ESTELLA MORRIS, LCSW
PROGRAM MANAGER, VA COMPREHENSIVE HOMELESS CENTER
CENTRAL ARKANSAS VETERANS HEALTHCARE SYSTEM
LITTLE ROCK, ARKANSAS
COMMITTEE ON VETERANS' AFFAIRS, SUBCOMMITTEE ON HEALTH AND
SUBCOMMITTEE ON BENEFITS
U. S. HOUSE OF REPRESENTATIVES
March 9, 2000
Mr. Chairmen and Members of the Committees
The Health Care for Homeless Veterans (HCHV) Program in Little Rock is one of 43 original Homeless Chronically Mentally Ill (HCMI) Programs implemented by VA in 1987. Since that time, we have expanded our services to address the myriad of physical, social, vocational and psychological problems that plague the population of homeless veterans in the state. In 1995, we were named one of eight Comprehensive Homeless Centers (CHC). The CHC in Little Rock includes HCMI street and shelter outreach and case management, Housing and Urban Development (HUD)-VA supported housing, HCMI supported housing, community residential contract treatment, domiciliary care, Compensated Work Therapy Therapeutic Residence (CWT/TR), VA benefits linkage, and a drop-in day treatment center. The Day Treatment Center is the newest component of Little Rock Homeless Programs. It has been the location for all Health Care for Homeless Veterans Programs since it opened March 15, 1996. The Center is in an accessible community-based location where homeless veterans can receive psychosocial and health assessments, participate in group activities, obtain donated military and civilian clothing, receive personal hygiene items, and use laundry and shower facilities.
The primary goal of the CHC is to expedite the transition of homeless veterans from a state of instability to one of physical, mental, vocational and social constancy. Methodologies for achieving this goal include outreach, referrals for acute and residential treatment in permanent housing and supported aftercare with clinical follow-up. In 1997, our innovative approaches to achieving this vision earned us the distinction of being named one of the first six Clinical Programs of Excellence for treatment of homeless veterans in the VA system. We received this two-year designation again in 1999.
We use a Social Treatment Model that focuses on the strengths of our veterans. After twelve years of operation, we take pride in knowing that we have consistently provided services of exceptional quality that adhere to the "highest standards of clinical care, patient satisfaction, resource utilization, teaching and research."
In FY 99, we completed 474 intakes with 7,214 visits to 1,065 separate individuals. Of this number, 96.62% were males and 3.3% were females. Ninety five percent reported history of alcohol abuse, 84% reported history of drug abuse, 49% mental illness, 43% reported a medical illness and 62% admitted social or vocational skill deficits. Of that number 57.60% were African-Americans, 40.51% were Caucasians, 0.84% were Hispanic and 1.05% were other. The periods of service represented were Vietnam era, 47%, with 5% being between Korea and Vietnam, 1.05% being Korean, 0.42% pre Korean, 0.63% WWII, 43% Post Vietnam and 3.00% being Gulf War. Twenty-four percent reported combat exposure. We show that 45.57% were divorced, 22.57% were separated, 3.8% widowed, 6% married and 21.73% never married. Of the veterans seen in Little Rock, 41% indicated having been homeless more than one year compared to a national average of 26.94%. This reflects a greater degree of chronicity among homeless veterans in Arkansas.
In addition to a higher degree of chronic homelessness among veterans in Arkansas, the veterans appear to be much sicker. Eighty-one percent of veterans report hospitalization for a psychiatric or substance abuse problem compared to 66.97% for all other sites. To further complicate the picture, a population-based study by Dr. Rosenheck and others found that, VISN 16 had the second highest number of veterans with incomes below $10,000. Despite the fact that our veterans are sicker, more chronically homeless and poorer, clinical outcome measures from VA’s Northeast Program Evaluation Center (NEPEC) show that veterans discharged from residential treatment in Little Rock were consistently above the VA national average in improvements shown for all diagnostic categories. NEPEC data demonstrates that in 1998, 75.6% of veterans discharged from the HCHV program at Little Rock showed improvements regarding alcohol abuse compared to 67.9% nationally. In the area of drug abuse, 82.6% showed improvements compared to a national average of 66.7%. Improvement in mental health status was 85.7% for Little Rock compared to 62.9% nationally. In the social/vocational arena, we showed 84.5% improvement compared to the national average of 60%. Finally, we had 85.7% improvement in medical problems compared to 64.8% nationally.
We make referrals to the medical center for acute treatment in cases where veterans are actively abusing alcohol or drugs, in need of mental health follow-up or medical screening. In addition, we have taken several other actions to improve the health of the homeless veteran population outside of the medical center. We conduct health screenings, provide flu shots and TB screening for veterans in shelters, at soup kitchens and at the Drop-In Center. In 1997 and 1998, we saw a significant number of veterans diagnosed with hepatitis C. This has resulted in targeted training during our health care prevention education groups at the Drop-In Center. During flu season, we undertake a significant outreach effort including making announcements at the shelters and soup kitchens and generally, "put the word out on the streets" when we receive the flu vaccine. This effort helps reduce the incidence of influenza in veterans on the streets, thus reducing the cases of emergency room visits or medical admissions.
We ensure the overall operating efficiency of the HCHV Program by closely monitoring admissions and discharges. This increases the probability of veterans taking advantage of the services of the program to improve their homeless status. This means assessing their motivation for treatment and testing to ensure that veterans going into residential treatment are not abusing alcohol or drugs. It also means discharging veterans abusing the drug and alcohol free environment of the treatment setting. This minimizes instances of veterans being admitted to treatment who are not sincere about maintaining their sobriety or working on mental health stability. In addition, we monitor the clinical capability of staff employed by the treatment facilities as a means of insuring that veterans are receiving the services that we are contracting for, rather than just maintenance services. Finally, we have weekly clinical case management conferences to insure that all staff are aware of clinical needs of veterans and to insure that those needs are addressed. We use these sessions to monitor progress of veterans in following their treatment plans, maintaining required savings and taking appropriate actions in working with VA Supported Housing and Supported Housing staff for locating permanent housing. We also invite clinical staff from our residential treatment facilities to participate in case conferences and provide monthly reports of program participants. The overall goal of these conferences is to insure continuity of care and to insure that all is being done that can be done on the part of the clinician and the veteran.
To improve veteran’s accessibility to our program we moved to a community location in March 1996. In our opinion this was a productive move. This location increased convenience for both customers and staff. It also allowed us to increase the number of services that are readily available to veterans. Many veterans come to the Drop-In Center for screenings and referrals rather than going to the medical center, because the waiting time is much shorter. We make an effort to insure that veterans needing services have to wait no longer than 15 minutes before being seen by a case manager; most are seen within five minutes. Several years ago, we increased our hours to cover twelve-hour periods Monday - Thursday. This allows workers to provide individual and group clinical services to veterans in the evening. We also provide services that they are unable to get at other locations, i.e., laundry and shower services, coffee, snacks for breakfast and lunch, lockers, clothing, recreational facilities, and a place to call their own. We allow them to have input into the services provided and often engage them in assisting with various chores around the center. We assign veterans frequenting the center to individual case managers for assistance with achieving stability. We have implemented a customer satisfaction survey that helps us monitor customer satisfaction with services. This helps to keep us aware of any need for targeted improvements or changes.
We place an average of 85 veterans annually in residential treatment with an average length of stay of 61 days. We seek to improve the overall standard of care for residential treatment facilities by identifying areas where gaps in services exist. CHC visit the treatment facilities 3-4 times per week and monitor documentation of staff treatment practices monthly. We also ensure continuity of care of patients discharged from residential care. In 1998, we scheduled follow-up treatment for 97% of veterans discharged from residential treatment, compared to 80.7% nationally. We scheduled 97.4% of veterans with a history of drug abuse for follow-up while 81.6% were scheduled for follow-up nationally. We had 98.4% scheduled for medical follow-up locally with 84.4% being scheduled for follow-up nationally. We have consistently remained above the national average in improvement and scheduling of follow-up care for all clinical areas since 1993.
Four years ago, we entered into an agreement with VA substance abuse staff to provide in-house treatment sessions to veterans in residential placement. This eliminated the problem veterans were having due to lack of city transportation in the evenings, discontinuance of weekend groups and problems with job scheduling.
We have consistently maintained a per diem rate in the contract residential care program well below the national average. Our overall cost for services is further reduced through use of non-VA resources when appropriate. This includes our collaboration with one non-profit homeless provider for a full time vocational case manager and a contract job counselor through the HUD Continuum of Care Grant and with another non-profit provider for a HUD Emergency Shelter grant to help cover expenses and provide food at the Drop-In Center.
We base our standards for success of the residential care program on the number of individuals in permanent housing at discharge. We use this measure, because the ultimate goal of HCMI Residential Treatment is permanent housing placement. Of veterans in HCMI residential treatment, 57.52 % were discharged to their own apartment, compared to 32% nationally. We believe one of the reasons for success in this area is the fact that we ensure that veterans have adequate funds saved that would allow them to remain in housing. Quantifiable evidence is seen in the improvements in permanent housing placement from 1991 to 1998. Our Domiciliary Program had 71% discharged to permanent housing, compared to 58% nationally. We also show that 70% of veterans discharged from the Domiciliary were employed, compared to 54% nationally.
Veterans without disability payments require 90 days on the average to save adequate money for an apartment and housing start-up items. In addition, veterans leaving the program are not allowed to return within a six months period. We will, however, assist them in getting into community programs with the understanding that they can again return to our program in six months. This has been an incentive for veterans to use the services for the purposes for which they were designed.
The Homeless Veterans and Families Program funded through the HUD Continuum of Care is one example of an innovative program that is coordinated by HCHV. This program provides a full-time (40 hours/week) vocational case manager and a contract job placement counselor that are available on site to assist veterans with employment. This is a collaborative program with Volunteers of America (VOA).
Our focus is on meeting the homeless veterans where they are and helping them to address their needs in an environment that is conducive to their lifestyle. We strive to be non-judgmental in our manner and supportive in our services, without fostering dependence. This is especially important in housing as we believe the individuals at greatest risk of homelessness are those who have been homeless in the past. Maintaining an awareness of this helps to keep us attentive to the needs of veterans in permanent housing. Their satisfaction and continued success means that we have achieved some level of success in and understanding of what we do to move veterans from the streets to permanent housing.
My appreciation of the value of VA homeless programs extends far beyond my experience over the past 13 years as a Program Manager for the exemplary VA Homeless Program that we have in Little Rock. I am the second oldest of 14 children, 6 sisters and 7 brothers, 10 of us have served in the military. I have a younger brother who completed the VA Homeless Program in San Diego, under the clinical Management of Elizabeth Pinner, 12 years ago. He experienced a traumatic head injury while completing a tour of duty in Germany. As a result he experienced migraine headaches and severe sleep disorders. He turned to alcohol as a means of self-medication. He was one of the first graduates of that program and has now been stable and in permanent housing for 12 years. He is currently completing a two-year Associate Degree Computer Training Program. I also have a younger sister who became homeless and moved into a shelter as a result of her involvement in a co-dependent relationship. She received assistance from the VA Homeless Program in Atlanta and now continues to maintain full-time employment and has now been in stable housing for approximately 4 years. I deeply appreciate the VA programs and clinicians that helped my brother and sister. Their progress and the progress of the homeless veterans seen at the Central Arkansas Comprehensive Homeless Center are vivid examples of the value of directly addressing the needs of homeless veterans.
This concludes my statement. I will be pleased to respond to the Committee’s questions.