D.5 Safe Haven Implementation Brief.pdf

VA National Center on Homelessness Among Veterans | U.S. Department of Veterans Affairs

Promoting data-driven, evidence-based solutions to end Veteran homelessness

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SAFE HAVEN IMPLEMENTATION BRIEF

July 2014

Roger Casey, PhD; Paul Smits; MSW, Scott Young, PhD

THE SAFE HAVEN MODEL

Ending Veteran homelessness is a top priority of President Obama. To meet this challenge, the U.S.

Department of Veterans Affairs (VA) launched a comprehensive, evidence-based, outcome-driven strategy consistent with Opening Doors: Federal Strategic Plan to Prevent and End Homelessness.

The VA transformation effort has resulted in several new service models for Veterans who are homeless or at risk that promote a more person-centered approach to rapidly connect Veterans in need to permanent housing, healthcare, and other supports designed to end homelessness and promote greater community reintegration and improved quality of life. One important development has been the implementation of Safe Havens within the VA.

A Safe Haven is a 24-hour/7-days-a-week community-based early recovery model of supportive housing. Safe Havens serve hard-to-reach homeless individuals with severe mental illness and/or substance use problems who are living on the street and have been unable or unwilling to participate in traditional treatment and supportive services. This model, consistent with principles of Housing First, does not require sobriety or full compliance with treatment for admission or continued stay in the program. Many individuals experiencing homelessness cannot be fully compliant with traditional program demands and consequently have repeated failures in these programs, resulting in chronic homelessness. Safe Havens attempt to reverse that trend by continuously engaging residents using state-of-the art, evidence-based therapies.

The Safe Haven model provides a housing environment that is safe, sanitary, flexible, and stable.

The small facilities, typically with 25 beds or fewer, provide a low-demand, non-intrusive setting designed to re-establish trust and re-engage residents in treatment services and permanent housing options. In fact, research indicates that low-demand housing programs are more effective than traditional programs in reducing hospitalizations and have similar outcomes regarding substance use and participation in mental health programs.

Safe Havens were initially authorized by the McKinney-Vento Act of 1994 with funding provided by the U.S. Department of Housing and Urban Development’s (HUD) Permanent Supportive Housing Program. The primary mission of the first funded programs was to target dually diagnosed chronically homeless individuals who were ineffectively served by traditional homeless programs.

HUD initially funded about 300 programs. The 2010 Annual Homeless Assessment Report to Congress (AHAR) indicated that, at that time, there were only 128 Safe Havens providing a total of only 2,199 year-round beds (HUD, 2011).

INITIAL IMPLEMENTATION OF VA’S SAFE HAVEN

Given the effectiveness of low-demand housing and the insufficiency of low-demand housing options within VA, in July 2010 the Veterans Health Administration (VHA) Homeless Program Office, under the leadership and direction of the VA National Center on Homelessness Among

4100 Chester Avenue, Suite 201 | Philadelphia, PA 19104 | 215.823.5800 x 6713 | www.endveteranhomelessness.org

Veterans (the Center), funded five Safe Haven model development projects. The projects were intiated in partnership with community providers who had experience serving this complex population and had good rapport with their local VA medical centers. Other selection criteria included a willingness to participate in an evaluation process as well as a commitment to maintain fidelity to the model and accept ongoing technical assistance from the Center. The five Safe Haven programs funded through VA were located at:

Boley, Inc. in St. Petersburg, FL Mental Health Care, Inc. in Tampa, FL Volunteers of America in Bronx, NY Massachusetts Housing and Shelter Alliance in Bedford, MA MinSec in Philadelphia, PA

Training for VA Staff and Safe Haven Providers

The Center provided a two-day training program on the Safe Haven model for both VA staff and community providers . The training encompassed both clinical and administrative issues in Safe Haven development and management. Clinical topics included creating and sustaining low-demand program designs, assessing participant treatment needs, developing plans for care that recognize Veteran choice, and leveraging community partnerships for outreach and to fill potential gaps in services. Management topics covered data collection and reporting, staffing, medication management, and Veteran safety.

Performance Metrics

As with all VHA Homeless Programs, Safe Havens collect a standard set of information—at entry and exit—for each Veteran accessing the program. Safe Haven Coordinators enter data in VA’s Homeless Operations Management and Evaluation System (HOMES). The goal of these data collection activities is to measure the extent to which the programs meet established objectives, including the following:

Target chronically homeless Veterans diagnosed with co-occurring disorders Increase Veterans’ housing stability Improve Veterans’ outcomes related to alcohol, drug, mental health, medical, social/vocational, and family problems Increase Veterans’ income and benefits

Specific performance metrics in line with the objectives listed above include the following:

Targeting – Veterans entering Safe Havens who are chronically homeless and diagnosed with mental illness, substance abuse, or co-occurring disorders or who were living in places not meant for human habitation.

Outcomes – Increase in housing stability, income and benefits, improvement in living situation, and follow-up treatment for identified problem areas (alcohol, drug, mental health, medical, social, vocational, family).

Program Fidelity Reviews

Center evaluators conducted fidelity visits to the first five Safe Havens. These visits occurred approximately six months after each program began operating. Findings indicated that Safe Havens

4100 Chester Avenue, Suite 201 | Philadelphia, PA 19104 | 215.823.5800 x 6713 | www.endveteranhomelessness.org demonstrated a very high degree of faithfulness to the Safe Haven principles with only minor differences between sites.

Implementation of 15 Additional Safe Havens in 2013

In 2012, VHA Homeless Programs solicited requests from VA medical centers to establish Safe Havens within their local communities to enhance the range of homeless program services.

Proposals required submission of need, evidence of chronic homeless Veteran populations, and commitment to program designs that reflected Safe Haven key principles. In 2013, the VHA Homeless Program Office funded 15 additional programs.

Program Outcomes

Safe Haven participants had characteristics consistent with a difficult-to-serve population: the majority (74%) was chronically homeless; 22% had five or more episodes of homelessness during the past three years; and 92% needed psychiatric or substance use treatment, based on clinical impression.

During calendar years 2011–2013, Safe Haven model development projects served 721 unique Veterans, including both males (96%) and females (4%). More than 55% of the Veterans who exited the program moved into stable housing. Upon discharge, 63% were receiving VA benefits or had pending applications and 67% were receiving non-VA benefits or had pending applications. Service linkages with VA and non-VA providers were in place for most of the Veterans following discharge:

62% for alcohol treatment, 64% for drug treatment, 76% for mental health treatment, and 85% for medical treatment.

General Guidance for VA Facilities Establishing New Safe Havens

VA facilities planning to establish a Safe Haven should recruit experienced Safe Haven providers or providers that are committed to establishing a low-demand model. Specific characteristics of the program should include:

Smaller sites that do not serve more than 30 Veterans at one time Sites that accommodate women Veterans and provide a safe environment that supports their security and well-being Focus on chronically homeless Veterans with severe mental illness and chronic substance abuse problems who require a low-demand environment to end their homelessness Expanded targeting for Veterans with medical problems or multiple homeless program failures

Facilities are urged to utilize training and technical assistance for both VA and Safe Haven provider staff that is provided by the Center. Because many VHA Homeless Program staff have been trained in traditional models of care, they may require additional education to acquire the expertise demanded by this model, including training on striking the balance of maintaining both a low-demand and a safe environment for residents and staff and developing appropriate policies to support that balance. In addition, facilities should utilize the fidelity reviews offered by the Center.

Studies of existing programs indicate that there can be “program drift” toward traditional homeless program modeling, reducing the intent and effectiveness of the Safe Haven model.

4100 Chester Avenue, Suite 201 | Philadelphia, PA 19104 | 215.823.5800 x 6713 | www.endveteranhomelessness.org

Finally, All facilities establishing a Safe Haven should consult the Safe Haven Tool Kit Manual developed by HUD and the Substance Abuse and Mental Health Services Admnistration as well as additional VA policy guidance, approved at the departmental level.

Roger Casey is Tampa Site Director and Director of Education and Dissemination at the VA National Center on Homelessness Among Veterans. Paul Smits is a Senior Policy Analyst for the Center, based at the University of South Florida. M. Scott Young is an Affiliated Investigator at the Center and a Research Assistant Professor in the Department of Mental Health Law and Policy at the University of South Florida.

Opinions expressed in this implementation brief represent only the position of the National Center on Homelessness Among Veterans and do not necessarily reflect the official policy of the U.S. Department of Veterans Affairs.

Resources Gerber, E. R., Haradon, S., & Phinney, R. (2008). Reforming the system of care: A review of the literature on housing and service arrangements for homeless populations. University of Michigan Center for Local, State, and Urban Policy. Policy Report, 12, 1–12.

Leff, H. S., Chow, C. M., Pepin, R., Conley, J., Allen, I. A., & Seaman, C. A. (2009). Does one size fit all? What we can and can’t learn from a meta-analysis of housing models for persons with mental illness. Psychiatric Services, 60(4), 473–482.

Olivet, J., McGraw, S., Grandin, M., & Bassuk, E. L. (2010). Staffing challenges and strategies for organizations serving individuals who have experienced chronic homelessness. The Journal of Behavioral Health Services and Research, 37(2), 226–238.

Schinka, J. A., Casey, R. J., Kasprow, W., and Rosenheck, R. A. (2011). Requiring sobriety at program entry: Impact on outcomes in supported transitional housing for homeless Veterans. Psychiatric Services, 62(11), 1325–1330.

U.S. Department of Housing and Urban Development (HUD). (2011). The 2010 annual homeless assessment report to Congress. Washington, DC: Author.

HUD & Substance Abuse and Mental Health Services Administration (SAMSHA). Developing and operating Safe Haven programs. Washington, DC: Author.

Ward Family Foundation, Inc. (2005). Safe Haven programs: Analysis of strategies and operating practices. Alexandria, VA: Author.