Online Program

Fidelity to Housing First in the Veterans Health Administration: Lessons for implementation

Tuesday, November 3, 2015 : 9:30 a.m. - 9:50 a.m.

Erika Austin, PhD, MPH, Department of Biostatistics, University of Alabama at Birmingham School of Public Health, Birmingham, AL
Sally Holmes, MBA, VA Boston Healthcare System, Boston, MA
David Pollio, PhD, Department of Social Work, University of Alabama at Birmingham, Birmingham, AL
Carol VanDeusen Lukas, EdD, Center for Evaluating Patient-Centered Care in VA, Center for Healthcare Organization and Implementation Research, US Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA
Stefan Kertesz, MD, MSc, School of Medicine, Division of Preventive Medicine, University of Alabama, Birmingham, Birmingham, AL
Aerin deRussy, MPH, Birmingham VA Medical Center

Housing First (HF), an evidence-based practice, provides permanent supportive housing to highly-vulnerable homeless individuals. VA Medical Centers (VAMCs) are charged with employing this approach to manage over 65,000 rental vouchers through the HUD-VASH program.


We operationally defined HF based on two expert panels comprised of leaders in homeless/housing research and policy. We conducted 2 site visits at 8 VAMCs (one year apart), completing over 170 interviews with leadership, managers, and staff. We crafted detailed narratives and applied consensus scoring for 20 HF criteria (1=low adherence, 4=maximum adherence); average scores at baseline and follow-up were computed after sorting the 20 scores into 5 overarching domains.


High fidelity to HF was attained in some domains but not others at 1-year follow-up. Fidelity was high for “No preconditions” (3.63) and “Rapid permanent housing” (3.28), key defining characteristics of HF. Formal program rules and performance measures/incentives enhanced HF fidelity in these domains. Fidelity was mixed for “Prioritization of the most vulnerable” (3.13) and lower for “Sufficient supportive services” (2.51) and “Recovery orientation” (2.44). Operational issues (e.g., difficulties hiring staff) and limited resources for staff training hindered fidelity in these domains.


Senior and program leaders were able to overcome most philosophical reservations about housing veterans without formal requirements for sobriety/treatment. The operational necessities of allocating vouchers, intake, outreach, community coordination, and case management were left to middle managers. Our study found some difficulties with providing support services due to resource constraints.

Learning Areas:

Administration, management, leadership
Conduct evaluation related to programs, research, and other areas of practice

Learning Objectives:
Describe which domains of Housing First were most readily implemented with the Veterans Health Administration's HUD-VASH supportive housing program.

Keyword(s): Homelessness, Organizational Change

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am a PhD level researcher and have conducted scientific research independently for over 10 years.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.