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United States Government Accountability Office: GAO:
Testimony before the Subcommittee on Health, Committee on Veterans'
Affairs, House of Representatives:
For Release on Delivery:
Expected at 10:00 a.m. EDT:
Thursday, September 27, 2007:
Homeless Veterans Programs:
Bed Capacity, Service and Communication Gaps Challenge the Grant and
Per Diem Program:
Statement of Daniel Bertoni:
Director:
Education, Workforce, and Income Security Issues:
GAO Highlights:
Highlights of GAO-07-1265T, a testimony before the Subcommittee on
Health, Committee on Veterans' Affairs, House of Representatives.
Why GAO Did This Study:
The Subcommittee on Health of the Committee on Veterans’ Affairs asked
GAO to discuss its recent work on the Department of Veterans Affairs’
(VA) Homeless Providers Grant and Per Diem (GPD) program.
GAO reported on this subject in September 2006, focusing on (1) VA’s
estimates of the number of homeless veterans and transitional housing
beds, (2) the extent of collaboration involved in the provision of GPD
and related services, and (3) VA’s assessment of program performance.
What GAO Found:
VA estimates that about 196,000 veterans nationwide were homeless on a
given night in 2006, based on its annual survey, and that the number of
transitional beds available through VA and other organizations was not
sufficient to meet the needs of eligible veterans. The GPD program has
quadrupled its capacity to provide transitional housing for homeless
veterans since 2000, and additional growth is planned. As the GPD
program continues to grow, VA and its providers are also grappling with
how to accommodate the needs of the changing homeless veteran
population that will include increasing numbers of women and veterans
with dependents.
The GPD providers we visited collaborated with VA, local service
organizations, and other state and federal programs to offer a broad
array of services designed to help veterans achieve the three goals of
the GPD program—residential stability, increased skills or income, and
greater self-determination. However, most GPD providers noted key
service and communication gaps that included difficulties obtaining
affordable permanent housing and knowing with certainty which veterans
were eligible for the program, how long they could stay, and when
exceptions were possible.
VA data showed that many veterans leaving the GPD program were better
off in several ways—over half had successfully arranged independent
housing, nearly one-third had jobs, one-quarter were receiving
benefits, and significant percentages showed progress with substance
abuse, mental health or medical problems or demonstrated greater self-
determination in other ways. Some information on how veterans fare
after they leave the program was available from a onetime follow-up
study of 520 program participants, but such data are not routinely
collected.
We recommended that VA take steps to ensure that GPD policies and
procedures are consistently understood and to explore feasible means of
obtaining information about the circumstances of veterans after they
leave the GPD program. VA concurred and, following our review, has
taken several steps to improve communications and to develop a process
to track veterans’ progress shortly after they leave the program.
However following up at a later point might yield a better indication
of success.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.GAO-07-1265T]. For more information, contact
Daniel Bertoni at (202) 512-7215 or bertonid@gao.gov.
[End of section]
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting me here today to discuss the Homeless Providers
Grant and Per Diem (GPD) program, the largest program of its kind
administered by the Department of Veterans Affairs (VA). On any given
night in the United States, an estimated 700,000 people, including
veterans, are homeless and may sleep on the streets or in shelters.
Veterans constitute about one-third of the adult homeless population,
and many veterans who are not yet homeless may be at risk. To address
the needs of these homeless veterans, VA officials told us that through
the GPD program they fund over 300 grants to local agencies to house
approximately 15,000 homeless veterans over the course of a year at a
cost of about $95 million. The program is not designed to serve all
homeless veterans--it focuses on transitional housing and supportive
services for veterans who are most in need, including those who have
had problems with mental illness, substance abuse, or both.
My statement draws on GAO's report on this program issued in September
2006 that focused on (1) estimates of the number of homeless veterans
and transitional housing beds, (2) the extent of collaboration involved
in the provision of GPD and related services, and (3) VA's assessment
of program performance.[Footnote 1] I have also included information we
obtained in following up on VA's efforts to implement our
recommendations.
In summary, VA reported in 2006 that about 196,000 veterans were
homeless and that not enough transitional beds were available through
VA and other organizations to meet the needs of homeless veterans
eligible to use this assistance. To help meet these needs, the GPD
program has quadrupled its capacity since 2000 to about 8,200 beds, and
additional growth is planned. In addition to increasing transitional
bed capacity, VA and its providers are also grappling with how to
accommodate the needs of the changing homeless veteran population that
will include increasing numbers of women and veterans with dependents.
When we met with GPD providers who operate the program and their local
VA liaisons, we found that they were working collaboratively with other
organizations to deliver supportive services, but most also noted key
resource and communications gaps. Specifically, providers reported
difficulties finding affordable permanent housing for veterans ready to
leave the program. In addition the eligibility rules for the GPD
program were not always clear, a fact that could cause confusion and
could keep veterans from obtaining needed care. VA data showed that
many veterans were better off in terms of housing; employment; receipt
of public benefits; and progress with substance abuse, mental health,
or medical problems at the time they left the program, but VA did not
know how they were faring months or years later.
We recommended that VA take steps to ensure that GPD policies and
procedures are consistently understood and to explore feasible means of
obtaining information about the circumstances of veterans after they
leave the GPD program. VA concurred and, following our review, has
taken several steps to improve communications and to develop a process
to track veterans’ progress shortly after they leave the program.
However following up at a later point might yield a better indication
of success.
Background:
The GPD program is one of six housing programs for homeless veterans
administered by the Veterans Health Administration, which also
undertakes outreach efforts and provides medical treatment for homeless
veterans.[Footnote 2] VA officials told us in fiscal year 2007 they
spent about $95 million on the GPD program to support two basic types
of grants—capital grants to pay for the buildings that house homeless
veterans and per diem grants for the day-to-day operational
expenses.[Footnote 3] Capital grants cover up to 65 percent of housing
acquisition, construction, or renovation costs. The per diem grants pay
a fixed dollar amount for each day an authorized bed is occupied by an
eligible veteran up to the maximum number of beds allowed by the
grant—in 2007 the amount cannot exceed $31.30 per person per day. VA
pays providers after they have housed the veteran, on a cost
reimbursement basis. Reimbursement may be lower for providers whose
costs are lower or are offset by funds for the same purpose from other
sources.
Through a network of over 300 local providers, consisting of nonprofit
or public agencies, the GPD program offers beds to homeless veterans in
settings free of drugs and alcohol that are supervised 24 hours a day,
7 days a week. Most GPD providers have 50 or fewer beds available, with
the majority of providers having 25 or fewer. Program rules generally
allow veterans to stay with a single GPD provider for 2 years, but
extensions may be granted when permanent housing has not been located
or the veteran requires additional time to prepare for independent
living. Providers, however, have the flexibility to set shorter time
frames. In addition, veterans are generally limited to a total of three
stays in the program over their lifetime, but local VA liaisons may
waive this limitation under certain circumstances. The program’s goals
are to help homeless veterans achieve residential stability, increase
their income or skill levels, and attain greater self-determination.
To meet VA’s minimum eligibility requirements for the program,
individuals must be veterans and must be homeless. A veteran is an
individual discharged or released from active military service. The GPD
program excludes individuals with a dishonorable discharge, but it may
accept veterans with shorter military service than required of veterans
who seek VA health care. A homeless individual is a person who lacks a
fixed, regular, adequate nighttime residence and instead stays at night
in a shelter, institution, or public or private place not designed for
regular sleeping accommodations.[Footnote 4] GPD providers determine if
potential participants are homeless, but local VA liaisons determine if
potential participants meet the program’s definition of veteran. VA
liaisons are also responsible for determining whether veterans have
exceeded their lifetime limit of three stays in the GPD program and for
issuing a waiver to that rule when appropriate. Prospective GPD
providers may identify additional eligibility requirements in their
grant documents.
While program policies are developed at the national level by VA
program staff, the local VA liaisons designated by VA medical centers
have primary responsibility for communicating with GPD providers in
their area. VA reported that in fiscal year 2007, there were funds to
support 122 full-time liaisons.[Footnote 5]
VA Has Expanded GPD Program Capacity to Help Meet Homeless Veterans’
Needs, but Demand Still Exceeds Supply:
Since fiscal year 2000, VA has quadrupled the number of available beds
and significantly increased the number of admissions of homeless
veterans to the GPD program in order to address some of the needs
identified through the its annual survey of homeless veterans. In
fiscal year 2006, VA estimated that on a given night, about 196,000
veterans were homeless and an additional 11,100 transitional beds were
needed to meet homeless veterans’ needs. However, this need was to be
met through the combined efforts of the GPD program and other federal,
state, or community programs that serve the homeless. VA had the
capacity to house about 8,200 veterans on any given night in the GPD
program. Over the course of the year, because some veterans completed
the program in a matter of months and others left before completion, VA
was able to admit about 15,400 veterans into the program, as shown in
figure 1. Despite VA rules allowing stays of up to 2 years, veterans
remained in the GPD program an average of 3 to 5 months in fiscal year
2006.
Figure 1: Numbers of GPD Admissions and Beds in Fiscal Years 2000 and
2006:
This is a vertical bar graph with Number on the vertical axis and Bed
and Admissions on the horizontal axis. The bars depict the following
data.
Number of Beds:
Fiscal year 2000: 2,000;
Fiscal Year 2006: 4,800.
Number of Admissions:
Fiscal year 2000: 8,200;
Fiscal Year 2006: 15,400.
Source: GAO analysis of VA data in annual reports from the Northeast
Program Evaluation Center.
{End of figure]
The need for transitional housing beds continues to exceed capacity,
according to VA’s annual survey of local areas served by VA medical
centers. The number of transitional beds available nationwide from all
sources increased to 40,600 in fiscal year 2006, but the need for beds
increased as well. As a result, VA estimates that about 11,100 more
beds are needed to serve the homeless, as shown in table 1. VA
officials told us that they expect to increase the bed capacity of the
GPD program to provide some of the needed beds.
Table 1: Available and Needed Transitional Beds for Homeless Veterans,
Fiscal Year 2006:
Transitional beds needed: 51,700;
Total transitional beds available, including GPD: 40,600;
Additional beds still needed: 11,100.
Source: GAO analysis of VA’s annual survey estimates rounded to nearest
100.
[End of table]
Most homeless veterans in the program had struggled with alcohol, drug,
medical or mental health problems before they entered the program. Over
40 percent of homeless veterans seen by VA had served during the
Vietnam era, and most of the remaining homeless veterans served after
that war, including at least 4,000 who served in military or
peacekeeping operations in the Persian Gulf, Afghanistan, Iraq, and
other areas since 1990. About 50 percent of homeless veterans were
between 45 and 54 years old, with 30 percent older and 20 percent
younger. African-Americans were disproportionately represented at 46
percent, the same percentage as non-Hispanic whites. Almost all
homeless veterans were men, and about 76 percent of veterans were
either divorced or never married.
An increasing number of homeless women veterans and veterans with
dependents are in need of transitional housing according to VA
officials and GPD providers we visited. The GPD providers told us in
2006 that women veterans had sought transitional housing; some recent
admissions had dependents; and a few of their beds were occupied by the
children of veterans, for whom VA could not provide reimbursement. VA
officials said that they may have to reconsider the type of housing and
services that they are providing with GPD funds in the future, but
currently they provide additional funding in the form of special needs
grants to a few GPD programs to serve homeless women veterans.
GPD Providers Collaborate to Offer a Range of Services, but Face
Challenges in Helping Veterans:
VA’s grant process encourages collaboration between GPD providers and
other service organizations. Addressing homelessness—particularly when
it is compounded by substance abuse and mental illness—is a challenge
involving a broad array of services that must be coordinated. To
encourage collaboration, VA’s grants process awards points to
prospective GPD providers who demonstrate in their grant documents that
they have relationships with groups such as local homeless networks,
community mental health or substance abuse agencies, VA medical
centers, and ancillary programs. The grant documents must also specify
how providers will deliver services to meet the program’s three
goals—residential stability, increased skill level or income, and
greater self-determination.
The GPD providers we visited often collaborated with VA, local service
organizations, and other state and federal programs to offer the broad
array of services needed to help veterans achieve the three goals of
the GPD program. Several providers worked with the local homeless
networks to identify permanent housing resources, and others sought
federal housing funds to build single-room occupancy units for
temporary use until more permanent long-term housing could be
developed.[Footnote 6] All providers we visited tried to help veterans
obtain financial benefits or employment. Some had staff who assessed a
veteran’s potential eligibility for public benefits such as food
stamps, Supplemental Security Income, or Social Security Disability
Insurance. Other providers relied on relationships with local or state
officials to provide this assessment, such as county veterans’ service
officers who reviewed veterans’ eligibility for state and federal
benefits or employment representatives who assisted with job searches,
training, and other employment issues. GPD providers also worked
collaboratively to provide health care-related services—such as mental
health and substance abuse treatment, and family and nutritional
counseling. While several programs used their own staff or their
partners’ staff to provide mental health or substance abuse services
and counseling directly, some GPD providers referred veterans off
site—typically, to a VA local medical center.
Despite GPD providers’ efforts to collaborate and leverage resources,
GPD providers and VA staff noted gaps in key services and resources,
particularly affordable permanent housing for veterans ready to leave
the GPD program. Providers also identified lack of transportation,
legal assistance, affordable dental care,[Footnote 7] and immediate
access to substance abuse treatment facilities as obstacles for
transitioning veterans out of homelessness. VA staff in some of the GPD
locations we visited told us that transportation issues made it
difficult for veterans to get to medical appointments or employment-
related activities. While one GPD provider we visited was able to
overcome transportation challenges by partnering with the local transit
company to obtain subsidies for homeless veterans, transportation
remained an issue for GPD providers that could not easily access VA
medical centers by public transit. Providers said difficulty in
obtaining legal assistance to resolve issues related to criminal
records or credit problems presented challenges in helping veterans
obtain jobs or permanent housing. In addition, some providers expressed
concerns about obtaining affordable dental care and about wait lists
for veterans referred to VA for substance abuse treatment.
We found that some providers and staff did not fully understand certain
GPD program policies—which in some cases may have affected veterans’
ability to get care. For instance, providers did not always have an
accurate understanding of the eligibility requirements and program stay
rules, despite VA’s efforts to communicate its program rules to GPD
providers and VA liaisons who implement the program. Some providers
were told incorrectly that veterans could not participate in the GPD
program unless they were eligible for VA health care. Several providers
understood the lifetime limit of three GPD stays but may not have known
or believed that VA had the authority to waive this rule.[Footnote 8]
As a consequence, we recommended that VA take steps to ensure that its
policies are understood by the staff and providers with responsibility
for implementing them.
In response to our recommendation that VA take steps to ensure that its
policies are understood by the staff and providers with responsibility
for implementing them, VA took several steps in 2007 to improve
communications with VA liaisons and GPD providers, such as calling new
providers to explain policies and summarizing their regular quarterly
conference calls on a new Web site, along with new or updated manuals.
Language on the number and length of allowable stays in the providers’
guide has not changed, however.
VA Data Show Many Veterans Have Housing and Jobs on Leaving the Program
and Plans Are Under Way for Follow-up:
VA assesses performance in two ways—the outcomes for veterans at the
time they leave the program and the performance of individual GPD
providers. VA’s data show that since 2000, a generally steady or
increasing percentage of veterans met each of the program’s three goals
at the time they left the GPD program.
Since 2000, proportionately more veterans are leaving the program with
housing or with a better handle on their substance abuse or health
issues. During 2006, over half of veterans obtained independent housing
when they left the GPD program, and another quarter were in
transitional housing programs, halfway houses, hospitals, nursing
homes, or similar forms of secured housing.[Footnote 9] Nearly one-
third of veterans had jobs, mostly on a full-time basis, when they left
the GPD program. One-quarter were receiving VA benefits when they left
the GPD program, and one-fifth were receiving other public benefits
such as Supplemental Security Income. Significant percentages also
demonstrated progress in handling alcohol, drug, mental health, or
medical problems and overcoming deficits in social or vocational
skills. For example, 67 percent of veterans admitted with substance
problems showed progress in handling these problems by the time they
left. Table 2 indicates the numbers or percentages involved.
Table 2: Number Served by VA’s Health Care for Homeless Veterans and
Grant and Per Diem Program and Veterans’ Outcomes, Fiscal years 2000
and 2006:
Participants served and outcomes: Number of veterans treated by VA’s
Health Care for Homeless Veterans’ (HCHV) staff;
2000: 43,082;
2006: 60,857.
Participants served and outcomes: Number of intake assessments of
homeless veterans by HCHV staff[a];
2000: 34,206;
2006: 38,667.
Participants served and outcomes: Number of admissions of veterans to
GPDs;
2000: 4,841;
2006: 15,443.
Participants served and outcomes: Number of discharges from GPDs;
2000: 4,020;
2006: 15,037[b].
Participants served and outcomes: Days a veteran stays at a GPD, on
average;
2000: 91;
2006: 139[c].
Participants served and outcomes: Housing stability outcomes: Number of
discharges from GPDs with independent housing;
2000: 1,163;
2006: 7,723.
Participants served and outcomes: Housing stability outcomes: Number of
discharges from GPDs with placement in halfway house or institution
such as hospital, nursing home, or domiciliary;
2000: 991;
2006: 3,648.
Participants served and outcomes: Increased income or skills outcomes:
Number of discharges from GPDs with full-time or part-time employment;
2000: 1,404;
2006: 4,766.
Participants served and outcomes: Increased income or skills outcomes:
Number of discharges from GPDs with VA benefits[d];
2000: Not Available;
2006: 3,648.
Participants served and outcomes: Increased income or skills outcomes:
Number of discharges from GPDs with Other public benefits[d];
2000: Not Available;
2006: 3,001.
Participants served and outcomes: Greater self-determination outcomes:
Percentage of discharges from GPDs with improved alcohol, drug, mental
health[e];
2000: 38-42;
2006: 60-67.
Participants served and outcomes: Greater self-determination outcomes:
Percentage of discharges from GPDs with improved medical,
social/vocational condition[e];
2000: 43-46;
2006: 57-62.
Participants served and outcomes: Greater self-determination outcomes:
Percentage of discharges from GPDs with success in meeting GPD provider
requirements;
2000: 30;
2006: 47.
Source: GAO analysis of VA data aggregated from individual discharge
forms completed by VA or GPD providers for veterans at the time they
leave the program and compiled in annual reports by VA’s evaluation
center.
[a] Intake assessments are completed by HCHV staff when they first
encounter a homeless veteran, unless the contact is casual and no
services are offered or referrals made. After a year, new assessments
are required if VA care or services are provided and VA staff have not
been working with the veteran.
[b] Number of discharges with complete data on their status is 14,710
and is used to calculate all numbers below.
[c] Mean is shown. Median is 81 days.
[d] Numbers shown here include veterans who receive both types of
benefits as well as those who receive only the designated benefits.
[e] Percentages are ranges showing the highest and lowest of each of
two or three outcome measures.
[End of table]
VA’s Office of Inspector General (OIG) found when it visited GPD
providers in 2005-2006 that VA officials had not been consistently
monitoring the GPD providers’ annual performance as required.[Footnote
10] The GPD program office has since moved to enforce the requirement
that VA liaisons review GPD providers’ performance when the VA team
comes on-site each year to inspect the GPD facility.
To assess the veterans’ success, VA has relied chiefly on measures of
veterans’ status at the time they leave the GPD program rather than
obtaining routine information on their status months or years later. In
part, this has been due to concerns about the costs, benefits, and
feasibility of more extensive follow-up. However, VA completed a
onetime study in January 2007 that a VA official told us cost about
$1.5 million. The study looked at the experience of a sample of 520
veterans who participated in the GPD program in five geographic
locations, including 360 who responded to interviews a year after they
had left the program. Generally, the findings confirm that veterans’
status at the time they leave the program can be maintained.
We recommended that VA explore feasible and cost-effective ways to
obtain information on how veterans are faring after they leave the
program. We suggested that where possible they could use data from GPD
providers and other VA sources, such as VA’s own follow-up health
assessments and GPD providers’ follow-up information on the
circumstances of veterans 3 to 12 months later. VA concurred and told
us in 2007 that VA’s Northeast Program Evaluation Center is piloting a
new form to be completed electronically by VA liaisons for every
veteran leaving the GPD program. The form asks for the veterans’
employment and housing status, as well as involvement, if any, in
substance abuse treatment, 1 month after they have left the program.
While following up at 1 month is a step in the right direction,
additional information at a later point would yield a better indication
of longer-term success.
Mr. Chairman, this concludes my remarks. I would be happy to answer any
questions that you or other members of the subcommittee may have.
Contact and Acknowledgements:
For further information, please contact Daniel Bertoni at (202) 512-
7215. Also contributing to this statement were Shelia Drake, Pat
Elston, Lise Levie, Nyree M. Ryder, and Charles Willson.
[End of section]
Footnotes:
[1] GAO, Homeless Veterans Programs: Improved Communications and Follow-
up Could Further Enhance the Grant and Per Diem Program, GAO-06-859
(Washington, D.C. Sept. 11, 2006).
[2] The other five programs are the Contracted Residential Treatment
Program, the Domiciliary Residential Rehabilitation and Treatment
Program, the Compensated Work Therapy/Transitional Residence Program,
the Loan Guarantee for Multifamily Transitional Housing, and the
Housing and Urban Development-VA Supported Housing program.
[3] On a limited basis, special needs grants are available to cover the
additional costs of serving women, frail elderly, terminally ill, or
chronically mentally ill veterans.
[4] The definitions appear at 42 U.S.C. § 11302 and 38 C.F.R. § 61.1.
[5] Liaisons told us in 2006 that they experienced large caseloads and
multiple GPD responsibilities—including eligibility determination,
verification of intake and discharge information, case management,
fiscal oversight, monitoring program compliance and inspections of GPD
facilities, among other duties. To address some of these concerns, VA
obtained funding to increase the number of full-time positions to 122.
[6] Through the local Continuum of Care networks, the Department of
Housing and Urban Development contracts with public housing agencies
for the rehabilitation of residential properties that provide multiple
single-room dwelling units. These agencies make Section 8 rental
assistance payments generally covering the difference between a portion
of the tenant’s income (normally 30 percent) and the unit’s rent to
participating owners (i.e., landlords) on behalf of homeless
individuals who rent the rehabilitated dwellings.
[7] VA issued a directive for a onetime dental care opportunity for
homeless veterans (VHA Directive 2002-080) in line with 38 U.S.C. § 101
note. VA officials told us that funding was provided in 2006 to
implement this directive.
[8] VA may waive the lifetime limit on program stays if the services
offered are different from those previously provided and may lead to a
successful outcome. The VA liaisons must review and approve or deny the
waiver based on their best clinical assessment of the individual case.
[9] Independent housing comprises apartments, rooms, or houses. While
independent housing may be a more desirable outcome, for some veterans,
including those with severe disabilities, secured housing may be more
appropriate.
[10] Veterans Affairs Office of Inspector General, Evaluation of the
Veterans Health Administration Homeless Grant and Per Diem Program,
Report No. 04-00888-215 (Washington, D.C.: Sept. 20, 2006).
[End of section]
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