Homelessness is associated with disproportionate medical morbidity and mortality and use of nonpreventive health services.1 In fiscal year 2010, veterans experiencing homelessness were 4 times more likely to use VA emergency departments and had a greater 10-year mortality risk than did veterans who were housed.1 Veterans experiencing homelessness were more likely to be diagnosed with substance use disorder, schizophrenia, liver disease, and/or HIV/AIDS than were their housed counterparts.
Ending veteran homelessness is a federal priority, exemplified by the goal of President Obama to end veteran homelessness by 2015.2 Since the goal’s articulation, veteran homelessness has declined nationally by 33% (24,117 veterans) from 2009 to 2014 however, 49,933 veterans were identified as being homeless on a given night in January 2014.3
Related: Landmark Initiative Signed for Homeless Veterans
A crucial element needed to end veteran homelessness is veteran and health care provider knowledge of existing homeless services and mechanisms of access. In 2012, VHA launched a homelessness screening clinical reminder in the Computerized Patient Record System (CPRS), which prompts a discussion of housing status between the veteran and provider.4 The staff of the VA North Texas Health Care System (VANTHCS) Comprehensive Homeless Center Programs (CHCP) realized that homeless housing programs at the facility could be more accessible if staff from each program could screen for all available programs and if a single phone number existed for scheduling appointments. Therefore, VANTHCS transformed its homeless housing screening process to a standardized process through which veterans are screened for all CHCP housing programs during a single screening assessment, Universal Homeless Housing Screening (UHHS).
This article describes the creation of the UHHS, the screening tool, 3-month postimplementation findings, and recommendations based on initial VANTHCS staff experiences with this process. During the redesign of screening process for homeless housing, VANTHCS staff found a paucity of guidance regarding best practices. This article attempts to fill this gap and provide guidance to institutions that are considering standardizing their screening process for homeless housing across multiple programs at different locations.
Background
Established in 1990, VANTHCS CHCP is VA’ s first comprehensive homeless center. The CHCP provides both housing and vocational rehabilitation programs, including 13 housing programs in 6 different cities and long-standing partnerships between CHCP and 3 community agencies whose programs have specific housing for veterans.5 Screenings performed in Dallas, Texas, for CHCP housing programs are completed at 4 separate locations.
Prior to the inception of the UHHS process, access to housing programs was limited by veteran awareness of the programs and transportation to various program locations. To participate in these programs, veterans needed to complete a form for the VA Northeast Program Evaluation Center (NEPEC), which staff at the Healthcare for Homeless Veterans (HCHV) CHCP program could administer. This process created an admission bottleneck, because HCHV staff needed to evaluate veterans even if they were being admitted to non-HCHV programs.
UHHS Creation Process
In 2011, NEPEC launched the electronic Homeless Operations Management and Evaluation System (HOMES) to replace paper-based reporting.6 This tool allowed non-HCHV CHCP staff to complete NEPEC evaluation and allowed CHCP to meet its goal of designing a system where all CHCP housing programs could complete a screening assessment. This goal originated from the desire of then CHCP Director Teresa House-Hatfield to create a more efficient housing screening process and from similar feedback from veterans.
Furthermore, in 2009, then Secretary of Veterans Affairs Eric K. Shinseki described a “no wrong door” philosophy for ending veteran homelessness, which CHCP operationalized by screening veterans for any CHCP housing program regardless of initial point of contact within the CHCP system.2 Subsequently, in 2010, the VA Office of Mental Health Services contracted with Mathematica Policy Research, Inc., to conduct a quality review of VA Mental Health Residential Rehabilitation Treatment Programs. Notable among their recommendations was to create a one-stop screening process for these programs.
Related: Primary Care Medical Services for Homeless Veterans
In 2010, CHCP embarked on a process to transform the facility’s screening procedure to a one-stop assessment with standardized screening questions and create a systematic process to track outcomes across all CHCP housing programs. The new process allowed for a standardized appeal procedure when eligibility for a program was not met. It also improved the ease of communication by having 1 phone number for making appointments or informing about screening times. These changes were enacted without the addition of any new staff positions. Instead, in October 2011, Ms. House-Hatfield tasked Dina Hooshyar of the VANTHCS to champion and spearhead this transformation.
The challenge associated with the UHHS creation process was to balance individual program autonomy with standardized processes. This balance was achieved through weekly calls where Ms. House- Hatfield, Dr. Hooshyar, and CHCP program managers discussed how to design UHHS. The management of the CHCP also actively sought input from CHCP frontline staff. During the preimplementation phase, Dr. Hooshyar gave multiple UHHS trainings to CHCP staff who would become involved in UHHS process, another feedback mechanism.
