VA Homeless Programs

VA’s Implementation of Housing First Over the Years

By Shawn Liu, director of communications, Homeless Programs Office

December 18, 2023

The U.S. Department of Veterans Affairs (VA) is committed to ending homelessness among Veterans because it is our nation’s duty to ensure all Veterans have a place to call home.

VA’s efforts to prevent and end Veteran homelessness are built around the evidence-based Housing First approach. This approach prioritizes getting a Veteran into housing and then assists the Veteran with access to health care and other supports that promote stable housing and improved quality of life. VA does not try to determine who is “housing ready” or demand treatment prior to housing. Instead, treatment and other support services are wrapped around Veterans as they obtain and maintain permanent housing. 

The core principles of Housing First have been critical components of VA’s broader homelessness assistance programs since it became VA’s official policy in 2012. The results speak for themselves. Since 2010, Veteran homelessness has decreased by over 52%, and 83 communities and three states have effectively ended homelessness.

When discussing Housing First, it is critical to acknowledge the important and stark differences between the original evidence-based model and evolving approach. These two concepts are often conflated or left unspoken, which has historically led to significant confusion and misunderstandings in conversations about Housing First implementation and efficacy. This paper explores the essential themes of VA’s implementation of Housing First, both as a model and as an approach.

The Housing First Model Background

The Housing First model, which first took root in the 1990s, was developed in North America to meet the housing and treatment needs of the chronic homeless population who typically have mental health disorders, including substance use disorders. Unlike the preexisting “linear” model, which required program participants to demonstrate increasing levels of stability before advancing to greater levels of both support and autonomy, the Housing First model principles maintain that housing is a fundamental right and that housing programs should identify and address the needs of the people it serves from the people’s perspective.

These principles are foundational to its hallmark features of providing immediate access to permanent, subsidized, independent housing without treatment participation or sobriety prerequisites. They also underlie the model’s name—“Housing First”—whereas the preexisting model requires a demonstration of “housing readiness” before the person is provided permanent, non-transitional housing. Here, permanent housing is considered a critical tool, rather than a reward, for recovery. It centers on providing or connecting homeless people to permanent housing as quickly as possible while offering services as needed and requested voluntarily and that do not make housing contingent on participation in services.

In its development, the Housing First model was often implemented through permanent supportive housing (PSH) interventions staffed by Assertive Community Treatment-style teams consisting of social workers, nurses, psychiatrists and vocational and substance abuse counselors available 24 hours a day, seven days a week.

Pathways to Housing, one of the originators of the model, developed a fidelity scale to evaluate the effectiveness of Housing First model implementations. The Joint Commission’s Behavioral Health Care accreditation standards also supported the Housing First model implementation. Over the years, the scientific evidence documenting the efficacy of the Housing First model has grown considerably.

VA’s History Implementing the Housing First Model

Initially, the Housing First model within VA was most closely associated with the HUD-VASH program. This PSH intervention pairs HUD’s Housing Choice Vouchers (which help make rental costs affordable) with VA’s clinical case management and health care services. HUD-VASH is universally recognized as the world’s most extensive permanent housing program, with more than 100,000 Housing Choice Vouchers nationwide.

HUD-VASH offers countless opportunities to evaluate Housing First model implementations naturalistically and at scale in contrast to the smaller demonstration projects that contributed to the original model evidence base. When Kertez, et al. conducted a fidelity review of VA’s implementation of the Housing First model within HUD-VASH, they identified several key themes broken out by strengths and challenges, described here as opportunities for improvement:

As these strengths and opportunities emerged over the last ten years, they also planted the seeds for expanding a Housing First approach across homeless programs and services.

The Housing First Approach

Today, the high-level principles for Housing First are widely accepted. From the National Alliance to End Homelessness:

Housing First is an approach that prioritizes providing permanent housing to people experiencing homelessness, thus ending their homelessness and serving as a platform from which they can pursue personal goals and improve their quality of life. This approach is guided by the belief that people need basic necessities like food and a place to live before attending to anything less critical, such as getting a job, budgeting properly or attending to substance use issues. Additionally, Housing First is based on the belief that client choice is valuable in housing selection and supportive service participation; exercising that choice is likely to make a client more successful in remaining housed and improving their life. Housing First programs remove barriers faced by households trying to attain permanent housing and do not require prerequisites to access housing support beyond what is required in a tenant’s lease.

Other key stakeholders, such as HUD, offer information on the adaptation and applicability of a Housing First approach.

Consistent with Kertez, et al.’s research on HUD-VASH programs, VA has received anecdotal reports suggesting it was:

• Easier for communities to implement the components of the Housing First model, which focused on eliminating enrollment preconditions and expediting placement into housing.
• Moderately challenging to implement the prioritization aspects.
• Significantly more complicated to implement the access to services and the recovery-oriented philosophies which many times is contingent to local available resources.

It is understandable then that communities would adopt the language of using Housing First as an approach.

VA’s Implementation of the Housing First Approach

VA has found significant value in adopting Housing First as an approach, not only through its rapid expansion of HUD-VASH but also in increasing vulnerable Veterans’ access to non-PSH programs such as Health Care for Homeless Veterans (HCHV) Contracted Residential Services emergency shelter, Grant and Per Diem (GPD) transitional housing and Supportive Services for Veteran Families (SSVF) rapid rehousing. Indeed, the emphasis on eliminating enrollment preconditions and expediting placement into housing is generally considered within VA to have contributed to shorter lengths of stay among transitional housing providers, maintaining or sometimes improving the rate of exit to permanent housing and increasing access to SSVF for Veterans who may not have income or may still struggle with minor substance use disorders or moderate mental health conditions. If not for VA’s adoption of the Housing First approach, which broadened its reach to programs other than PSH and encouraged systemwide Housing First orientations, we would not have seen the over 52% reduction in Veteran homelessness since 2010.

At the center of VA’s Housing First approach is Veteran choice and dignity—VA honors Veteran autonomy and the decisions that shape their arc of homelessness to housing journey. Historically, transitional housing has been most closely associated with the “linear” model that the Housing First emerged to refute. The prior orientation required homeless individuals and families to demonstrate increasing levels of stability as they progressed through different stages of the system: emergency shelter to transitional housing to permanent supportive housing. This orientation was perceived as working well for people with minimal treatment needs or who can navigate the steps of the linear model.

However, it raised insurmountable barriers for those with serious mental illness, significant substance addiction or severe chronic medical conditions (e.g., people experiencing chronic homelessness or other vulnerabilities). Previously, people experiencing street homelessness could not choose to go directly to permanent housing. However, with the rise of Housing First over the last 10 years, people experiencing homelessness could now decide to go right to housing, skipping over shelter and transitional housing interventions.

VA’s historical strength has been, and should continue to be, honoring Veterans’ choices, preserving their dignity by ensuring housing is immediately offered as a tool rather than a reward that has to be earned and ensuring they can easily access the full continuum of VA and community programs and services.

VA Homeless Programs Guiding Principles

As VA continues to reduce the number of Veterans experiencing homelessness in America, both the model and approach of Housing First will be its “North Star.”

The following Housing First approach guiding principles are shared among key stakeholders and have helped VA continue to progress in reducing and ending Veteran homelessness.

1. Honor Veteran housing and treatment choices and dignity at the forefront. Not only is this the right thing to do to honor their service, but it’s also scientifically more effective. Studies have shown that when consumers have choices in the interventions they receive, they adhere to treatment plans and are less likely to drop out. This often involves ensuring that housing options and services can effectively accommodate Veterans with disabilities, minimize harm or traumatization, promote health and, ultimately, community and independence among tenants.
2. Improve methods of prioritization of the most vulnerable homeless Veterans. “First come, first served” approaches to service delivery often negatively impact vulnerable populations (e.g., Veterans who are women, Black, persons of color, older, have chronic disabilities and LGBTQ+) and can lead to more extended periods of homelessness, longer times to be housed and higher rates of returns to homelessness. These groups should be prioritized for services to ensure equitable access to housing resources.
3. Provide few to no programmatic prerequisites to permanent housing entry. The option of permanent housing with no programmatic preconditions, such as demonstration of sobriety, completion of alcohol or drug treatment or agreeing to comply with a treatment regimen upon entry into the program, should be immediately available to Veterans, including not requiring Veterans to enter a transitional housing program as a prerequisite for permanent housing.
4. Provide low barrier and immediate access admission policies. Admissions policies are designed to “screen in” rather than screen out applicants with the most significant barriers to housing, such as having no or very low income, poor rental history, past evictions or criminal histories. Housing programs should try to offer the choice of permanent housing as quickly as possible, streamlining application and approval processes and reducing wait times.
5. Offer rapid and streamlined entry into housing. Many people experiencing chronic homelessness may encounter anxiety and uncertainty during a lengthy housing application and approval process. To ameliorate this, Housing First permanent supportive housing models make efforts to help people experiencing homelessness move into permanent housing as quickly as possible, streamlining application and approval processes and reducing wait times. Supportive services are voluntary but can and should be used to engage tenants to ensure persistent housing stability.
6. Proactively offer supportive services to help tenants achieve and maintain housing stability. But tenants are not required to participate in services as a condition of tenancy. Techniques such as harm reduction and motivational interviewing may be helpful. Also, it helps shift the perception that Housing First is not “Housing Only.” It offers the robust supportive services and benefits that VA provides Veterans through the Health and Benefits Administrations.
7. Incorporate practices and policies to prevent lease violations and evictions among tenants. For instance, not considering alcohol or drug use in and of itself to be a lease violation unless such use results in disturbances to neighbors or is associated with illegal activity (e.g., selling illicit substances). Rather than moving towards eviction proceedings due to missed rent payments, programs may allow tenants to enter payment installment plans for rent arrearages or offer money management assistance to tenants.
8. Increase the prevalence of recovery-oriented philosophies among service providers. Recovery-oriented care is patient-centered care and can help individuals move beyond managing symptoms of mental illness and towards improved life satisfaction and quality of life. In VA, recovery-oriented care is Veteran-directed, which means the Veteran is actively engaged throughout the treatment planning and recovery process. Through the Recovery Support Strategic Initiative, the Substance Abuse and Mental Health Services Administration (SAMHSA) has delineated four major dimensions that are essential to a life in recovery:                                                                                                                                                         
   1. Health: overcoming or managing one’s disease(s) and living physically and emotionally healthy.
   2. Home: a stable and safe place to live.
   3. Purpose: meaningful daily activities, such as a job, school, volunteerism, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society.
   4. Community: relationships and social networks that provide support, friendship, love, and hope.
9. Increase availability and access to sufficient supportive services in a community context. Housing First is not “Housing Only”—access to services such as case management, primary care, mental health and substance treatment, vocational and employment services and others is critical to ensuring that Veterans can achieve financial and housing stability. Housing providers can and should serve as brokers, linking Veterans to the right combination of resources for their individual needs.

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