Many people would view the impetus for programs serving homeless veterans
merely as a lucky break.FIG1
In 1987 a Republican staff member of the Senate Veterans Affairs Committee
who was about to lose her job inserted the word "homeless" into a
bill that appeared targeted for defeat.
However, Sen. Frank Murkowski (R-Alaska) inserted the legislation into a
comprehensive bill that addressed problems related to health care services for
The immediate result was a pilot program, housed in what was then the
Veterans Administration (VA), specifically targeted at homeless veterans with
serious mental illness or substance abuse problems.
Paul Errera, M.D., however, prefers to look at this apparent stroke of
serendipity as a "happening," a term that he borrowed from
political scientist Charles Lindblom and captures the importance both of
opportunity and of one's ability to exploit it.
Errera, in 1985, had moved to Washington, D.C., from his position as chief
of psychiatry at VA Medical Center (VAMC) at West Haven, Conn., to direct the
mental health component of the VA's health care system, because he was
concerned about the erosion of funding for psychiatry in the VA.
He also was committed to community-based treatment for people with serious
mental illness, and the new program offered opportunities to advance that
The Homeless Chronically Mentally Ill (HCMI) program, later renamed Health
Care for Homeless Veterans (HCHV), provides outreach to homeless veterans
living on the streets and in shelters with serious mental illness or substance
abuse problems and connects them with psychiatric, medical, and rehabilitative
Errera and Gay Koerber, now associate chief consultant for HCHV, moved
quickly to take advantage of the possibilities of the new legislation.
Within three months, a social worker had interviewed the first client. Four
months later, the number of homeless veterans had swelled to 4,000.
Perhaps even more important than the speed with which Errera acted was the
groundwork he and Robert Rosenheck, M.D., laid for the long-term survival of
efforts to help the homeless.
The two men and other VA staff focused on program evaluation that was"
practical and accountable," said Rosenheck.
Evaluation of federal programs at that time typically produced data about
clients seen and staff hours and dollars spent, rather than about the impact
on those whom a program was designed to serve.
VA staff not only collected data that initially offered a crude way of
assessing outcomes, but also used the information to redesign elements of the
program and identify services needed.
Rosenheck is director of the VA's Northeast Program Evaluation Center
(NEPEC), which evolved from efforts to evaluate HCMI.
To the most obvious question about homeless veterans, there is no
In late April, Wesley J. Kasprow, Ph.D., M.P.H., project director for the
VA's HCHV's program evaluation, told an audience at a VA-sponsored meeting on
homelessness and serious mental illness, "We don't know with certainty
how many homeless veterans there are in the United States."
On any given day, as many as 250,000 veterans are living on the street or
in shelters, and perhaps twice as many experience homelessness during the
course of a year.
Researchers have, however, unearthed important and sometimes puzzling
information about the characteristics of homeless veterans.
Veterans are overrepresented in the homeless population, despite the fact
that surveys have shown that veterans have higher incomes, lower rates of
poverty and unemployment, and higher levels of education than men in similar
age groups who are not veterans.
But, surprisingly, epidemiological studies do not show a causal connection
between exposure to combat and homelessness. In fact, Rosenheck said,"
Those veterans who served in the early years of the `All Volunteer
Army' when the Vietnam War was winding down are at greatest risk."
Factors such as family background and various personal characteristics
better predict the risk of homelessness than does exposure to combat.
Not at all unexpected, however, are the findings, as reported by Kasprow,
that about half of the clients of HCHV programs have "serious
psychiatric problems," about 70 percent have "substance abuse
problems," and about a third have co-occurring disorders (see page
The Advisory Committee on Homeless Veterans has identified services for
those with mental illness and substance abuse disorders as its top priority.
(This is a VA committee that advises the secretary of veterans affairs on
issues affecting homeless veterans.)
Frances Murphy, M.D., M.P.H., deputy undersecretary for health policy at
the VA, testified before a congressional committee in March 2000 that the VA's"
major homeless programs constitute the largest integrated network of
homeless assistance programs in the country...." (see box).
She added that through NEPEC, the VA conducts the nation's most extensive
and long-standing program of monitoring and evaluating data concerning
homeless individuals and the programs that serve them.
Kasprow told the audience that outcomes at the end of three years show"
maintenance of independent housing" for veterans in a program
jointly offered with the Department of Housing and Urban Development that
provides sustained case-management services and housing vouchers.
Unfortunately, however, according to service providers at the April
conference, the number of housing vouchers available has always been
inadequate and is decreasing. They also said that in general, there is a"
great lack" of affordable supportive housing.
In mid-May, at a meeting sponsored by the National Coalition for Homeless
Veterans, a congressional aide asked a panel of formerly homeless veterans how
to respond to criticism that programs are a "waste of money,"
because veterans will become homeless again.
Kevin Wingate, an intelligence specialist and veteran of a 12-year military
career, said, "Tell them the programs work for about half of us, and
when they do, they make all the difference in the world. There are those of us
who are trying. We need and will use the help."
Numerous reports on the subject are posted online at<www.nepec.org/PHV/default.htm>.▪