Homeless Veterans: VA Expands Partnerships, but Effectiveness of Homeless Programs Is Unclear

Published by the Government Accountability Office on 1999-06-24.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                          United States General Accounting Office

GAO                       Testimony
                          Before the Subcommittee on Oversight and Investigations,
                          Committee on Veterans’ Affairs, House of Representatives

For Release on Delivery
Expected at 10:00 a.m.
Thursday, June 24, 1999
                          HOMELESS VETERANS

                          VA Expands Partnerships,
                          but Effectiveness of
                          Homeless Programs Is
                          Statement of Cynthia A. Bascetta, Associate Director
                          Veterans’ Affairs and Military Health Care Issues
                          Health, Education, and Human Services Division

Homeless Veterans: VA Expands
Partnerships, but Effectiveness of Homeless
Programs Is Unclear
               Mr. Chairman and Members of the Subcommittee:

               We are pleased to be here today to discuss our recent report on VA’s
               homeless programs.1 Homelessness is a complex and difficult problem.
               The exact number of homeless is unknown, but on any given night an
               estimated 500,000 to 600,000 homeless people live on the streets or in
               shelters.2 The Department of Veterans Affairs (VA) reports that
               approximately one-third of the adult homeless population are veterans,
               and these homeless veterans suffer about the same relatively high rates of
               psychiatric and substance abuse disorders as the general homeless
               population. Over the past decade or so, VA has established several
               programs to address the special needs of homeless veterans; these
               targeted programs supplement the health care services provided through
               VA’s medical facilities. In fiscal year 1997, VA obligated approximately
               $84 million to these programs targeted to homeless veterans. Other federal
               departments and agencies have also developed programs to assist the
               homeless. In fiscal year 1997, the federal government, including the
               Departments of Education, Health and Human Services (HHS), Housing and
               Urban Development (HUD), Labor, and VA, and the Federal Emergency
               Management Agency, spent approximately $1.2 billion on targeted
               homeless assistance.3

               Federal agencies serving the homeless, including VA, have begun to
               coordinate their activities with each other and with community-based
               service providers. These collaborative efforts are intended to minimize
               barriers to service, avoid unnecessary duplication of services, and enhance
               service provision. The development of these programs and the investment
               in them have generated questions about their effectiveness. As you
               requested, my remarks today will focus on (1) VA’s programs to address
               homelessness, including efforts made in partnership with
               community-based organizations, and (2) what VA knows about the
               effectiveness of its homeless programs. To develop this information, we
               conducted work at VA headquarters and VA’s Northeast Program Evaluation
               Center (NEPEC) in West Haven, Conn., and reviewed reports from federally
               funded research programs. We visited VA and community-based homeless

                Homeless Veterans: VA Expands Partnerships, but Homeless Program Effectiveness Is Unclear
               (GAO/HEHS-99-53, Apr. 1, 1999).
                Martha R. Burt, “Demographics and Geography: Estimating Needs,” paper presented at the National
               Symposium on Homelessness Research: What Works, cosponsored by the Department of Housing and
               Urban Development and the Department of Health and Human Services, Oct. 1998.
                Homelessness: Coordination and Evaluation of Programs Are Essential (GAO/RCED-99-49, Feb. 26,
               1999) provides an inventory of targeted and nontargeted federal programs that assist the homeless.

               Page 1                                                                        GAO/T-HEHS-99-150
             Homeless Veterans: VA Expands
             Partnerships, but Effectiveness of Homeless
             Programs Is Unclear

             programs in Little Rock, Ark.; Denver, Colo.; Washington, D.C.; Los
             Angeles and San Diego, Calif.; and New York, N.Y.

             In brief, we found that in addition to the need for housing, homeless
             veterans typically have multiple problems, which may include medical and
             mental health problems, limited work skills, and long-standing social
             isolation. Research suggests that effective interventions for the homeless
             involve comprehensive, integrated services to address their multiple
             needs. VA provides medical, mental health, and substance abuse treatment
             to homeless veterans through its health care facilities. In addition, VA’s
             targeted homeless programs address a variety of nonmedical needs by
             providing services such as case management, employment assistance, and
             transitional housing. To leverage its efforts, VA has developed partnerships
             with other federal departments, state and local government agencies, and
             community-based organizations. While much activity has occurred and
             many millions have been spent, VA has little information about the
             long-term effectiveness of its homeless programs. VA has conducted some
             research over the years to identify program outcomes, but methodological
             weaknesses in those studies have limited the extent to which they can be
             used to assess program effectiveness. As a result, little is known about
             whether veterans served by VA’s homeless programs remain housed or
             employed, or whether they instead relapse into homelessness. For this
             reason, we recommended that VA initiate a series of program evaluation
             studies designed to clarify the effectiveness of its homeless programs. VA
             concurred with this recommendation. It has one study of outcomes for
             veterans judged ready for permanent housing under way and plans several
             more on its new homeless initiatives.

             Veterans constitute about one-third of the adult homeless population in
Background   the United States on any given day. They form a heterogeneous group and
             are likely to have multiple needs. Many homeless veterans need treatment
             for medical or psychiatric conditions in addition to housing and other
             supportive services. Although many questions remain about how to treat
             homelessness, a series of research initiatives launched in 1982 and funded
             primarily by HHS suggests that effective interventions for the homeless
             involve comprehensive, integrated services. These initiatives also suggest
             that a range of housing, treatment, and supportive-service options needs to
             be available to the homeless, and that flexibility is needed to appropriately
             match services to the individual needs of homeless people.

             Page 2                                                     GAO/T-HEHS-99-150
Homeless Veterans: VA Expands
Partnerships, but Effectiveness of Homeless
Programs Is Unclear

Although meeting the most basic needs of a homeless person for food,
clothing, and shelter is a first step, it is rarely sufficient to enable a person
to exit homelessness. Instead, progress in achieving housing stability
requires comprehensive attention to the full range of a homeless person’s
needs. VA estimates that approximately one-half of homeless veterans have
a substance abuse problem, approximately one-third have a serious mental
illness (and of those, about half also have a substance abuse problem), and
many have other medical problems. Some homeless veterans need
assistance in obtaining benefits, managing their finances, resolving legal
matters, developing work skills, or obtaining employment. Supportive
services such as transportation or child care may also be needed.
Problems in any of these areas can interfere with progress. As examples,
untreated mental illness may interfere with a person’s ability to retain
housing, and lack of transportation may limit access to medical
appointments or job interviews.

Research suggests that positive outcomes are promoted by integration of
services, as well as by comprehensive services. Attempts to address the
needs of a homeless person sequentially, or simultaneously but without
coordination, seem less effective than strategies that involve integrated
efforts to address multiple needs. For example, homeless people who have
both a mental illness and a substance abuse problem have been found to
benefit more from integrated treatment programs than from programs that
approach these problems separately. Similarly, the effectiveness of
employment and training programs for the homeless is enhanced by
linkage to housing assistance and supportive services. Integration is
needed in part because of fragmentation of the homeless service-delivery
system, which involves different organizations that address different
needs. Case managers can facilitate integration by helping the homeless
obtain services in ways that complement rather than conflict with one
another. In addition, organizations that serve the homeless can collaborate
to promote integrated, comprehensive service provision.

Experts suggest that in terms of housing, the goal of homeless assistance
programs should be stable residence in a setting that allows the highest
level of independence each person can achieve. For some homeless
veterans, independent housing and economic self-support are reasonable
goals. But for others, including many seriously mentally ill homeless
people, neither full-time work nor independent housing may be feasible.
Instead, for these individuals, residence in a supportive environment, such
as a group home, may be the most reasonable outcome. In addition,
transitional housing may be necessary before a more permanent housing

Page 3                                                         GAO/T-HEHS-99-150
                            Homeless Veterans: VA Expands
                            Partnerships, but Effectiveness of Homeless
                            Programs Is Unclear

                            arrangement can be achieved. Thus, efforts to assist the homeless require
                            a range of housing options (including emergency shelter as well as
                            transitional and permanent housing); treatment for medical, mental health,
                            and substance abuse problems; and supportive services such as
                            transportation and case management. This spectrum of options is referred
                            to as the continuum of care. Because the homeless have diverse needs and
                            local resources vary, flexibility in arranging partnerships among
                            organizations optimizes the development of a continuum of care at the
                            local level.

VA Provides Key Services,   VA provides key services to homeless veterans through its mainstream
Builds Capacity Through     health care programs. In addition, VA has established several programs
Partnerships                specifically targeted to homeless veterans, providing veterans at some VA
                            facilities services such as case management, work rehabilitation, or
                            residential treatment for mental illness or substance abuse. Because it
                            does not have sufficient resources to address all the needs of homeless
                            veterans, VA has expanded its partnerships with community-based
                            providers. Thus, VA is working with other agencies to identify and
                            prioritize gaps in service availability and to develop strategies for meeting
                            those needs—that is, to develop a continuum of care for homeless

                            Many homeless veterans receive medical, mental health, and substance
                            abuse services through VA’s mainstream health care programs. Although VA
                            does not know the extent to which its annual health care appropriations
                            are spent on medical care and other treatment services for homeless
                            veterans, recent estimates suggest the amount is substantially greater than
                            the level of funding for VA’s targeted homeless programs. VA’s targeted
                            homeless efforts include additional services, such as outreach to identify
                            homeless veterans, case management to assess the needs of homeless
                            veterans and link them with appropriate VA or community-based service
                            providers, job counseling and placement assistance, and referral to
                            residential treatment programs to address clinical disorders.

                            Since establishing its targeted homeless programs, VA has worked with
                            other service providers and expanded its relationships with
                            community-based organizations. This commitment to partnering is
                            reflected in annual meetings among VA homeless program staff and other
                            homeless service providers and organizations. These meetings are
                            intended to promote a collaborative effort to assess, plan for, and address
                            the needs of homeless veterans. VA has acknowledged that it alone cannot

                            Page 4                                                      GAO/T-HEHS-99-150
Homeless Veterans: VA Expands
Partnerships, but Effectiveness of Homeless
Programs Is Unclear

meet all the needs of homeless veterans. Not only are its resources
insufficient, but VA’s homeless programs are not available in all locations.
By partnering with other providers, VA increases its potential for stretching
its resources to provide needed services to homeless veterans and ensure
better coordination of services.

The specific services available to homeless veterans vary across VA
facilities and may be offered through VA or through arrangements made by
VA with community-based service providers. Through VA’s Homeless
Chronically Mentally Ill (HCMI) program, 62 VA medical facilities contract
with existing community-based providers to provide time-limited
residential treatment to mentally ill or substance abusing homeless people.
For example, some homeless veterans seen at San Diego’s VA Medical
Center are referred to the Veterans Rehabilitation Center operated by
Vietnam Veterans of San Diego. This facility specializes in treating
substance abusing homeless veterans with post-traumatic stress disorder
or serious depression. As another example, some homeless veterans with
substance abuse problems or mental illness receive convalescent medical
care at Christ House through a contract with the VA medical center in
Washington, D.C. Veterans served through these contracts receive case
management from VA staff and may receive some of their medical or
mental health treatment through VA.

As part of VA’s effort to expand its partnerships with community-based
providers and increase the availability of transitional housing, VA
developed the Homeless Providers Grant and per Diem (GPD) program. In
contrast with the HCMI program, which involves contracting with existing
community-based residential treatment facilities, the GPD program awards
grants and per diem payments to public and nonprofit organizations that
establish and operate new supportive housing and services for homeless
veterans. When grants awarded during this program’s first 5 years (1994
through 1998) become fully operational, VA estimates that over 2,700 new
community-based transitional housing beds will be available for homeless
veterans. Moreover, VA has indicated its intention to continue expanding
this program. To date, a heterogeneous group of programs has been
funded. In some cases, veterans who have completed a residential
treatment program through VA’s HCMI contract program move on to a GPD
facility, which offers transitional housing in conjunction with supportive
services. As an example, at the West Los Angeles VA Medical Center,
homeless veterans may first be referred for residential substance abuse
treatment and then, once they have completed such a program, be referred
to L.A. Vets’ welfare-to-work program, where they receive housing and

Page 5                                                      GAO/T-HEHS-99-150
                       Homeless Veterans: VA Expands
                       Partnerships, but Effectiveness of Homeless
                       Programs Is Unclear

                       assistance in obtaining and maintaining employment through a GPD
                       program. In a few instances, VA has awarded GPD funds to programs with
                       more unique missions. For example, the Veterans Hospice Homestead in
                       Leominster, Massachusetts, provides housing and support for terminally ill
                       homeless veterans.

                       In addition, the Veterans Programs Enhancement Act of 1998 (P.L.
                       105-368) authorized VA to guarantee up to $100 million in loans to
                       construct, rehabilitate, or acquire land for multifamily transitional housing
                       projects for homeless veterans.

Effectiveness of VA    VA’s NEPEC  monitors and evaluates VA’s homeless programs. Although NEPEC
Homeless Programs Is   collects extensive descriptive data, it has only limited information about
Unclear                the effectiveness of VA’s homeless programs. Homeless program sites
                       routinely submit data to NEPEC, but this information is generally used for
                       monitoring program activities rather than for evaluating program
                       effectiveness. That is, the data routinely collected by NEPEC are used
                       primarily to provide program managers with information about aspects of
                       specific homeless program sites, such as characteristics of the veterans
                       served and length of stay in treatment. This information is used for
                       comparison with other program sites or with standards established by
                       legislation or VA policy. Research designed to evaluate program
                       effectiveness requires more rigorous and costly data collection methods
                       than those NEPEC routinely uses for monitoring purposes. For example,
                       NEPEC collects some data about program participants upon discharge from
                       a homeless program, including information about housing and
                       employment status and changes in substance abuse and mental health
                       problems. These data are of limited use, however, in assessing program
                       effectiveness, because the measures are relatively imprecise and do not
                       indicate what happens after a veteran is discharged from treatment. As a
                       result, VA cannot use this information to determine whether veterans
                       served by its homeless programs remain employed or stably housed over
                       the long term. NEPEC has conducted several studies in which additional
                       data, sometimes collected on follow-up, were obtained from program
                       participants. Results of these studies led NEPEC to conclude that veterans
                       served by VA’s major homeless programs, the HCMI and Domiciliary Care
                       for Homeless Veterans (DCHV), derived substantial benefit from their
                       participation. We found, however, that methodological shortcomings in
                       that research prevent firm conclusions about program effectiveness.

                       Page 6                                                      GAO/T-HEHS-99-150
                               Homeless Veterans: VA Expands
                               Partnerships, but Effectiveness of Homeless
                               Programs Is Unclear

Program Data Focus on          NEPEC collects and analyzes a wide range of descriptive information
Descriptive Characteristics,   regarding program structure, veteran characteristics, program processes,
Status at Discharge            and veteran status at discharge for specific sites. Program managers use
                               this information to monitor and compare program sites. These data would
                               indicate if programs failed to conform to intended guidelines. For
                               example, by monitoring diagnostic information, NEPEC can determine
                               whether programs designed for homeless mentally ill veterans are serving
                               that population.

                               When discharged from a VA homeless program involving transitional
                               housing or residential treatment, a veteran’s reported housing and
                               employment status are recorded. In addition, participants are rated for
                               changes in alcohol, drug, and mental health problems, but the rating
                               system that VA has been using has allowed case managers, at most, to
                               indicate that the problem has worsened, remains unchanged, or has
                               improved.4 These assessments are made at the time that the veteran is
                               discharged from a DCHV program or at the time that VA stops paying a per
                               diem fee to a contract residential treatment facility or a GPD facility. If VA
                               pays for only part of a veteran’s course of treatment, and the veteran
                               remains in treatment with a community-based provider after discharge
                               from VA’s homeless program, then the veteran’s status upon completion of
                               treatment (which may occur some time later) is not captured in NEPEC’s

                               In fiscal year 1997, about 8,500 veterans were discharged from VA’s two
                               largest and oldest residential treatment programs, the DCHV program (in
                               which homeless veterans receive rehabilitative services while occupying
                               dedicated beds at VA medical centers) and the contract-based HCMI
                               program. NEPEC reported that of the homeless veterans served through the
                               DCHV program, 62 percent successfully completed the program (that is, the
                               veteran and clinician agreed that program goals had been met). It also said
                               that 57 percent of DCHV veterans were housed at discharge, and 52 percent
                               reported full- or part-time employment at discharge. NEPEC reported that of
                               those served through the HCMI program, 52 percent successfully completed
                               the program. It further said that 39 percent of HCMI veterans reported
                               having their own apartment, room, or house at discharge, and 43 percent
                               reported full- or part-time employment at discharge. About three-fourths
                               of participants in each program were rated by VA as improved in drug,
                               alcohol, and mental health problems. How to interpret these ratings,
                               however, is not entirely clear. Almost all participants who were deemed to

                                NEPEC has indicated its intention to begin using a 5-point rating scale to assess changes in alcohol,
                               drug, and mental health problems.

                               Page 7                                                                           GAO/T-HEHS-99-150
                                Homeless Veterans: VA Expands
                                Partnerships, but Effectiveness of Homeless
                                Programs Is Unclear

                                have completed a program successfully were rated as improved in these
                                domains. It is difficult to interpret a rating of “improved” with regard to
                                drug or alcohol use when that assessment is made at the end of a program
                                that requires participants to avoid alcohol and drugs (as VA residential
                                treatment programs do), especially when the only alternative ratings are
                                “unchanged” or “worse.”

                                During fiscal year 1997, over 1,000 veterans were discharged from VA’s GPD
                                program. Reported outcomes were less favorable for these veterans; in
                                particular, the proportion of unsuccessful discharges from GPD programs
                                was high. As VA noted, however, the GPD program is relatively new, and
                                early data may not provide a clear basis for evaluation. For example,
                                veterans who were benefiting from their placements might not have been
                                discharged from the GPD program yet, so no information about them would
                                have been included in the data.

Limited Information Available   Although outcome research can be difficult and costly, VA has
About Program Effectiveness     acknowledged the need for program evaluation and includes such efforts
                                in its strategic plan under the Government Performance and Results Act of
                                1993. In addition to routine monitoring of homeless programs, NEPEC has
                                conducted studies that suggest that veterans served through VA’s homeless
                                programs are better off after receiving program services than before
                                admission. Methodological shortcomings in that research, however,
                                prevent strong conclusions regarding program effectiveness. NEPEC does
                                not typically collect or examine data in a way that clarifies the long-term
                                effectiveness of its programs, the effect of specific interventions in
                                comparison with alternative treatments, or which interventions work for
                                specific populations. We noted in our April report that program
                                effectiveness could be clarified by additional evaluation research.

                                To identify the benefits associated with program participation, NEPEC
                                conducted pilot follow-up projects at a sample of its homeless program
                                sites between 1987 and 1990, using more detailed outcome measures than
                                VA typically collects from program participants. Follow-up is needed to
                                determine whether veterans are still employed, housed, or successfully
                                dealing with substance abuse or mental health problems after program
                                completion. NEPEC concluded that, compared with their status at
                                admission, veterans showed improvements in housing, employment,
                                mental health, and substance abuse problems 6 months after discharge
                                from DCHV treatment and that, with the exception of alcohol use, these
                                improvements remained evident 1 year after discharge. Similarly, veterans
                                who participated in the HCMI program were assessed from 1 month to 2

                                Page 8                                                    GAO/T-HEHS-99-150
Homeless Veterans: VA Expands
Partnerships, but Effectiveness of Homeless
Programs Is Unclear

years after their initial contact with VA homeless staff. On average, these
veterans were last interviewed 8.3 months after their first contact. About
two-thirds were admitted to residential treatment; of these, some were still
in residential treatment when last interviewed. NEPEC concluded that
veterans who participated in VA’s HCMI program (including both those who
were and those who were not provided with contract residential
treatment) showed improvements in terms of housing, employment,
psychiatric problems, and substance abuse upon follow-up relative to
initial contact.

These follow-up studies represented a major undertaking in terms of
resources and effort, and they suggest that the DCHV and HCMI programs are
worthy of further investigation. However, these studies had two major
shortcomings that NEPEC acknowledged in its reports and that limit the
extent to which firm conclusions can be drawn about program
effectiveness. First, post-program outcome data were not obtained from a
substantial number of veterans. As a result, interview data were not
collected from a fully representative sample. Follow-up interviews were
conducted with only 72 percent of the veterans who agreed to participate
in these studies. Although the status of those veterans who were not
reinterviewed is not known, it is possible that the veterans who were
doing the poorest were also less likely to be reinterviewed. As a result, the
data from those who were reinterviewed could suggest more positive
outcomes than would be true for the program as a whole. Second, no data
were obtained from veterans who did not participate in the DCHV or HCMI
programs. Data from such groups would have allowed an estimate of the
degree of improvement attributable to the DCHV or HCMI programs. It is
possible that some of the improvements noted among those veterans who
were reinterviewed would have occurred in the absence of DCHV or HCMI
treatment. Other research suggesting that some improvement over time
may occur among the homeless, even in the absence of intensive
treatment, highlights the importance of comparison data. Without data
from an appropriate comparison group of veterans who were not served
through VA’s homeless programs, VA cannot determine how much veterans
benefited from those programs.

In addition, NEPEC analyzed data from small subsamples of participants in
the HCMI follow-up study to examine relationships between measures of
program participation and improvement. These analyses suggested that
certain aspects of participation in the program, such as longer stays in
residential treatment, were associated with greater improvement. Again,
these findings are promising, but NEPEC acknowledged that strong

Page 9                                                      GAO/T-HEHS-99-150
Homeless Veterans: VA Expands
Partnerships, but Effectiveness of Homeless
Programs Is Unclear

conclusions could not be reached because of methodological limitations.
Research designed to clarify the processes that make interventions
effective, or what aspects of treatment are associated with positive results
for different clinical groups (for example, those with serious mental
illnesses or those with a substance abuse disorder), can yield information
relevant to efforts to improve programs or to optimize program outcomes.
NEPEC officials have occasionally conducted such analyses, which require
them to supplement their data files with additional information (for
example, about treatment approaches). Clear conclusions about what
treatment strategies are most strongly associated with achieving housing
stability, and about which strategies work best for which veterans, require
more rigorous and costly research methods than NEPEC has typically

NEPEC  officials stated that they have not conducted additional evaluation
research on VA’s core HCMI and DCHV programs because obtaining follow-up
information on this hard-to-serve population is difficult and expensive. A
NEPEC official estimated that if it were to conduct another follow-up study,
the cost would be about $60,000 per site per year, and noted that multiple
sites would be needed to ensure generalizability. Total cost would thus
depend on the number of sites sampled and the length of the follow-up

NEPEC is not currently conducting evaluation research on its largest
residential treatment and transitional housing programs (the DCHV, HCMI,
and GPD programs). It is, however, studying some of VA’s other programs.
Follow-up data are being collected from participants in one of VA’s smaller
programs called the Housing and Urban Development-VA Supported
Housing program. In this program, intensive case management and
vouchers for permanent, subsidized housing are made available to
homeless veterans through a cooperative arrangement between VA and
HUD. To evaluate this program, NEPEC has collected follow-up information
from a sample of program participants, as well as from a comparison
group of veterans who were considered appropriate candidates for
permanent housing but who were randomly assigned to receive either
intensive case management without a housing voucher or more traditional
case management through VA’s HCMI program, again without a housing
voucher. In addition, veterans who have participated in the Compensated
Work Therapy/Transitional Residence and VA Supported Housing programs
are also reinterviewed periodically.5 VA has recently indicated its intention

 In addition, a small sample of veterans who participate in the GPD program are being surveyed within
a few months of their discharge from that program, but the questions focus on verification of the
services received, rather than on outcomes.

Page 10                                                                       GAO/T-HEHS-99-150
Homeless Veterans: VA Expands
Partnerships, but Effectiveness of Homeless
Programs Is Unclear

to initiate three new homeless programs and to evaluate each of those
programs using follow-up procedures similar to those it has used in the
past. These new initiatives involve using a promising case management
strategy called Critical Time Intervention, developing programs for
homeless women veterans, and implementing a vocational service called
Therapeutic Employment, Placement and Support. A NEPEC official
acknowledged that to minimize the cost of these evaluative efforts, the
methods used to evaluate Critical Time Intervention and the homeless
women programs are likely to be less rigorous than would be ideal.

In our April report, we recommended that a series of program evaluation
studies be conducted to clarify the effectiveness of VA’s core homeless
programs and provide information about how to improve those programs.
We concluded that this series of studies should address long-term effects,
processes associated with positive outcomes, and program impact. Thus,
VA could design follow-up studies to examine, for example, the stability of
housing and employment in the year or two after discharge from
transitional housing or residential treatment. VA could also undertake
outcome evaluations designed to assess program processes to better
understand the factors that produce desirable outcomes and how they
could be replicated. Such studies could also identify aspects of treatment
that are associated with positive outcomes for veterans with different
conditions. Finally, VA could estimate how program outcomes differ from
outcomes that would be likely in the absence of the program. For
example, results observed for a sample of homeless veterans who received
a particular kind of treatment could be compared with results for a control
group who did not receive that treatment. We also recommended that,
where appropriate, VA should make decisions about these studies
(including the type of data needed and the methods to be used) in
coordination with other federal agencies with homeless programs,
including HHS, HUD, and Labor.

Even though evaluation research can be difficult and expensive to
conduct, we concluded that such studies are necessary to ensure that VA
directs its resources to those efforts with the greatest potential for
beneficial effects. VA concurred with our recommendation and described
plans to initiate evaluations of several new homeless projects and to
supplement NEPEC’s budget with $600,000 from the additional $50 million
VA requested for its homeless programs in its fiscal year 2000 budget.

In summary, VA provides medical, mental health, and substance abuse
treatment to homeless veterans through its mainstream health care

Page 11                                                   GAO/T-HEHS-99-150
                  Homeless Veterans: VA Expands
                  Partnerships, but Effectiveness of Homeless
                  Programs Is Unclear

                  programs, and it offers additional specialized services for homeless
                  veterans at many of its medical centers and through partnerships with
                  community-based service providers. As VA facilities attempt to develop a
                  continuum of care for homeless veterans, variations in local needs and
                  resources will result in different patterns of involvement for VA and its
                  partners. Because homeless veterans differ from one another in their
                  needs, no single treatment program can serve all veterans with equal
                  effectiveness. Local programs designed to serve groups with different
                  needs are likely to be important components of any continuum of care for
                  the homeless. VA has obtained some information about outcomes for
                  veterans who have participated in its programs, but methodological
                  shortcomings of that research prevent clear conclusions about program
                  effectiveness. Further research on program effectiveness could provide
                  the information needed to make decisions about how to direct VA’s limited
                  resources and improve its homeless programs.

                  Mr. Chairman, this concludes my prepared statement. I will be happy to
                  answer any questions you or other Members of the Subcommittee may

                  For future contacts regarding this testimony, please call Cynthia A.
GAO Contact and   Bascetta at (202) 512-7207. Individuals making key contributions to this
Acknowledgments   testimony included George Poindexter, Kristen Anderson, Timothy Hall,
                  Jean Harker, and Deborah Edwards.

(406172)          Page 12                                                   GAO/T-HEHS-99-150
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