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

objectives

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.

methods

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.

results

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.

conclusions

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.