HENRIETTA FISHMAN, DCSW, CASAC
SERVICE LINE MANAGER, VISN 3 HOMELESS VETERANS TREATMENT PROGRAMS
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
It is an honor to be here as the Manager of the Network 3 Homeless Veterans Treatment Programs Service Line. This is the first homeless veterans programs service line in the Veterans Health Administration. It includes all of the specialized interdisciplinary programs aimed at providing treatment and assistance to homeless veterans. The continuum encompasses outreach throughout southern New York and New Jersey, including shelters, prisons and areas where the homeless congregate; inreach to homeless veterans in VA acute and longterm beds; case management; drop-in centers; day treatment programs; domiciliary residential treatment programs; contract residential care; Compensated Work Therapy and Veterans Industries; transitional supported housing; and long-term housing with case management through the HUD-VASH Program. In addition, the comprehensive range of our community partnerships has enriched services and the lives of the veterans served.
Why did we establish a service line, given the range of other options possible? In announcing the designation of the service line, Mr. James J. Farsetta, Network Director, stated that "Helping homeless veterans move from streets and shelters to productive lives in the community is a priority in Veterans Integrated Service Network (VISN) 3." First and foremost, the top leadership in VISN 3 was committed to providing a single standard of care for homeless veterans. The concept of ‘one VA’ is particularly relevant. When programs are medical-center based, instead of integrated as a network, there always is the possibility that veterans will not have access to the full compliment of specialized programs. Moving from a medical-center-based perspective to a network focus, positions the homeless programs to serve as resources for all homeless veterans in the Network, wherever they are located. The service line organization provides a venue for standardizing policies and procedures and criteria for admission. Inconsistencies in resources, staffing, treatment outcomes and productivity can be monitored and appropriately addressed. The goal is to improve homeless veterans’ access to the right type of treatment at the right time and in the right place.
As a service line we are able to minimize the ‘administrative layering’ which can significantly compromise the timeliness, effectiveness and creativity necessary to forge community alliances. While the VA neither can nor should meet all of the complex needs of homeless veterans, we cannot form effective service partnerships with the community unless we can speak with one voice and as one VA. By minimizing the horizontal and vertical layers for input and approval at each medical center, we are able to come to the table to negotiate with the community for the priorities established by the network. This enhances the ability of the VA to build bridges to the community, working together as members of one team to provide quality, effective and efficient services to homeless veterans.
The VISN 3 Homeless Veterans Treatment Programs Service Line is based on a matrix management model, with oversight provided by an Executive Council comprised of site managers from each facility. In addition, the chair of the Consumer Council, which is composed of homeless and formerly homeless veterans, is a member; as is the chair of the Consortium, which includes representatives from all of the VA’s homeless veterans programs. This service line formalizes structures which have operated informally for a number of years. The Consortium, which was initiated in 1991, won the Hammer Award in 1995 and the Public Employees Roundtable Award for the Federal Government for Excellence in Public Service in 1998. In developing and coordinating the Consortium, it was a never ending challenge and a privilege for me to work with a uniquely talented and dedicated team of staff representing all the VA homeless programs throughout the metropolitan area, Vet Center and Veterans Benefits Administration (VBA) to create a network of client-centered, innovative services.
The VA Consortium grew from a need to coordinate the VA homeless programs across medical center lines so that we could speak with one voice with city, state, federal and nonprofit agencies in advocating for homeless veterans’ needs and in developing services within the VA as well as between the VA and the community. Homeless veterans often fall between the cracks among the overwhelming numbers of homeless in this area. Working in tandem with homeless and formerly homeless veterans, the Consortium took leadership in creating models of service delivery which have been successfully replicated throughout the country. There was precedent for this as Project TORCH, VA’s first drop-in, day treatment program for homeless veterans, was developed in 1987 at the Brooklyn VA campus of what is now the New York Harbor Health Care System. Some of the initiatives developed by the Consortium include:
A number of activities have taken place or are ongoing within our new service line. They include:
While we are very proud of the accomplishments of our staff and the homeless and formerly homeless veterans who are valued members of our team, much work remains to be done. An accurate count of the number of homeless veterans in our VISN often depends on which data base and what definition is being used. However, some numbers invite attention. The FY 98 End-of-Year Survey of Homeless Veterans in VISN 3 compiled by NEPEC indicated that 24% of the 1227 veterans in acute beds, domiciliaries and PRRTP programs were homeless at admission. However, the residence of an additional 19% of the veterans at admission was in an institution. It is likely that these veterans also were homeless, which suggests that 43% of the veterans surveyed were homeless. An additional data source, using the Social Security numbers of veterans receiving outpatient treatment services in FY99, indicated that 4,345 homeless veterans were treated in VA clinics in this VISN.
An accurate count of homeless veterans within the New Jersey/southern New York area is not available. However, the New Jersey Department of Military and Veterans Services states that there are 7,000 homeless veterans in their state. The Coalition for the Homeless estimates that there are approximately 100,000 homeless individuals in the New York metropolitan area. If 23% are veterans [Findings of the National Survey of Homeless Assistance Providers and Clients, Interagency Council on the Homeless, December, 1999], then there could be as many as 23,000 homeless veterans. Our colleagues in Long Island and the southern New York counties report similarly high numbers. While these numbers are staggering, it is critical that we continue to approach the complex problems underlying the symptom of homelessness with all the hope, skill and compassion that we can muster. In our programs, we treat one veteran at a time, one day at a time, because each homeless veteran is unique, with his or her own needs, values and strengths. Lives are being saved by these programs; and large numbers of formerly homeless veterans have achieved goals that they would not have thought possible when we first met them on the streets and in shelters. We must never grow complacent about homelessness! And we never can accept that our streets have become "home" for countless veterans who served our country so that we could have safe homes.
The solutions to the problem of homelessness are as complex as the causes. While it is clear that homeless veterans need and want jobs and affordable housing, and that these things are critical for their recovery and healing, we must not lose sight of the big picture. The ongoing availability of case management, as well as medical, psychiatric and substance abuse treatment services is a major factor in veterans’ maintaining stability in the community. Our Consumer Council has urged that case management services be provided, as needed, to formerly homeless veterans after they obtain housing. They point out that this is the time when veterans are most vulnerable to relapse. The HUD-VASH program in our Network - which provides long-term case management - has demonstrated that over 68% of the veterans referred during a five-year period successfully completed the program and are leading productive lives in the community.
Some current trends have been noted. Extensive pre-vocational remedial skills building is needed by the majority of the homeless veterans we’re seeing, many of whom are not ready for Compensated Work Therapy. The number of veterans leaving domiciliary care programs on disability or retirement status has increased dramatically. For many, this increase appears to be based on the acuity of their medical and psychiatric problems; for others, there are very real barriers to employment faced by middle-aged and older veterans. Additional barriers to housing and employment are faced by the large numbers of African-American and Hispanic veterans in this Network’s homeless programs. Homeless veterans have been on the streets for longer periods of time than in earlier years, generally as the result of several episodes of homelessness. They are sicker than veterans seen in the past, with a number of serious medical and psychiatric diagnoses. With shorter lengths of stay in the VA hospitals, and the transition in mental health from a maintenance treatment philosophy of to that of recovery, there is growing demand for the specialized homeless treatment programs. Homeless veterans often are stabilized in the psychiatric and medical units and transferred to the domiciliaries to develop the skills necessary to transition to the community. Many of these veterans are unable to live independently. Discharge planning involves helping the veteran accept that he or she needs to live in a supervised environment in the community to prevent relapse into illness and homelessness. Given the high percentage of homeless veterans in our hospitals, domiciliaries and residential care facilities are major resources in the continuum of care.
A major focus in our service network is empowering homeless veterans to take an active role in their own recovery from homelessness. They work as partners with staff in setting and prioritizing goals for their lives, progressing at their own pace. Many veterans, sometimes while still homeless, begin to volunteer in the programs, leading self-help groups, and mentoring fragile peers. Our vision is to create a supportive community of veterans helping veterans which can be transferred to the community outside the VA’s walls. "…what appears to be most central to the reparation of the veterans’ broken spirit is the development of hope in the real possibility of connecting to others and belonging in the world." [Amelio A. D’Onofrio, Ph.D., "On the Psychology of the Homeless Veteran"].
Within VISN 3, a Mental Illness Research, Education and Clinical Center (MIRECC) clinical demonstration project will provide peer-assisted case management services to seriously and persistently mentally ill homeless veterans. Formerly homeless veterans will be employed as counselors to offer supportive services to these veterans in community settings. The goal is to enhance their quality of life, community tenure and treatment compliance as a result of the interventions and activities provided by their peers. Clinical services will be provided and supervised by professional staff. The social worker who will mentor and supervise the peer counselors is a formerly homeless veteran who graduated from the Domiciliary Care Program at the Brooklyn campus of the VA New York Harbor Health Care System. Mr. Angel Caban is a Vietnam Era Air Force veteran who recently was awarded the Master of Social Work degree from Hunter College in New York. He is here with us today.
This concludes my statement. I will be happy to respond to any questions from the Committees.