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

objectives

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. 

methods

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.

results

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. 

conclusions

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.