASH program hiring as of February 29, 2012. The report showed that 95 percent of program positions across all VISNs were filled. Among the VAMCs we contacted, the percentage of HUD-VASH positions filled ranged from 50 percent to 100 percent. Case managers represent the majority of HUD-VASH positions, but some facilities have also hired clinical supervisors, substance use disorder specialists, peer support and housing specialists, and other program support staff.

Identifying housing for veterans. Staff at VAMCs in several locations told us that veterans experienced challenges with finding housing. In Wyoming, the VAMC staff explained that the market for affordable housing was tight in Casper and Sheridan, areas served by the VAMC. Additionally, they said that the partnering PHA that served Sheridan recently reduced the maximum allowable housing assistance payment from $595 to $571 and this amount limited access to decent housing in the area. The staff added that many landlords also have been reluctant to rent to veterans with criminal histories. VAMC staff in South Dakota similarly noted that a partnering PHA had decreased the housing allowance for the area it served while some landlords had increased their rents. They explained that they used communications with a local homeless coalition, community stakeholders, and landlords to identify options for affordable housing. At Greater Los Angeles Health Care System, the staff told us that a housing specialist had been hired and kept staff informed of new housing stock while working with developers and realtors to identify suitable housing. According to the VAMC staff, the housing specialist also has conducted outreach to educate landlords on HUD-VASH and advocate for veterans, making them aware that case management will be available to HUD-VASH tenants.

Move-in resources for veterans. Both PHA and VAMC staff discussed challenges veterans experience accessing the funds and household items that they needed to move in once they found a suitable housing unit. In some instances, veterans were delayed in moving into their units because of a lack of available funds to pay rental application fees, security deposits for rent or utilities, and the first month’s rent. Such delays could affect VA’s goal for placing veterans into housing within 100 days of being accepted into the program.

The availability of resources to help veterans varied among locations, but generally was more limited outside of larger cities. Two of the 10 locations had a consistent source that could provide this type of assistance to veterans. For example, New York City has a Department of Homeless Services that provides a range of services to homeless individuals. Through this entity, HUD-VASH veterans could receive assistance with security deposits, first month’s rent, and household items. In Seattle, HUD-VASH veterans could access a limited-term Human Services and Veterans Levy that assisted veterans, military personnel and their families, and others in need through a variety of housing and supportive services. In other locations, VAMC and PHA staff told us that veterans had relied on local public or nonprofit assistance and on Homeless Prevention and Rapid Re-Housing Program funds that were temporarily provided under the Recovery Act. Additionally, several said that they hoped veterans would be able to use funds that would be provided under the new Supportive Services for Veteran Families grant program.Homeless Prevention and Rapid Re-Housing Program funds are no longer available and the other sources mentioned, according to the staff, often were insufficient or were not guaranteed.

In some locations, the VAMC staff had developed other approaches to mitigating this challenge for veterans. For example, at several facilities, including Greater Los Angeles Health Care System, Black Hills Health Care System in South Dakota, and Washington, D.C. VAMC, the staff explained that they solicited landlords’ cooperation in waiving or spreading out up-front fees. Additionally, staff at White River Junction VAMC in Vermont had developed a handbook for veterans participating in VA’s homeless programs that included a community resources guide. They explained that the guide was included to assist veterans with obtaining furniture, household items, and other resources they needed to move into housing.

In April 2012, HUD released a best practices document that included practices submitted by PHAs and VAMCs that administer HUD-VASH. According to HUD, the purpose of the document is to share effective strategies for administering HUD-VASH and highlight the efforts of specific sites and other partners. According to HUD officials, VA was involved in soliciting best practices from VAMCs and reviewed the document that HUD developed. HUD intends to revise the document over time. While the document was developed from the housing standpoint, it includes information on strategies for carrying out procedures pertaining to general PHA and VAMC management. More specifically, it describes the ways in which individual sites have addressed specific challenges such as those identified previously. For example, in addition to the Los Angeles VAMC hiring a housing specialist, the document described other facilities’ efforts to direct veterans to suitable housing by contracting with a nonprofit housing referral organization, maintaining a list of potential housing options in the VAMC’s service area, and conducting targeted landlord outreach. Similarly, several PHAs had established a loan fund or trust fund to assist veterans with move-in costs, and one PHA applied for county Community Development Block Grant funds to assist veterans with security and utility deposits.

Advocacy Organizations Generally Shared Positive Views of HUD-VASH and Also Suggested Program Improvements

Advocates for veterans and the homeless that we contacted generally agreed that HUD-VASH was essential in helping homeless veterans to access housing and long-term treatment. Representatives at one of the organizations stated that the long-term housing HUD-VASH provides was crucial to addressing the immediate and long-term needs of homeless individuals and that combining case management with housing was appropriate for veterans with the most significant problems. Additionally, representatives at two organizations told us that HUD and VA sharing a common strategic goal had been beneficial and that program administrators had been responsive to the HUD-VASH community. Moreover, they noted that the program’s administration had improved over time. Specifically, they explained that VA had been willing to make changes to improve HUD-VASH, including in terms of leadership.

The advocates offered suggestions for improving the HUD-VASH program, including the following.

One advocate suggested that the program should continue to target those with the greatest need for assistance and explore flexibility for service delivery mechanisms, including having case managers conduct more work in communities and outside of the traditional VAMC appointment approach. Related to this point, recently the Veterans Health Administration Homeless Program National Director noted that VA was taking steps to have more of a presence in the community. This included hiring HUD-VASH case managers living in communities where veterans were being served and seeking more opportunities to have case managers co-located with community- based organizations.

A second advocate thought it would be useful to remove the section 8 limits on project-based housing under HUD-VASH to allow developers to allocate portions of higher-quality, mixed-use developments for project-based HUD-VASH vouchers. The representative explained that this would be particularly helpful in locales with limited affordable housing and in areas that are desirable (particularly for female veterans with dependent children). HUD officials clarified that PHAs can make the case to HUD to have funding for project-based HUD- VASH vouchers exceed the voucher budget authority limit of 20 percent. According to HUD officials, exceeding the limit must be tied to effective administration of HUD-VASH, and HUD had not received any such requests as of May 2012.

A third advocate expressed that VA should increase its outreach to veteran service organizations to advertise to veterans who may not be participating in VA programs. VA officials told us that VA has a national outreach initiative under way that includes collaborating with veteran service organizations to make information on HUD-VASH and other VA programs more readily available.

Finally, a fourth advocate emphasized that sufficient resources needed to be committed to HUD-VASH in support of the goal of ending veteran homelessness. The representative explained that a certain volume of vouchers needed to be in the system for it to be successful and that inconsistent resources led to uncertainty among service providers and veterans who need to access the program.

Agency Comments

We provided a draft of this report to the Secretary of Housing and Urban Development, the Secretary of Veterans Affairs, and the Executive Director of the U.S. Interagency Council on Homelessness. We received comments from HUD, VA, and the Interagency Council that are reproduced in appendixes II, III, and IV, respectively. HUD and VA also provided technical comments, which we incorporated in the report as appropriate. In their responses, HUD, VA, and the Interagency Council generally agreed with our conclusions. HUD and VA noted that they were committed to their partnership and the continued improvement of the HUD-VASH program. The Interagency Council stated in its response that VA and HUD work closely on local implementation through VA medical centers and public housing agencies, and have improved lease-up rates, enhanced data collection, and reduced the amount of time it takes to house veterans in the HUD-VASH program.

We are sending copies of this report to appropriate congressional committees; the Secretary of Housing and Urban Development; Secretary of Veterans Affairs; and the Executive Director of the U.S. Interagency Council on Homelessness. This report will also be available at no charge on GAO’s Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please contact me at (202) 512-8678 or cackleya@gao.gov. Contact points for our Offices of Congressional Affairs and Public Affairs may be found on the last page of this report. GAO staff who made major contributions to this report are listed in Appendix V.

Appendix I: Objectives, Scope, and Methodology

Our objectives were to examine (1) how the Department of Veterans Affairs (VA) and the Department of Housing and Urban Development (HUD) determine that veterans who participate in the HUD-VA Supportive Housing (HUD-VASH) program meet the statutory eligibility criteria, (2) what data VA and HUD collect and report on the HUD-VASH program and the steps that VA and HUD take to help ensure the reliability of these data, and (3) what is known about the performance of the HUD-VASH program.

To address all three objectives, we reviewed VA and HUD documents to determine the purpose of the HUD-VASH program and the agencies’ roles and responsibilities related to HUD-VASH. In addition, we reviewed federal strategic plans that address veteran homelessness to obtain information on VA’s and HUD’s goals related to reducing veteran homelessness. We interviewed officials at the Veterans Health Administration within VA and in HUD’s Office of Public and Indian Housing and Office of Community Planning and Development. We reviewed VA and HUD Office of Inspector General reports pertaining to HUD-VASH and our previous reports. We selected a purposive, non- representative sample of 10 locations in which to interview management and staff at VA medical centers (VAMC) and their partnering public housing agencies (PHA) (see fig. 4). Results of these interviews cannot be projected to other VAMCs or PHAs. We selected the 10 locations (9 states and the District of Columbia) based on several criteria, including a significant presence of homeless veterans in and a large allocation of HUD-VASH vouchers to the state, identified best practices or challenges in administering the HUD-VASH program, and geographic diversity. To obtain information on the presence of homeless veterans by state, we reviewed the jointly developed veteran supplements to HUD’s 2009 and 2010 Annual Homeless Assessment Reports to Congress. We used information from HUD on annual HUD-VASH voucher allocations by PHA and partnering VAMC for fiscal years 2008 through 2010.

To address our first objective, we reviewed eligibility requirements in the HUD-VASH statute to assess how VA and HUD are to determine that veterans who participate in HUD-VASH meet the statutory eligibility criteria. We also reviewed requirements specific to VA in the Veterans Health Administration’s HUD-VASH handbook and a HUD-VASH resource guide developed by the National Center for Homelessness among Veterans. To obtain specific information on how VA screened veterans to determine if they were eligible for the program, we interviewed VAMC management and staff in the selected 10 locations. The centers are responsible for screening and evaluating veterans for acceptance into HUD-VASH, referring veterans to partnering PHAs, and coordinating veterans’ case management under HUD-VASH. Similarly, to obtain more specific information on how PHAs (following HUD’s procedures) screened veterans referred by partnering VAMCs, we interviewed management and staff at PHAs that partner with the 10 VAMCs to assess veterans and also manage various aspects of the housing process. In our interviews with VAMC and PHA staff, we asked about their general procedures for administering HUD-VASH, including how they made eligibility determinations based on VA’s requirements and HUD’s guidelines, respectively. We also discussed cooperation at the local level between partnering VAMCs and PHAs.

To address our second objective, we reviewed program manuals and guidance on data that VA and HUD collect on HUD-VASH, their data collection mechanisms, and reliability controls. We interviewed VA and HUD officials to determine what HUD-VASH information the agencies report and the systems they use for collecting and reporting the related data. We obtained and reviewed selected monthly Dashboard-based reports that VA provided to Congress during fiscal years 2011 and 2012 to identify the data elements typically reported for HUD-VASH; we reviewed VA program data through March 2012. While VA provides monthly voucher utilization reports to Congress, HUD reports to Congress on HUD-VASH only upon request. To identify the steps that VA takes to help ensure the reliability of its data, we interviewed knowledgeable VA officials about the purpose, structure, and quality controls used to capture or report HUD-VASH program data using VA’s Dashboard and HOMES. We reviewed VA documentation, including the HOMES user manual, HUD-VASH data entry forms, and data validity checks. In interviews with VAMC staff at the 10 selected locations, we asked about data collection and reporting, and any related challenges. In addition, we observed a demonstration of VA’s reporting mechanism for HUD-VASH on-site. Finally, we compared VA’s data collection and reporting procedures to standards for internal control in the federal government. To identify the steps that HUD takes to help ensure the reliability of its data, we interviewed knowledgeable HUD officials about the purpose, structure, and relevant quality controls for HUD-VASH data, including information captured in HUD’s Voucher Management System (VMS) and Public and Indian Housing Information Center (PIC). We also interviewed PHA staff at the 10 selected locations about data collection and reporting, and any related challenges. We reviewed relevant documentation, including the information systems’ user guidance and HUD’s documented analysis of comparisons between VMS, PIC, and VA data.

To address our third objective, we reviewed performance-related information reported by VA such as monthly Dashboard-based reports on HUD-VASH voucher utilization and a more descriptive report submitted to Congress in October 2011. In addition, we interviewed representatives of, and gathered documentation from, HUD and VA headquarters; the U.S. Interagency Council on Homelessness (Interagency Council); and veteran and homeless advocacy organizations, including the National Coalition for Homeless Veterans, the National Coalition for the Homeless, the National Alliance to End Homelessness, and Vietnam Veterans of America. In interviews with VA and HUD officials, we asked about performance measures the agencies were monitoring for HUD-VASH. In interviews with representatives of advocacy organizations, we discussed their perspectives on HUD-VASH administration and the program’s performance. We also asked VAMC and PHA staff for their perspectives on HUD-VASH performance, potential ways to measure program success, and opportunities for improvement.

We conducted this performance audit from September 2011 through June 2012 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Appendix II: Comments from the Department of Housing and Urban Development

Appendix III: Comments from the Department of Veterans Affairs

Appendix IV: Comments from the U.S. Interagency Council on Homelessness

Appendix V: GAO Contact and Staff Acknowledgments

GAO Contact

Staff Acknowledgments

In addition to the contact named above, Marshall Hamlett (Assistant Director), Bernice Benta, F. Chase Cook, Pamela Davidson, Cynthia Grant, John McGrail, Marc Molino, and Barbara Roesmann made key contributions to this report.