Making Housing First Happen: Organizational Leadership in VA’s Expansion of Permanent Supportive Housing

ABSTRACT

BACKGROUND

While most organizational literature has focused on initiatives that transpire inside the hospital walls, the redesign of American health care increasingly asks that health care institutions address matters outside their walls, targeting the health of populations. The US Department of Veterans Affairs (VA)’s national effort to end Veteran homelessness represents an externally focused organizational endeavor.

OBJECTIVE

Our aim was to evaluate the role of organizational practices in the implementation of Housing First (HF), an evidence-based homeless intervention for chronically homeless individuals.

DESIGN

This was an interview-based comparative case study conducted across eight VA Medical Centers (VAMCs).

PARTICIPANTS

Front line staff, mid-level managers, and senior leaders at VA Medical Centers were interviewed between February and December 2012.

APPROACH

Using a structured narrative and numeric scoring, we assessed the correlation between successful HF implementation and organizational practices devised according to the organizational transformation model (OTM).

KEY RESULTS

Scoring results suggested a strong association between HF implementation and OTM practice. Strong impetus to house Veterans came from national leadership, reinforced by Medical Center directors closely tracking results. More effective Medical Center leaders differentiated themselves by joining front-line staff in the work (at public events and in process improvement exercises), by elevating homeless-knowledgeable persons into senior leadership, and by exerting themselves to resolve logistic challenges. Vertical alignment and horizontal integration advanced at sites that fostered work groups cutting across service lines and hierarchical levels. By contrast, weak alignment from top to bottom typically also hindered cooperation across departments. Staff commitment to ending homelessness was high, though sustainability planning was limited in this baseline year of observation.

CONCLUSION

Key organizational practices correlated with more successful implementation of HF for homeless Veterans. Medical Center directors substantively influenced the success of this endeavor through their actions to foster impetus, demonstrate commitment and support alignment and integration.

Appendices

Appendix 1: Assessment Criteria for Domains of Housing First

1. Housing assistance is the key intervention for ending homelessness	2. Consumer choice and self-determination are central	3. Housing is targeted to the most vulnerable consumers first	4. A full range of services should be available to consumers though housing is not contingent on treatment participation or success	5. Consumers are seen as able to take incremental steps toward positive behavior change and reduced harm
1.1 Housing and services are functionally separate	2.1 Each consumer sets personalized goals according to their own values	3.1 Prioritizes chronically homeless consumers using formally established criteria	4.1 No preconditions for housing readiness	5.1 Consumer selects the sequence, duration, and intensity of services
1.2 Time to housing is minimized	2.2 Consumers select a residence from among other options with choice in type and location of residence	3.2 Prioritizes consumers with complex medical and/or psychological needs	4.2 Multidisciplinary service teams (including persons such as nurses, doctors, employment specialists, peer specialists) provide individualized services	5.2 Motivational interviewing is used to help consumers identify and meet their self-defined goals
1.3 Housing is permanent	2.3 No institutional housing	3.3 Well-developed systems to identify and outreach to consumers who need housing	4.3 There are regular face-to-face encounters between staff and consumers
1.4 Specific assistance for the client with locating and securing housing is offered	2.4 No live-in staff	3.4 Services are adjusted during times of crisis	4.4 Support services are available 24/7
1.5 Additional placement opportunities are offered when an initial housing placement has failed	2.5 Occupancy arrangements are standard for the market	3.5 Support is provided to local community (especially landlords, property managers) for dealing with hard-to-house consumers	4.5 Strength-based orientation in all services provided
		3.6 Staff have the capacity to meet the needs of highly vulnerable consumers	4.6 Continuation of support services if the consumer leaves housing or is hospitalized

Appendix 2: Assessment Criteria for Domains in the Organizational Transformation Model

1. Impetus	2. Leadership commitment	3. Alignment throughout organization (vertical)	4. Integration across organizational boundaries (horizontal)	5. Staff engagement	6. Sustainability
1.1 Strong impetus among Medical Center leadership to implement HF and/or to meet VA goals for ending Veteran homelessness	2.1 Medical center leadership provides vision and direction, demonstrate constancy of purpose for HF implementation	3.1 Alignment of goals regarding HF throughout the Medical Center	4.1 Presence of high-level structures to facilitate cooperation across organizational boundaries; coordinate staff providing services for homeless Veterans.	5.1 Staff buy-in for national, local mandates for housing homeless Veterans.	6.1 Attention to sustaining progress achieved in meeting goals.
1.2 Urgency, sense of impetus among mid-level managers	2.2 Department chiefs and mid-level managers demonstrate support of HF goals and activities	3.2 Measurement of progress and success of HF activities	4.2 Progress and lessons learned are shared across the Medical Center	5.2 Motivational interviewing is used to help consumers identify and meet their self-defined goals	6.2 Attention to maintaining Veterans in housing
			4.3 Efforts to ensure engagement/alignment with external organizations