A review of homelessness among veterans:

A review of homelessness

among veterans:

Policy and practice

implications for prevention

and intervention efforts

Blake Barrett, B.A.

Colleen Clark, Ph.D.

Roger Peters, Ph.D.

Michael Caudy, M.A.

Department of Mental Health Law & Policy

Louis de la Parte Florida Mental Health Institute

University of South Florida

Prepared for the National Center on Homelessness among Veterans

January 18, 2010

The goal of this report is to provide a comprehensive review of the individual and

structural factors and interactions that contribute to homelessness; to describe different levels of

interventions, promising practices, and policy recommendations with a focus on preventing

homelessness among Veterans. Topics and areas covered in this report include, but are not

limited to: individual factors (socioeconomic status, gender/family issues, mental health and

substance use disorders, criminal justice interactions); structural factors (housing

availability/affordability, job security/unemployment/underemployment, health insurance,

current recession and healthcare crisis); and Veterans issues (maintaining housing/employment

after combat deployments, trauma experiences, PTSD and other clinical issues, need for

continuity of care with VA services, factors that facilitate/interfere with benefit receipt).

Due to these authors areas of expertise there special recommendations focusing on gender

issues, co-occurring disorders; integrated treatment (including substance use disorders,

psychiatric disorders, trauma disorders, and criminal justice issues); discharge planning and an

extensive discussion of criminal justice system issues for Veterans.

A prevention-oriented model for homelessness assistance policies and services

Incorporated into this report is the public health model of primary, secondary, and tertiary

prevention of homelessness (Shinn, Baumohl & Hopper, 2001; Burt, Pearson & Montgomery,

2005; Culhane & Meltraux, 2008). Supported by recent legislation (i.e., the American Recovery

and Reinvestment Act of 2009 and its “Homelessness Prevention and Rapid Rehousing

Program”), a prevention-oriented service system model represents a paradigm shift in the

provision of homelessness assistance policies and services. Specifically, by providing

preventative services and supports to a larger number of people before they become homeless,

and providing increasingly intensive services to fewer numbers of individuals and families with

more intensive needs, this preventative model seeks to offer the greatest amount of aid to the

greatest amount of people in the most effective and efficient manner. Additionally, primary

features of this preventative model focus on “attaining housing stability and maintaining ties

with community-based social and health services delivery networks” (Culhane, Metraux, &

Byrne, 2010).

This prevention-oriented discussion is consistent with the great variability in the patterns

of homelessness as well as for the creation and provision of the best services for specific

populations (Burt, Aron, Lee, & Valente, 2001). Studies employing cross-sectional or point-in-

time methodologies often over represent the proportion of homeless persons with long and/or

continuous histories of homelessness (Burt et al. 2001). Results from a study by Culhane and

Kuhn (1998) utilizing shelter tracking databases in New York and Philadelphia found that only

around 10 percent of the shelter-using homeless population could be considered long-term or

chronically homeless; further, the study found that the vast majority of shelter-users (~80%)

were individuals experiencing first-time/crisis or transitional homelessness. Beyond those

experiencing first-time/crisis or transitional and long-term/chronic homelessness, there are also

individuals who experience periodic spells of homelessness across many years which require

additional, specific interventions and services (Burt et al. 2001).

Those individuals experiencing their first episode of homelessness, as well as individuals

who experience short terms of homelessness, may only need simple emergency assistance to help

alleviate the immediate crisis which triggered their literal state of homelessness (e.g., loss of a

job, death of an income-earning spouse, loss of transportation). However, given the extreme rise

in both housing costs and poverty levels the probability that a very poor person/family will

experience one such emergency event within a year is very high; with these precarious

conditions, 1 out of every 10 poor households has a strong possibility of experiencing a spell of

homeless over the course of a year (Burt et al. 2001, pg. 322). As such, policy efforts should

focus resources on providing both comprehensive and continuous support (as necessary) to poor

and very poor families and individuals to prevent their fall into homelessness.

Those individuals who experience periodic spells of homelessness over many years

benefit from policy and intervention efforts that: assist in finding more affordable housing;

develop or increase social networks; help manage limited financial resources; continue treatment

for behavioral health needs; and provide subsidize housing, with and without supportive services,

to those who otherwise would not achieve housing stability on their own (Burt et al. 2001).

These services are also appropriate for individuals who are chronically homeless, however, this

population also benefits from and often requires: basic life-skills training; remedial education

and basic job training; longer-term behavioral health services; as well as subsidized housing with

supportive services. These supportive services must be provided in an prescribed fashion that

recognizes the specific needs of individuals and does not waste limited resources on services that

are unneeded (Burt et al. 2001).

General causes and phenomena related to homelessness

Homelessness is caused by and related to a variety of individual and structural factors,

characteristics, and systemic interactions. In this report, these factors, characteristics, and

systemic interactions will first be discussed in the context of the general population and then

focused specifically to the needs and experiences of Veterans. Speaking broadly, Veterans are

subject to the same risk factors for homelessness as those in the general population – e.g., lack of

affordable, available housing, employment issues, mental health and substance abuse problems,

criminal justice interactions. However, Veterans are also subject to a variety of other risk factors

for homelessness – e.g., maintaining housing and employment during and after deployment, the

effects of combat exposure and related conditions such as post-traumatic stress disorder (PTSD)

- as well as protective factors such as access to VA healthcare and other services. The following

sections will describe the structural and individual factors, characteristics, and systemic

interactions related to homelessness, as well as risk and protective factors related to

homelessness specifically for Veterans and Veterans’ issues.

Individual factors

Prior research has identified many individual characteristics associated with

homelessness (e.g., male gender, lack of a high school education, physical or mental illness,

substance use disorders, previous criminal incarceration, adverse childhood experiences, foster

care or out-of-home placement, etc). However, these characteristics are much better understood

as descriptive information rather than predictors of homelessness. These characteristics describe

who will become homelessness, but only in the context of significant structural stress wherein

“some among the very poorest will become homeless at a particular time in a particular place

(Burt et al. 2001, pg. 236). Accordingly, policy and preventative efforts should interpret

research findings regarding who is homeless as indicators of at-risk populations and focus

resources accordingly to address the larger structural conditions which enable people to fall into

homelessness (e.g., lack of education, job training, sufficient wages, affordable and available

housing).

A recent case-control study of all Veterans who used VA services in 2008 compared

those who did and did not recently experience homelessness, finding several characteristics of at-

risk populations (National Center on Homelessness among Veterans: December 23, 2009).

Results from this study found that having a diagnosis of a mental health or substance use

disorder, being black, and being male (except among Operation Enduring Freedom/Operation

Iraqi Freedom [OEF/OIF] Veterans), increased the risk of a recent experience of homelessness.

However, these findings only generalize to Veterans who have access to and have utilized VA

services; risk factors for homelessness may differ when compared to Veterans without access to

VA services.

Demographic factors related to homelessness

Younger Veterans are at increased risk of homelessness following their military service

for a variety of reasons (Fairweather, 2006). For those entering into military service at a younger

age, many have not yet had the opportunity to develop life skills necessary for independent living

and often have difficulty transferring military training to employment opportunities (this issue is

further exacerbated by civilian employment which may trigger PTSD symptoms). Additionally,

young Veterans exposed to earlier adverse childhood experiences (e.g., unstable housing and

marginal family status) often return to similar unstable environments following military service,

which serves as an additional risk factor for homelessness.

Women Veterans are at a higher risk for experiencing homelessness when compared to

other women. Gamache, Rosenheck, and Tessler (2003) conducted a study examining the

likelihood of homelessness among women Veterans, utilizing data from a clinical sample of

homeless persons with mental illness treated in the ACCESS program as well as a nationally

representative sample of persons who used homeless assistance services in 1996 (NSHAPC).

Data from a joint project of the Bureau of Labor Statistics and Bureau of the Census (CPS)

provided estimates of homelessness among the domiciled general population and in subsample of

low-income domiciled women. Results from this study that, when compared to both the

domiciled and low-income domiciled populations, women Veterans are 2 – 4 times more likely

to be homeless when compared to non-veteran women.

Women attribute their experience(s) of homelessness to different causes when compared

to men, offering opportunities for targeted interventions among women and women Veterans to

prevent homelessness. Tessler, Rosenheck, and Gamache (2001) conducted a study examining

gender differences in self-reported reasons for homelessness among a homeless sample with

mental illness treated through the ACCESS program. Self-reported reasons for homelessness

were described in three categories: 1) those related to alcohol, drugs, and mental health

problems; 2) those related to problems in interpersonal relationships; and 3) those related to

poverty. Analyses focused on gender differences as well as gender by veteran interactions for

self-reported reasons for homelessness. Results indicated that men were more likely to report

problems related to alcohol, drugs, or mental health as their reason for experiencing

homelessness while women were more likely to report interpersonal reasons and eviction as

causes for homelessness. Women may be more likely to report interpersonal reasons as the

cause of their homelessness as many “find themselves in interpersonal relationships in which

they are dependent on another person or persons for their (and their children’s) survival”

(Tessler, Rosenheck, & Gamache, 2001, p. 251). Additionally, a significant gender by veteran

status interaction was found, wherein female Veterans were more likely than male Veterans to

self-report eviction as the reason for their experience of homelessness. Findings from this study

suggest that women Veterans would benefit from homelessness prevention efforts that focus on

addressing relationship issues, as well as housing subsidies or assistance efforts to prevent

eviction and a subsequent experience of homelessness.

Behavioral health issues

There is a strong tendency in America to perceive those with alcohol/drug and mental

health issues (ADM) as “less deserving” when it comes to assistance and the allocation of scarce

resources for homeless populations (despite the prevalence of ADM issues in homeless

populations). Around half of all homeless adults will report a problem with ADM at any given

point; additionally, four out of five homeless persons will report some ADM problem(s) at some

point in their life. However, around 25% of homeless persons will report having no problems

with ADM in the past year. The relationship between homelessness and ADM is complicated

and not necessarily a causal one. The existence of ADM problems is strongly related to adverse

experiences during childhood and adolescence which are strongly associated with the probability

that a person will “experience a spell of homelessness, experience it early, and experience it

often or for a long duration” (Burt et al. 2001, pg. 320). The policy question is then why does the

existence of ADM problems lead to homelessness (Burt et al. 2001, pg. 99).

Amongst those experiencing homelessness, there are several delineations concerning

behavioral health issues (no ADM, alcohol/drug only, mental health only, co-occurring

disorders) which profoundly shape their need for services, experiences across service sectors

(including barriers to service access/provision), as well as the ideal service types and provision

for specific populations. Individuals who report no ADM problems experience the fewest

negative experiences and circumstances, those with either alcohol/drug or mental health

problems only experience more negative experiences and circumstances, and those with co-

occurring disorders experience the most (Burt et al. 2001, pg. 137). Individuals with only mental

health problems are more likely to have experienced childhood mental health problems, receive

cash benefits from disability programs (e.g. SSDI) which often serves as a barrier to employment

and self-sufficiency, as well as utilize specifically designed transitional housing services for

homeless persons with disabilities. Individuals with only substance use disorders are likely to

have histories of heavy alcohol/potential drug use during early adolescence as well histories of

criminal justice interaction and incarceration (which often serves as a barrier to employment and

access to services to prevent/transition out of homelessness). Those with co-occurring disorders

experience the highest level of negative experiences and vulnerability (e.g., hunger, criminal

victimization, and health problems) compared to those with only one type of disorder as well as

those with no ADM problems (Burt et al. 2001).

The effects of ADM problems on the “likelihood of homelessness [indicates a] broad

failure of formal care systems to adequately treat their clients and to develop effective support

mechanisms that will prevent their descent into homelessness” (Burt et al., 2001, p. 236). Policy

and preventative efforts should focus on integrating behavioral healthcare with housing supports

in the community, as well as measures to prevent acute episodes of care that jeopardize

residential stability (e.g. psychiatric and substance abuse residential treatment), to increase and

facility the community tenure of those with ADM problems. It has also been recommended that

supplying housing vouchers along with intensive case management supports range of positive

outcomes among formerly homeless Veterans with behavioral health issues (O’Connell,

Kasprow, Rosenheck, 2008).

The frequency of co-occurring substance use and other mental health disorders not only

increases the severity of each disorders but suggests the need for systems serving Veterans to

become “co-occurring competent”. These includes increasing knowledge and responsiveness to

one of the emerging issues for Veterans, dependency on opioids including prescription

painkillers.

Alcohol use disorders play a pervasive and complex role in the experience of

homelessness (Clark & Rich, 2005). Alcohol use disorders play a predisposing, precipitating,

mediating and moderating, and maintaining and perpetuating role in homelessness. In addition,

alcoholism is often comorbid with mental health and physical disorders, causing and making

these disorders worse. The risk of comorbidity with trauma-related disorders including PTSD is

also very high. These relationships highlight the importance of integrated treatment at multiple

intervention sites. For example, that includes screening for alcohol use disorders at medical

clinics, housing outreach with harm-reduction models. Further, due to the nature of the disease

and its insidious relationship to homelessness, alcoholism should be treated in a continuing and

long term manner, rather than one time episodes of treatments (McKay, 2009).

Structural factors

Veterans are subject to the same larger structural factors that increase the risk of

homelessness among the general population, including: the lack of available and affordable

housing; unemployment, underemployment, and job security issues; difficulties in accessing

needed health care services; as well as systemic interactions which increase the risk of

homelessness (e.g., incarceration, acute psychiatric hospitalization).

Institutions and the public system of care

Those who are homeless, or at-risk of homelessness, often cycle through many public

systems of care (e.g., psychiatric and substance abuse treatment facilities, jails/prisons,

emergency departments, etc.) which perpetuate or leave them further at-risk for experiencing

homelessness. Despite the magnitude of interaction between those who are homeless/at-risk of

homeless and the public systems of care cited above, there is a pervasive lack of planning and

coordination amongst these systems. Individuals discharged from these systems of care are often

left in situations “where they immediately, or at least very quickly, fall into homelessness (Burt

et al. 2001, pg. 183). Those mainstream programs which serve populations who are homeless or

are at-risk of homelessness must hold greater accountability for “their most vulnerable clients

and wards” (National Alliance to End Homelessness, 2000, p. 10); this applies especially to

institutions that discharge individuals who are currently homeless or at-risk of homelessness. The

Department of Veterans Affairs has opportunities to prevent homelessness institutional

commitment to their residential stability in the community at time of discharge. Policy and

prevention efforts should focus on: 1) promoting a culture of communication and relationships

across public systems of care that recognizes the cyclical nature of homeless interactions with

adult public systems of care; 2) providing resources to and incentivizing public systems of care

to facilitate community tenure for homeless persons who interact with the public systems of care;

and 3) forming partnerships amongst the public systems of care and housing authorities to help

those who cannot maintain housing on their own secure adequate permanent housing (Burt et al.

2001).

To prevent homelessness there will have to be improvement in all adult systems of care

 Mental health, substance abuse

 Invest in improving and coordinate homeless systems of care

 Structure and invest in services for high-risk populations

 Cost-effective if consider all public systems of care and support (health, mental health,

SUD, corrections, housing) (pg. 332 for citations that support cost savings)*

 Commit societal resources to eliminating conditions in which people grow up that

increase their vulnerability to homelessness

 Some populations need long-term support (e.g., those with SMI); those systems with

official responsibility should structure housing as additional resources to their comprehensive

services offered to meet individuals need

*Taken from Burt and colleagues (2001).

As an example, a recent report by the LA County Department of Public Social Services

says that the County will realize significant savings by investing in a housing subsidy program

for homeless general relief recipients who are either employable or eligible to receive SSI

benefits.

Criminal justice system interactions as a risk factor for homelessness

Those incarcerated in jails and prisons experience rates of homelessness much higher

than those of the general population (Greenberg & Rosenheck, 2008a, 2008b). A secondary

analysis of a 2002 national survey of jail inmates conducted by the Bureau of Justice Statistics

found that 12.4% of inmates had been homeless in the year prior to their incarceration, and 2.9%

were homeless at the time of their arrest (Greenberg & Rosenheck, 2008a). Further, results from

this study found the rate of homelessness among jail inmates to be 7.5 to 11.3 times the annual

rate of homelessness when compared to the general population. Past criminal justice system

involvement, mental illness and substance abuse, and the lack of sociodemographic assets were

found to be the largest contributors to the high rate of homelessness among jail inmates. The

authors suggest that a bidirectional association between homelessness and incarceration may

exist in part due to the detrimental effects of prior incarceration on family and community ties, as

well as employment and public housing opportunities. However, while mental illness and

substance abuse indicators were both associated with greater risk of homelessness among jail

inmates, substance abuse appeared to be “the stronger risk factor for incarceration among both

homeless and nonhomeless inmates” (Greenberg & Rosenheck, 2008a, p. 176).

The finding that substance abuse emerged as a stronger risk factor for homelessness

among jail inmates as compared to mental illness is mirrored by another study predicting

incarceration among homeless Veterans leaving VA inpatient units (Erickson, Rosenheck,

Trestman, Ford, & Desai, 2008). The study by Erickson and colleagues examined factors

predicting arrest among all male Veterans treated in inpatient units in the VA Connecticut

Healthcare System between 1993 and 1997, merging these data with the Department of

Corrections database for the same period. Descriptive information revealed that those Veterans

experiencing an incarceration episode were more likely to have mental health, substance abuse,

and co-occurring disorders. However, in multivariate models predicting incarceration, having a

diagnosis of a severe and persistent mental illness (i.e., bipolar or schizophrenia disorder), as

well as co-occurring mental health and substance abuse disorders, were no longer independent

predictors of incarceration. In multivariate models, only substance abuse disorders remained an

independent predictor of incarceration. The authors note that these results are consistent

criminological theories which suggest substance abuse is largely responsible for incarceration

risk (Andrews & Bonta, 2006; Bonta, Law, & Hanson, 1998; Lamberti, 2007). These models

view substance abuse as a problematic behavior (rather than a secondary consequence of mental

illness), and support interventions using legal leverage to maintain community tenure.

Investments in such interventions should be increased and promulgated to help prevent

homelessness among those arrested/incarcerated in jails.

Those in prison experience much greater rates of homelessness when compared to that of

the general population. Greenberg and Rosenheck (2008b) conducted a secondary analysis of a

national sample of adult state and federal prison inmates who completed the 2004 Survey of

Inmates in State and Federal Correctional Facilities. Results from this study found that 9.2% of

prison inmates had been homeless in the year prior to their arrest with 1.7% homeless at the time

of their arrest. Further, the rate of homelessness among prison inmates was found to be 4 to 6

times the annual rate of homelessness in the general population. While mental illness and

substance abuse were common among all prison inmates, those who were homeless had

significantly higher rates of behavioral health needs. When compared to other prison inmates,

those who were homeless were more likely to have past criminal justice system involvement,

mental illness and substance abuse problems, histories of trauma, as well as to be poor.

Research conducted by Metraux and Culhane (2004, 2006) suggests that different

trajectories exist between homelessness/jail and homelessness/prison for those utilizing shelter

services. Findings from these studies indicate that there is a much more immediate link between

prison release and shelter utilization (with an episode of homelessness most likely to incur within

30 days of release); this suggests that homelessness among those released from prisons is more

an issue of reentry into the community. For those leaving jails, a different relationship exists

between incarceration and shelter utilization (Metraux & Culhane, 2006). This relationship is

characterized by a “more sequential pattern featuring multiple stays in each system and a more

prolonged pattern of residential instability” (Metraux, Roman, & Cho, 2007, p. 8)

Taken together, current research supports the concept of the “institutional circuit”

between shelters, jails, prison and other institutions experienced by homelessness proposed by

Hopper and colleagues (1997). While most of the existing evidence linking homelessness and

criminal justice interaction is correlational, this research provides factors which may be

amenable to intervention to prevent homelessness among those leaving carceral institutions

(Metraux, Roman, & Cho, 2007). Interventions to prevent homelessness among those leaving

carceral institutions should focus on: adequate discharge planning and other support services

available to those incarcerated prior to their release; the provision of a continuum of housing

options for those who have been incarcerated, specific to the needs of persons released from

carceral institutions and including supported housing; integrating services and treatment with

housing services (permanent or transitional); the use of case management models for service

delivery; the “front-loading” of services whereby more intensive services are provided during a

critical time period where persons are thought to be at high risk for subsequent re-incarceration

and/or homeless (Nelson, Deess, & Allen, 1999)

Criminal justice system interactions as a risk factor for homelessness among Veterans

Approximately 9% of U.S. jail and prison populations consist of Veterans, amounting to

well over 200,000 who are incarcerated nationwide (Greenberg & Rosenheck, 2008; National

GAINS Center, 2008; Noonan & Mumola, 2007). These numbers are likely to rise with the large

number of returning Veterans from Afghanistan and Iraq, who are at elevated risk for

incarceration due to high rates of substance use disorders, mental disorders (e.g., trauma/PTSD,

depression), and domestic violence. Most Veterans in jail are there for non-violent offenses

(McGuire, 2009). However, Veterans face longer sentences than other arrestees for some types

of offenses (Bureau of Justice Statistics, 2007). From 15-16% of jail inmates are homeless

(Greenberg & Rosenheck, 2008; McNiel, Binder, & Robinson, 2005), including significant

numbers of Veterans. Veterans who are released from custody are at particular risk for

homelessness (McGuire, 2007).

A number of legislative and programmatic interventions have been developed for

Veterans in the justice systems that are likely to address homelessness, including the Department

of Veterans Affairs criminal justice outreach program. Several states (i.e., California,

Minnesota) have enacted statutes which authorize diversion of Veterans from the criminal justice

system who have service-related mental and substance use disorders, and other states are

considering similar legislation. Veterans Courts have been established in several jurisdictions

across the country to divert nonviolent Veterans who have substance use disorders to long-term

drug treatment and community supervision, and provide linkages and coordination with VA

services. SAMHSA has recently sponsored several pilot jail diversion programs for Veterans

who have co-occurring mental and substance use disorders.

Several recent reports provide recommendations for improving services for Veterans in the

criminal justice system, including those who are homeless or at risk for homelessness. These

include a Consensus Report issued by the National GAINS Center’s Forum on Combat Veterans,

Trauma, and the Justice System (2008); a white paper issued by the Drug Policy Alliance

(“Healing a Broken System: Veterans Battling Addiction and Incarceration, 2009), and a review

by McGuire (2007) entitled “Closing a Front Door to Homelessness among Veterans”. Key

recommendations from these reports are relevant for homeless veteran populations, including the

following:

 Provide routine screening at various points in the criminal justice system for military

service, homelessness, and related issues (e.g., trauma, other mental disorders, substance use

disorders). Key points include pre-trial screening, intake to probation and parole settings, jail

booking, and prison reception.

 Encourage use of veteran peer specialists who can work in the criminal justice system,

and who are knowledgeable about homeless and VA services.

 Homeless services for Veterans exiting the justice system (either from custody or post-

sentence community dispositions) should address a comprehensive range of needs, including

trauma, depression, and other mental disorders, substance abuse treatment needs, physical health

issues, and employment.

 Law enforcement, court, community supervision, correctional, and other criminal justice

professionals should receive training in identifying signs and symptoms of combat-related

trauma, triage to VA and other community services (e.g., homeless, behavioral health services),

and to help respond effectively to Veterans who are experiencing mental health crises. For

example, law enforcement Crisis Intervention Teams (CITs) would benefit from specialized

training in deescalation techniques for combat Veterans who are experiencing PTSD.”

 Technical assistance should be offered to existing diversion programs (e.g., drug courts,

mental health courts, jail diversion initiatives) to adapt and refine specialized programs for

Veterans, and specialized approaches/interventions for Veterans who are homeless or at risk for

homelessness.

 Policy initiatives at the county, state, and federal level should focus on: (1) encouraging

legislation that authorizes diversion of non-violent Veterans from the criminal justice system to

community dispositions that include linkage with homeless services and participation in mental

health and substance abuse treatment services, (2) funding for development of innovative

programs to divert this population from the justice system, (3) research to examine criminal

justice and economic outcomes of these interventions, and (4) reducing barriers to community

integration among Veterans with criminal justice involvement, homelessness, and related

psychosocial problems. Initiatives in this latter area would address issues of engagement in VA

services, eligibility for short and long-term housing, community outreach and case management,

and reinstatement of SSI benefits.

 For homeless Veterans with substance abuse problems, community-based services should

be expanded to include greater use of methadone and buprenorphine.

 Support should be provided to Veterans Justice Outreach specialists (VJOs) within the

VA system to address the reentry needs of incarcerated Veterans, including housing. For

example, reentry plans should be developed for all incarcerated Veterans that address

homelessness and housing issues. Veterans in the justice system who are homeless or at risk for

homelessness should receive priority among VJOs in receiving services.

In addition, McGuire (2007) proposes the following recommendations or lessons learned on

preventing homelessness among incarcerated Veterans

 First, a collaborative partnership with the corrections system must be established and

nurtured over time to gain access to Veterans and to insure coordination of re-entry planning.

 Second, practical planning to assure that Veterans leaving prison or jail are actually

connected to the VA for follow-up services is essential. Without such arrangements in place,

barriers (lack of transportation, money) at the time of release may prevent follow-through by the

Veterans.

 Third, an array of both VA and non-VA community services is needed to provide the

scope and intensity of services needed by re-entering Veterans.

 Finally, Veterans who have been incarcerated for long periods, usually in prison, benefit

from an extended process of deinstitutionalization upon release during which considerable

structure is initially provided that is gradually replaced by personal initiative; new coping skills

are also developed to support adaptation to community living over time.

Preliminary planning for development of the model has incorporated five principles:

 encouraging voluntary participation by Veterans;

 coordinating with corrections and non-VA community providers;

 providing information on VA benefits, including healthcare;

 screening for medical, social, mental health, and substance abuse problems; and

 using outreach workers to serve as referral and linkage points of contact upon release as

well as follow-up contact for re-entry crises and linkage problems.

Homelessness and Health Services

Homelessness and health care needs are interrelated in numerous ways with homeless

persons facing a myriad of barriers which limit their access to and quality of health care services.

Homeless individuals experience high rates of physical illness, mental illness, substance use

disorders, and early mortality (Kushel, Vittinghoff, & Haas, 2001; National Coalition for the

Homeless, 2009). Health problems may be exacerbated among homeless veteran populations

due to increased rates of co-occurring substance use disorders and mental illness (Rosenheck,

Leda, Frisman, Lam, & Chung, 1996). Barriers that limit the access to and quality of health care

among homeless persons include their multiple and diverse health care needs, lack of health

insurance and health benefits, lack of coordination between systems of care, as well as

perceptions of uncompassionate care (Kushel, Vittinghoff, & Haas, 2001; National Coalition for

the Homeless, 2009; Rosenheck, Resnick, & Morrissey, 2003).

The well-established relationship between homelessness and health care needs has led to

a growing body of empirical research on the topic of improving access to and quality of health

services among this population. Two suggested interventions that have received strong empirical

support include the provision of and maintenance of health care benefits (Kushel, Vittinghoff, &

Haas, 2001), as well as the improvement of communication and cooperation between systems of

care to provide more uniform services for the diverse needs of homeless individuals (Rosenheck,

Resnick, & Morrissey, 2003). Efforts may also be made to increase awareness of services

among homeless populations and encourage individuals to seek available health care services.

Nature of OEF/OIF and implications for homelessness

While numerous studies document the increased risk of homeless between Veterans and

non-Veterans, Veterans of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) are

becoming homeless sooner than earlier Veterans (Fairweather, 2006). The repeated and

extended employments faced by OEF/OIF Veterans are themselves a risk factor for

homelessness, related to combat exposure and the development of post-traumatic stress disorder

(PTSD), as well as the inability to maintain continuity in civilian life (e.g., housing and

employment) and social supports (Fairweather, 2006).

Difficulties in accessing VA services (both during and after service), as well as the

difficulties of the meeting the mental health needs among OEF/OIF Veterans, increases the risk

of homelessness among this population (Fairweather, 2006). Many OEF/OIF Veterans are

National Guard or Reserve troops (approximately 40%); National Guard and Reserve troops are

about as half as likely to file VA claims and about half as likely to have their claims approved

when compared to regular forces. Additionally, the needs of Veterans experiencing PTSD as

well as traumatic brain injuries (TBI), characterized by a broad range of physical, cognitive,

behavioral, emotional, and social challenges, offer particular challenges to Veterans’ access and

receipt of necessary services. Antisocial behaviors related to TBI may place our troops at

further risk of homelessness due to legal issues and/or dishonorable discharges. Many Veterans

are receiving inappropriate less-than-honorable discharges for relating to behavioral health needs

symptomatic of PTSD and TBI. While OEF/OIF Veterans may be receiving less-than-honorable

discharges due to psychological symptoms, the will be barred from receiving VA mental health

services in the future.

Homelessness prevention efforts among OEF/OIF Veterans should focus on the proper

diagnosis and provision of adequate care to Veterans during deployments, between deployments,

and after military service. Many Veterans with mental health needs go undiagnosed, not

receiving the proper services and/or being barred from ever again receiving mental health

services from the VA which would greatly increase their ability to remain stably housed within

the community. More resources should be devoted to: VA outreach efforts for OEF/OIF

Veterans and limiting bureaucratic obstacles and delays to care and services; meeting the mental

health needs of OEF/OIF Veterans seeking counseling and PTSD treatment; meeting VA

disability claims (long waits for income increase the risk of homelessness); and providing family

services and gender-specific care to Veterans.

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