Statement of the National Coalition for Homeless Veterans

Submitted to the VA Secretary’s Task Force on Mental Health Care
February 2004

The National Coalition for Homeless Veterans is pleased to have the opportunity to submit comments to the Secretary of Veterans Affairs’ Task Force on Mental Health Care, which is charged with studying the delivery of VA mental health services to veterans and making recommendations on how to reverse the decline in availability of those services.

Introduction

The National Coalition for Homeless Veterans (NCHV), established in 1990, is a nonprofit organization with the mission of ending homelessness among veterans by shaping public policy, promoting collaboration, and building the capacity of service providers.  NCHV’s membership of nearly 250 organizations in 41 states and the District of Columbia provides housing and supportive services to homeless veterans and their families, such as street outreach, drop-in centers, emergency shelter, transitional housing, permanent housing, recuperative care, hospice care, food and clothing, primary health care, addiction and mental health services, employment supports, educational assistance, legal aid and veteran and public benefit advocacy.

The U.S. Department of Veterans Affairs (VA) estimates that more than 299,000 veterans are homeless on any given night; more than 500,000 experience homelessness over the course of a year.  Conservatively, one out of every three homeless adult males sleeping in a doorway, alley, box, car, barn or other location not fit for human habitation in our urban, suburban and rural communities has served our nation in the Armed Forces.  It is estimated that as many as three-quarters of veterans experiencing homelessness also have an addiction and/or mental illness.

Preventing and ending homelessness among veterans with mental illnesses and addictions requires public commitment and action to ensure their access to treatment, supportive housing, supported employment and income assistance.  This must be accomplished both through general responses of benefit to veteran and non-veteran persons with disabilities, and through specialized responses targeted to homeless people with disabilities and homeless veterans with disabilities.

Mental Illness and Addiction among Veterans Experiencing Homelessness

The findings below are illustrative of the research into the intersection of military service history, homelessness and mental and addictive disorders, and make evident the high prevalence of these disabilities among veterans experiencing homelessness.

A federally-funded survey of homeless services users published in 1999 found that 76 percent of currently homeless veterans surveyed had an active alcohol, drug or mental health problem, or some combination thereof.  Of this total, 49 percent reported an alcohol problem, 40 percent a mental health problem, and 31 percent a drug problem.  When the time frame is expanded to a full year, 83 percent of currently homeless veterans reported an alcohol, drug or mental health problem, or some combination thereof.  Fifty-eight percent of the homeless veterans surveyed reported an alcohol problem, 46 percent a mental health problem and 40 percent a drug problem.

VA’s Health Care for Homeless Veterans (HCHV) Sixteenth Annual Report (March 1, 2003) reports that of 42,668 initial clinical assessments conducted by HCHV teams, 81 percent of veterans had a serious psychiatric or substance abuse disorder, and 33 percent had both psychiatric and substance abuse disorders.

The 4th Annual Psychosis Registry Report (FY 2002) of the VA Serious Mental Illness Treatment Research and Evaluation Center indicates that of the 205,620 veterans with a qualifying psychosis diagnosis receiving care from the Veterans Health Administration (VHA) in Fiscal Year 2002, 12.4 percent reported homeless status at some point during that same fiscal year.  Of this subtotal, 12.4 percent had a schizophrenia diagnosis, 14.7 percent had a bipolar disorder diagnosis, and 8.3 percent had another psychosis diagnosis.

A “pulse check” survey of NCHV member organizations conducted in preparation for this statement found that the percentage of homeless veterans with mental health services needs in the respondent organizations ranged from 50 percent to 93 percent.
 
Continuum of Care for Veterans with Mental Illnesses and Addictions 

Veterans with mental illnesses and addictions may access publicly funded treatment services through Veterans Affairs Medical Centers (VAMCs) and VA Community-Based Outpatient Clinics (CBOCs); community mental health and addiction services systems; or private, nonprofit and public health services providers via Medicaid and Medicare health insurance.

Veterans with mental illnesses and addictions who also have a housing need may access publicly funded housing through the VA’s domiciliary, state veterans home, Homeless Providers Grant and Per Diem, and HUD-VASH programs,; HUD-funded supportive housing programs; or general low-income housing assistance programs.

Veterans with mental illnesses and addictions who also have income needs may access publicly funded employment services through VA’s compensated work therapy program; workforce investment programs targeted to veterans and administered by state and local workforce development agencies such as Disabled Veterans Outreach Program and Veterans Workforce Investment Program; or general workforce investment programs.  Veterans with mental illnesses and addictions may be eligible for veteran disability benefits, Supplemental Security Income, or Social Security Disability Insurance.

With limited exceptions, eligibility for these programs is limited to veterans with low incomes and/or veterans whose disabilities are connected to their military service.
 
Challenges to Veterans’ Access to Mental Health and Addiction Services:

NCHV has identified three global-level challenges that work to prevent veterans with mental illnesses and addictions, including veterans experiencing homelessness, from accessing the services and supports necessary for their recovery and reintegration into the community:
 
Diminishing Capacity in VA Mental Health and Addiction Treatment Services

Our nation’s specialized health care system for veterans is in transition.  Transformation of the system from inpatient-heavy and targeted to veterans with disabilities to outpatient-oriented and available to all veterans has not been without consequence for veterans with mental illnesses and addictions.

Congress anticipated that the transformation could result in erosion of services for veterans with disabilities.  To avert such possibility, Congress, in the laws that set the transformation of the VA health care system into motion (P.L. 104-262, amended by P.L. 107-135), required the Department to “maintain capacity to provide for specialized treatment and rehabilitative needs of disabled veterans (including veterans with spinal cord dysfunction, blindness, amputations, and mental illness) within distinct programs or facilities of the Department….”

Despite these statutory requirements — and annual increases in the VHA budget each year since the transformation commenced — the VA’s mental health and addiction treatment capacity has deteriorated.  Closures or curtailment of inpatient psychiatric and residential substance abuse rehabilitation facilities have not been counteracted by complementary increases in outpatient treatment capacity.  According to the VA Committee on the Care of Veterans with Serious Mental Illness (SMI Committee), VA spending on mental health and addiction services has declined by 8 percent over the past seven years, and by 25 percent when adjusted for inflation.

Compounding the problem is the disparate impact the diminution is having among veterans depending on the region of the country in which they live.  A key element of the VA health care system’s transformation has been the devolution of planning and decision-making to 21 Veterans Integrated Service Networks (VISNs).  Decentralized management has led to variations in mental health and addiction services scope, duration and intensity across VISNs.  Consequently, as overall mental health capacity has diminished, some veterans have been more disadvantaged than others, depending on which VISN serves them.  This has led to inequity in care among veterans within the VA health care system, contrary to the very purpose of a national system.  NCHV’s “pulse check” survey of member organizations reveals long waiting periods (up to three months) for homeless veterans in accessing mental health treatment.  Also reported were shortages of VA mental health and addiction services professionals.  These are among the real consequences of capacity diminution.
Veterans, veteran advocates including NCHV, the SMI Committee, and Congressional veteran affairs committees are in agreement that this erosion in the VA health care system’s mental health and addiction treatment capacity must be reversed.
 
VA Mental Health and Addiction Services are not Recovery-Based

The VA health care system uses a medical model in the design of its mental health and addiction treatment programming.  Advances in the science and art of mental health and addiction treatment however demonstrate efficacy of a recovery-based model.  Such care requires an array of services that include intensive case management, peer support, psychosocial rehabilitation, pharmacologic treatment, housing, employment services, independent living and social skills training, and psychological support.  This continuum of supports is not uniformly available across the VA health care system. 

Failure to Serve Veterans in Community-Based Mental Health and Addiction Systems

Diminution in VA’s capacity to provide mental health and addiction services to veterans with disabilities has placed even greater burden on already oversubscribed and underfunded community mental health and addiction services systems as veterans unable to secure services from the VA turn to community care.  Veterans face barriers in accessing these state-administered community-based systems.  Veterans are rarely considered a priority group for community mental health or addiction services, for the very reason that system managers assume the VA is already “taking care of its own.” 

Recommendations:

NCHV has identified numerous actions that, if adopted, would significantly strengthen the array of publicly funded programs intended to support veterans with mental illnesses and addictions and other persons with such disabilities.  To aid the Task Force on Mental Health Care, we have marked with a “**” those of our recommendations that are most critical to bring to the Secretary’s attention in the Task Force’s imminent report.

Planning

Recommendation 1:  Develop a Veterans Mental Health and Addiction Services Strategic Plan — NCHV urges the VA to develop a mental health and addiction services strategic plan.  The plan should articulate objectives, activities, and timelines that respond to at least these following goals:  increase capacity of VA health care system to provide mental health and addiction services; ensure availability of a comprehensive continuum of treatment, supported employment and supportive housing services through the VA health care system; and leverage the resources of other federal, state, local, private and nonprofit organizations to ensure mental health and addiction services to veterans.

Recommendation 2:  Develop VISN Mental Health Tactical Plans — NCHV urges the VA to issue a Directive instructing all VISNS to develop comprehensive mental health and addiction services tactical plans.  The Directive should outline the components of the tactical plans and the minimum criteria for each that VISNs must meet.

Recommendation 3:  Continue VA Participation in Interagency Activities — NCHV urges the VA to continue to actively participate in the various councils and committees established at the federal level that address issues pertinent to mental health and addiction services, including the Interagency Council on Homelessness, the advisory councils of the Substance Abuse and Mental Health Services Administration, and the Veterans Advisory Council to the Secretary of Labor.

Recommendation 4:  Ensure VA Involvement in State and Local Services Planning — NCHV urges the VA to issue a directive to VISNs, Veterans Affairs Medical Centers, and Veterans Benefit Administration regional offices instructing them to participate in state and local planning bodies and activities that address issues pertinent to mental health and addiction services for veterans, including state mental health planning councils, consolidated plans for housing and community development, continua of care for homeless assistance, and workforce investment boards.

Mental Illness and Addiction Treatment

**Recommendation 5:  Increase Funding for VA Mental Health and Addiction Treatment Services — NCHV urges Congress to increase funding for VA mental health and addiction services by $500 million above the current level for such services in FY 2005 VA-HUD appropriations legislation.  Congress should explicitly target a set amount of funds from within the VA health care account to mental health and addiction services.  Further, NCHV urges the Administration to accede to this Congressional directive in FY 2005, and to include specific levels of funding for VA mental health and addiction treatment services in the FY 2006 VA budget request and thereafter.
**Recommendation 6:  Establish an Explicit Authorization Level of $4 billion annually for VA Mental Health and Addiction Treatment Services — NCHV urges Congress and the Administration to enact legislation authorizing at least $4 billion annually from FY 2006 through FY 2009 for VA mental health and addiction treatment services.  NCHV urges the Administration to submit legislation to Congress to implement this recommendation.

Recommendation 7:  Ensure Adequate VISN Spending on Mental Health and Addiction Treatment Services — NCHV urges the VA to institute a mechanism to “fence” funding for mental health and addiction treatment services programs for those VISNs whose mental health and addiction services funding levels are out of line with inflation-adjusted 1996 funding.

Recommendation 8:  Increase Appropriations for Community Mental Health Program — NCHV urges Congress and the Administration to appropriate at least $500 million in FY 2005 for the Community Mental Health Services Performance Partnership program.  Further, NCHV urges the VA Secretary to request his Health and Human Services counterpart to include this funding level in HHS’s FY 2006 budget request, and to support HHS’s request during the Administration’s development of the FY 2006 budget.

**Recommendation 9:  Issue Guidance to Community Mental Health and Addiction Services Systems on Veterans Mental Health and Addiction Services Needs — NCHV urges HHS and VA to jointly develop guidance for state and local mental health authorities and community-based and faith-based mental health and addiction services providers on the prevalence of mental illness and addiction services among the veteran population; VA’s mental health and addiction services continuum (and their limitations); the role that homeless veteran service providers and veteran service organizations should play in the community mental health and addiction services systems; and the role that the non-veteran sector must play in meeting the needs of veterans with mental illnesses and addictions.

Recommendation 10:  Increase Appropriations for PATH — NCHV urges Congress and the Administration to appropriate the full authorized level of $75 million in FY 2005 for the Projects for Assistance in Transition from Homelessness program.  Further, NCHV urges the VA Secretary to request his Health and Human Services counterpart to include this funding level in HHS’s FY 2006 budget request, and to support HHS’s request during the Administration’s development of the FY 2006 budget.

Recommendation 11:  Increase Appropriations for GBHI — NCHV urges Congress and the Administration to appropriate at least $75 million in FY 2005 for the Grants for the Benefit of Homeless Individuals program.  Further, NCHV urges the VA Secretary to request his Health and Human Services counterpart to include this funding level in HHS’s FY 2006 budget request, and to support HHS’s request during the Administration’s development of the FY 2006 budget.

Recommendation 12:  Prioritize Homeless Veterans for PATH and GBHI Services—The PATH and GBHI statutes include language implicitly suggesting or explicitly requiring a priority for veterans experiencing homelessness.  NCHV urges HHS to ensure that such priorities are honored.

Supportive Housing

**Recommendation 13:  Increase Appropriations for Homeless Provider Grant and Per Diem Program — NCHV urges the Secretary of Veterans Affairs to allocate the full authorized level of $75 million from each of the FY 2004 and FY 2005 VHA appropriations to the Grant and Per Diem program.

**Recommendation 14:  Streamline Reimbursement for Grant and Per Diem Providers — The Homeless Veterans Comprehensive Assistance Act of 2001 includes a provision requiring the VA to reimburse grantees under the Homeless Provider Grant and Per Diem Program (GPD) for services to homeless veterans at the same rate VA pays states for domiciliary care services provided in State Veterans Homes.  The VA has implemented the provision in a manner that requires GPD grantees to submit extensive documentation on their services costs, rather than simply reimbursing them at the State Veterans Home rate.  NCHV urges the VA Secretary to instruct the VHA to reimburse GPD grantees at the State Veterans Home rate, without requiring documentation.

**Recommendation 15:  Reauthorize the Grant and Per Diem Program — NCHV urges Congress and the Administration to reauthorize GPD at a $200 million level in each of FY 2006 through FY 2011.  Further, NCHV urges the Administration to submit legislation to Congress to implement this recommendation.

**Recommendation 16:  Maintain Technical Assistance to Homeless Veteran Service Providers — NCHV urges the VA Secretary to allocate $750,000 from the FY 2004 and FY 2005 VHA appropriations to maintain a technical assistance program for homeless veteran service providers.  Further, NCHV urges the Administration to submit legislation to reauthorize the technical assistance authority at the $750,000 level for each of FY 2006 through FY 2011.

**Recommendation 17: Increase Funds for Additional Domiciliary Care — Domiciliaries are a distinct component of the VA’s continuum of care for homeless veterans, assuring the availability of biopsychosocial treatment and rehabilitation to homeless veterans in residential settings.  The Homeless Veterans Comprehensive Assistance Act of 2001 authorized appropriations of $5 million in each of FY 2003 and FY 2004 for the VA to open 10 new domiciliaries for homeless veterans.  Regrettably, the Department did not request and Congress did not appropriate these funds.  NCHV urges the Secretary of Veterans Affairs to allocate $10 million from the FY 2004 and FY 2005 VHA appropriations to establish 10 additional domiciliaries for homeless veterans, either within the VA system or via contractual agreements with community-based providers.

**Recommendation 18:  Establish Minimal Charges for Use of VA Space for Homeless Veterans — The VA enters into space agreements with nonprofit organizations to utilize VA capital assets to offer services to homeless veterans.  Rates for use of the space fluctuate greatly.  NCHV urges the VA to issue a Directive to VISNS and VAMCs instructing them to negotiate space agreements with homeless service providers without charge or at the lowest charge possible, and certainly at a rate not to exceed 30 percent of their tenants’ aggregate adjusted monthly incomes.

Recommendation 19:  Increase Appropriations for HUD-Veterans Affairs Supportive Housing Program — The Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) Program provides permanent housing subsidies and case management services to homeless veterans with mental and addictive disorders.  NCHV urges Congress and the Administration to appropriate at least $13.5 million for HUD-VASH vouchers in FY 2005 VA-HUD appropriations legislation.  Further, NCHV urges the VA Secretary to request his Housing and Urban Development counterpart to include this funding level in HUD’s FY 2006 budget request, and to support HUD’s request during the Administration’s development of the FY 2006 budget.

**Recommendation 20:  Strengthen VA Implementation of McKinney-Vento Title V Program — Title V of the McKinney-Vento Homeless Assistance Act makes vacant federal properties available at no cost to nonprofit organizations, including state and local government agencies, for use as facilities to assist people experiencing homelessness.  VA compliance with the Title V law is spotty.  NCHV urges the Secretary of Veterans Affairs to do the following: issue a Department-wide directive that articulates that surplus, excess, unutilized or underutilized VA properties shall first be made available on a no-cost or lowest-cost basis to nonprofit or public organizations responding to the human needs of veterans (and low-income persons in general secondarily), with a primary preference for organizations experienced in serving homeless veterans; establish as a Departmental goal the establishment of at least 50,000 additional supportive housing units for homeless veterans on VA property, and to instruct VISNs to develop concrete action plans for reaching this goal; instruct VISNs to identify and advertise properties currently or potentially suitable and available for disposition under the McKinney-Vento Title V program; instruct VISNs to use the Title V criteria for determining suitability for homeless uses when conducting these property assessments; take action to ensure the Department’s full compliance with the Title V Program; prepare an analysis of VA property acquisition and disposition statutes, regulations and policy guidance and their intersection with the Title V program; recommend or adopt any changes needed in order for the VA to fully participate in the Title V program.

Recommendation 21:  Increase Appropriations for Section 811 Program — NCHV urges Congress and the Administration to appropriate at least $309 million for the Section 811 Supportive Housing for People with Disabilities program in FY 2005 VA-HUD appropriations legislation.  Further, NCHV urges the VA Secretary to request his Housing and Urban Development counterpart to include this funding level in HUD’s FY 2006 budget request, and to support HUD’s request during the Administration’s development of the FY 2006 budget.

Recommendation 22:  Increase Appropriations for HUD McKinney-Vento Homeless Assistance Programs — NCHV urges Congress and the Administration to appropriate at least $1.8 billion for HUD McKinney-Vento programs in FY 2005 VA-HUD appropriations legislation.  Further, NCHV urges the VA Secretary to request his Housing and Urban Development counterpart to include this funding level in HUD’s FY 2006 budget request, and to support HUD’s request during the Administration’s development of the FY 2006 budget.

Supported Employment and Income Assistance

Recommendation 23:  Increase Funding for the Compensated Work Therapy (CWT) and CWT/Therapeutic Residences Programs — NCHV urges the Secretary of Veterans Affairs to allocate sufficient sums from the FY 2004 and FY 2005 VHA appropriations to establish additional CWT/TR programs for veterans with disabilities.

Recommendation 24:  Increase Appropriations for Homeless Veterans Reintegration Program — The Homeless Veterans Reintegration Program (HVRP), within the Department of Labor’s Veterans Employment and Training Service (VETS), provides competitive grants to community-based, faith-based and public organizations to offer outreach, job placement and supportive services to homeless veterans.  NCHV urges Congress and the Administration to appropriate $50 million for HVRP in FY 2005 Labor-HHS-Education appropriations legislation. 
Further, NCHV urges the VA Secretary to request his Labor counterpart to include this funding level in DOL’s FY 2006 budget request, and to support DOL’s request during the Administration’s development of the FY 2006 budget.

Recommendation 25:  Increase Appropriations for the Veterans Workforce Investment Program — The Veterans Workforce Investment Program (VWIP), within the Department of Labor’s Veterans Employment and Training Service (VETS), provides competitive grants to states geared toward training and employment opportunities for veterans with service-connected disabilities, those with significant barriers to employment (such as homelessness), and recently separated veterans.  NCHV urges Congress and the Administration to appropriate at least $20 million for VWIP in FY 2005 Labor-HHS-Education appropriations legislation.  Further, NCHV urges the VA Secretary to request his Labor counterpart to include this funding level in DOL’s FY 2006 budget request, and to support DOL’s request during the Administration’s development of the FY 2006 budget.

**Recommendation 26:  Improve coordination between SSA and VA disability benefit determination processes — NCHV urges the VA to collaborate with the Social Security Administration to improve coordination between SSA and VA disability benefit programs and to provide funding to homeless veteran service providers to enable them to assist their program participants in navigating both processes.

Conclusion

The National Coalition for Homeless Veterans is eager to work with the Mental Health Task Force, Advisory Committee on Homeless Veterans, Under Secretary for Health, and the Secretary of Veterans Affairs in implementing the recommendations enumerated above.

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