Online Program

Case management in the Veterans Health Administration's transition to Housing First

Monday, November 2, 2015

Erika Austin, PhD, C-SMART, Birmingham VA Medical Center, Birmingham, AL
David Pollio, PhD, Department of Social Work, University of Alabama at Birmingham, Birmingham, AL
Sally Holmes, MBA, VA Boston Healthcare System, Boston, MA
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

The VA has adopted Housing First (HF), an evidence-based practice for providing permanent supportive housing to highly-vulnerable homeless individuals, as a primary mechanism for achieving the goal of ending Veteran homelessness. While variations in organizational uptake and fidelity to the HF model have been documented, the impact and consequences of variations in fidelity to the model on the daily practice of case management remains unclear. 


Examining case management behaviors requires direct observation of practice. Two experienced ethnographic researchers conducted day-long shadowing of case managers as they interacted with clients and other case management staff. These data were collected as part of a multisite study of HF implementation at 8 VA Medical Centers (VAMCs). Comprehensive narratives were developed for each day of shadowing; these were paired with qualitative interview data and fidelity ratings from the larger study to produce a comprehensive understanding of the context of case management at each study site.


The narratives revealed strong general knowledge of both HF philosophy and specific HF practices. Variations in the depth of commitment to the model were noted, roughly corresponding with each VAMC’s overall level of fidelity to the HF model. Modifications to practice were observed as a result of geographies, resources, or transportation availability. Differences were not observed based on level of education or discipline of the specific case managers. 


The findings of this ethnographic study suggest congruence between organizational adoption of and fidelity to HF and case management behaviors. Case managers expressed (and were observed to have) a strong and positive commitment to the Veterans. Although ethnography is limited in generalizability, the results suggest that fidelity to HF is informally modified by the realities of providing daily services, and that some of these challenges could be more directly addressed by VAMCs as part of the implementation process.

Learning Areas:

Implementation of health education strategies, interventions and programs
Other professions or practice related to public health
Social and behavioral sciences

Learning Objectives:
Describe variations in case management practices in the VA's Housing First program.

Keyword(s): Homelessness, Case Management

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I have been a PhD level researcher 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.