Applying the Housing First approach to single-site permanent supportive housing

Journal of Social Distress and the Homeless ISSN: 1053-0789 (Print) 1573-658X (Online) Journal homepage: https://www.tandfonline.com/loi/ysdh20 Applying the Housing First approach to single-site permanent supportive housing Ann Elizabeth Montgomery, Sonya Gabrielian, Meagan Cusack, Erika L. Austin, Stefan G. Kertesz & Jesse Vazzano To cite this article: Ann Elizabeth Montgomery, Sonya Gabrielian, Meagan Cusack, Erika L. Austin, Stefan G. Kertesz & Jesse Vazzano (2019) Applying the Housing First approach to singlesite permanent supportive housing, Journal of Social Distress and the Homeless, 28:1, 24-33, DOI: 10.1080/10530789.2018.1546796 To link to this article: https://doi.org/10.1080/10530789.2018.1546796 Published online: 20 Nov 2018. Submit your article to this journal Article views: 62 View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ysdh20 JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 2019, VOL. 28, NO. 1, 24–33 https://doi.org/10.1080/10530789.2018.1546796 Applying the Housing First approach to single-site permanent supportive housing Ann Elizabeth Montgomerya,b, Sonya Gabrielianc,d, Meagan Cusack and Jesse Vazzanog e , Erika L. Austinb, Stefan G. Kerteszb,f a U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans & Birmingham VA Medical Center, Birmingham, AL, USA; bSchool of Public Health, University of Alabama, Birmingham, AL, USA; cU.S. Department of Veterans Affairs, Greater Los Angeles VA Medical Center, Birmingham, AL, USA; dDavid Geffen School of Medicine, University of California, Los Angeles, CA, USA; eU.S. Department of Veterans Affairs, Center for Health Equity Research and Promotion, Philadelphia, PA, USA; fU.S. Department of Veterans Affairs, Birmingham VA Medical Center, Birmingham, AL, USA; gU.S. Department of Veterans Affairs, Homeless Programs Office, HUD-VA Supportive Housing, Washington, DC, USA ABSTRACT ARTICLE HISTORY This study explored how the U.S. Departments of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program applies Housing First principles in the context of ten single-site programs. Focus group discussions with 64 HUD-VASH staff and community partners explored how the programs were influenced by Housing First principles and specific strategies to implement these principles in a single-site setting. Focus group respondents described resourceful ways that the principles of Housing First were implemented in their programs specifically related to (1) housing choice and structure, (2) separation of housing and services, (3) service philosophy, and (4) service array. Several of the Housing First domains cite the importance of integrated housing and the provision of services off-site; it was of particular interest to learn how single-site programs address these issues logistically. Lessons learned from this study include the importance of leveraging the independent yet overlapping tasks of case management and property management to ensure functional – if not geographic – separation of housing and services; maintaining staff on-site to address Veterans’ needs; working with community service organizations to complement the array of service available to residents; and housing single-site programs in mixed-use buildings. Received 29 August 2018 Revised 10 October 2018 Accepted 7 November 2018 Introduction To end homelessness among Veterans, the U.S. Departments of Housing and Urban Development (HUD) and Veterans Affairs (VA) provide permanent supportive housing (PSH) for Veterans who are low-income, experiencing homelessness, are eligible for VA healthcare, and need case management or supportive services to maintain housing stability. Through the HUD-VA Supportive Housing (HUD-VASH) program, HUD provides a permanent financial subsidy for housing (Housing Choice Voucher) while VA provides clinical services through multidisciplinary teams. HUDVASH has substantially expanded since 2008, housing more than 156,000 Veterans over the past decade. HUD-VASH has national requirements regarding eligibility and minimum service provision for Veterans (VA, 2018), including a 2012 VA mandate that HUD-VASH utilize a Housing First approach (i.e. provide field-based services including linkages to nonmandated clinical services); however, there is variation in how HUD-VASH programs operate locally (Austin et al., 2014). KEYWORDS Veterans; permanent supportive housing; singlesite; housing first One source of variation is whether HUD-VASH enrollees receive a HUD Housing Choice Voucher for scattered-site housing, in which Veterans select independent apartments in the mainstream community, or single-site housing, in which Veterans move into units concentrated at one site often with on-site services offered through regularly-stationed personnel (also referred to as project-based or congregate housing) (Larimer et al., 2009). Scattered-site housing became the preferred approach to provision of PSH, and public housing generally, as public housing projects (i.e. single-site housing for low-income households) funded by HUD and developed locally “became isolated communities of concentrated poverty” (p. 2131), leading to the popularity of “mobility” programs that enable voucher holders to access housing throughout the community (Bostic, Thornton, Rudd, & Sternthal, 2012). However, there has been a rise in the development of single-site HUD-VASH due to increasing needs of vulnerable and aging Veterans and barriers to accessing private market rental housing using a Housing Choice Voucher (Montgomery et al., 2018; Montgomery et al., in press; Dickson- CONTACT Ann Elizabeth Montgomery aemontgo@uab.edu U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans & Birmingham VA Medical Center; School of Public Health, University of Alabama, Birmingham, AL, USA This work was authored as part of the Contributor’s official duties as an Employee of the United States Government and is therefore a work of the United States Government. In accordance with 17 U.S.C. 105, no copyright protection is available for such works under U.S. Law. JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS Gomez et al., 2017; Hsu, Simon, Henwood, Wenzel, & Couture, 2016). As of July 2018, approximately 4,300 HUD-VASH vouchers are allocated across hundreds of single-site programs throughout the country, with an additional 3,200 in development. The first and most widely described Housing First model – Pathways to Housing – favors independent, scattered-site units to support community integration and social inclusion of program participants (Tsemberis, 2010). However, the limited research comparing single-site and scattered-site PSH has found no difference in the impact on quality of life (Patterson et al., 2013; Whittaker, Dobbins, Swift, Flatau, & Burns, 2017) and there is no evidence that participating in one type leads to better outcomes over the other (Nelson, 2010). Various instruments developed to assess the fidelity of PSH programs to a Housing First approach emphasize the importance of scattered-site housing (or lack of concentration of program participants within a certain building) (Gilmer, Stefancic, Sklar, & Tsemberis, 2013; Stefancic, Tsemberis, Messeri, Drake, & Goering, 2013). Fidelity to Housing First principles is important to ensure positive participant outcomes demonstrated by Housing First programs, such as increases in housing stability (Montgomery, Hill, Kane, & Culhane, 2013; Pearson, Montgomery, & Locke, 2009; Tsemberis, Gulcur, & Nakae, 2004) and reduction in the use of acute care services (Montgomery et al., 2013; Stefancic et al., 2013). To our knowledge, no studies have explored the degree to which single-site PSH programs exhibit fidelity to the Housing First model. The aim of the present study is to use qualitative methods to explore how single-site HUD-VASH programs apply Housing First principles. We first provide an overview of single-site HUD-VASH programs and then structure our exploration of fidelity to Housing First around four domains identified by Stefancic et al. (2013) as part of the Pathways Housing First Fidelity Scale. Methods This study – part of larger study intended to describe HUD-VASH scattered-site programs and key service design features that assist or impede service delivery and identify factors associated with good health and housing outcomes (Montgomery et al., 2018) – uses qualitative methods to explore how single-site HUDVASH programs applied Housing First principles. The study team conducted 16 focus groups lasting approximately 60 min each with 64 HUD-VASH staff (i.e. program leadership, case managers, peer support specialists) and community partners (i.e. landlords, property managers, representatives from communitybased organizations, public housing authority staff) affiliated with 10 single-site HUD-VASH programs in five urban communities (referred to as programs and 25 communities, respectively) throughout the United States between May and July 2017. Purposeful sampling conducted in consultation with the Veterans Health Administration (VHA) Homeless Programs and HUD-VASH Offices allowed for significant diversity in geography, housing market, and cultural milieu. The results reflect focus group participants’ responses to the following questions: How is the program influenced by Housing First principles? Do specific practices influence fidelity to these principles? How has the program integrated specific aspects of Housing First (e.g. separation of housing and services, consumer choice) that may be more difficult in a single-site setting? Focus groups were audio-recorded with participants’ consent. Focus groups at the final site were used to check for thematic saturation and perform member checking of key insights to ensure validity of study findings; quotations from the focus groups at this site are not included in the present analysis (Creswell, 1994). Focus groups were transcribed verbatim by a professional transcription service; Atlas.ti was used for qualitative data management, coding, and analysis. The codebook, based on interview guide topics and recurrent themes discussed by respondents, was developed by three members of the study team (“coders”) with experience in qualitative methods and refined following an initial review of transcripts; emergent codes were added and minor disagreements were resolved through discussion. Coders completed coding summaries with exemplar quotes, which were reviewed by a fourth member of the study team for validity and comprehensiveness. We used a template analysis approach based on a priori domains (i.e. those specifically related to programs’ application of Housing First principles) included in the focus group discussion guide (Brooks, McCluskey, Turley, & King, 2015; King, 2004). We organized the results around the first four domains of the Pathways Housing First Fidelity Scale, excluding the fifth domain, program structure, as it represents operations strategies rather than general guiding principles of Housing First (Stefancic et al., 2013). The four domains are (1) housing choice and structure, (2) separation of housing and services, (3) service philosophy, and (4) service array. This study was designated a quality improvement project by leadership of the VHA Homeless Program Office and the Institutional Review Board at the local VA Medical Center (VAMC) (U.S. Department of Veterans Affairs, Veterans Health Administration, 2011). Overview of single-site HUD-VASH programs Of the 10 single-site HUD-VASH programs studied, the most “mature” program opened in 1993 and the most recent in 2016; one program, though funded in 2014, was still under development and not yet operating at full capacity. The number of housing units at 26 A. E. MONTGOMERY ET AL. description of these programs’ application of Housing First principles, delineated by principle and illustrated by exemplar quotes from HUD-VASH staff and community partners. Quotations are attributed to specific programs or to representatives of the larger community in which the program is located (e.g. public housing authority and VA staff). each program ranged from 75 to more than 600. Each program accepted other housing subsidies in addition to HUD-VASH (e.g. Housing Choice Vouchers allocated for the general, non-Veteran population) and half offered private market units earmarked as affordable housing. More than half of the programs were in Veteran-only buildings. All programs offered on-site property management, and the majority were owned and managed by mission-driven organizations (i.e. nonprofit landlords whose mission was to address homelessness generally, often with a specific focus on Veterans); two of the buildings were privately owned and four used outside property management contractors. Half of the sites exclusively offered single-room occupancy (SRO) units and only one offered housing suitable for families with children (i.e. units with more than one bedroom). A variety of amenities were available on-site, such as art rooms, cafeterias, community spaces, computer rooms, gardens, gyms, kitchens, and libraries (See Table 1). Nearly all of the single-site programs had at least one on-site HUD-VASH case manager (generally a social worker) who either worked at the program full-time or split time among multiple programs. Several programs had two or more HUD-VASH case managers or utilized additional HUD-VASH staff (e.g. peer support specialist, occupational therapist, nurse) to augment on-site services. Whether offered on-site or in the community, staff reported a broad range of groups, organizations, and services accessed by Veterans, including self-help groups, classes (e.g. financial literacy, cooking), activities (e.g. tenant councils), and other amenities, including reduced-cost meals. About half of the facilities were co-located with other VHA Homeless Programs providing transitional housing, resources to assist with homelessness prevention and rapid rehousing, and methadone maintenance. All of the programs were located, on average, within 3.5 miles of a VA healthcare facility and several offered daily shuttles to and from the local VAMC. Housing choice and structure The first principle of Housing First is related to participants’ choice of housing in terms of location and type of unit, as well as ensuring rapid access to housing (i.e. within four months). The housing unit is intended to be permanent and affordable (i.e. no more than 30% of income is allocated toward rent); given the use of a Housing Choice Voucher, this was the case for all housing units at each of the programs studied here. Housing First participants should be housed in a building where fewer than 20% of the other residents are also program participants and where they have access to their own private spaces; due to the nature of single-site housing (i.e. concentration of multiple units within one building or facility), this criterion was not met although each program offered private apartments (Stefancic et al., 2013). Focus group respondents stressed the importance of consumer choice in housing, which occurred at the outset when programs gave Veterans the option of scattered-site housing in the community or placement in single-site housing: Where do you want to live? You have the list of apartment complexes. We can go in the community. We can look at apartment complexes. We also have [singlesite] apartment complexes. And it’s your choice and your decision where you want to go. (Program A) Several programs emphasized the need to be explicit regarding the differences between single-site housing and scattered-site housing to ensure that Veterans fully understood their choices and could express their housing preferences: Results A lot of education has to go with it and I just simply term it that [single-site], the voucher stays with the apartment unit, whereas the [scattered-site] VASH The following presents an overview of the single-site HUD-VASH programs studied here, followed by a Table 1. Characteristics of single-site housing first programs. Community Community A Community B Community C Community D Washington Single-Site Program Total Units HUD-VASH Single-Site Vouchers Landlord Property Management SRO Furnished Program A Program D Program G 155 150 600 Program B Program E Program C Program F Program H North Capitol Commons/ Conway 220 264 497 131 75 124 10 25 50 100 22 75 50 75 60 60 Mission-driven Mission-driven Mission-driven Mission-driven Private Mission-driven Mission-driven Private Mission-driven Mission-driven Contractor Landlord Landlord Landlord Contractor Landlord Landlord Contractor Landlord Contractor No No No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No Yes No No Yes Yes JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS voucher is attached to you. But then I also let them know that it’s not like you’re trapped … after one year of staying, you can request a regular Housing Choice Voucher. (Community A) Sites acknowledged, however, that Veterans’ preferences regarding housing were often constrained by the realities of their background characteristics and rental histories: Now, we’ve had some [tenants] that have had criminal histories that we’ve had the discussion; boy, it’s going to really be hard in the community, especially depending on how long ago it was or how recent it was … It’s Veteran choice, so we … lay out the options and then they make their decisions, but it is a good option for a lot of the Veterans that would have challenges in their community. (Community A) Similarly, local housing markets also played a role in prompting some Veterans to choose single-site programs. Offering single-site programs as an option often translated to shorter waiting periods for housing when the local context made finding a rentable unit more difficult: For the most part, it’s trying to see what’s out there, and then not having success, and then saying, “Okay, I see what the real estate market’s like. I’ll move to [a single-site program].” (Community D) HUD-VASH staff may have tried to persuade Veterans in one direction over the other, given Veterans’ needs or the particular challenges of the local housing market, but the choice was ultimately up to the Veteran: It’s a little bit of a challenge. I mean, when we do try to give people the ability to live where they want to live, even though we may think something might be better for them than something else, we can only sort of offer them and maybe show them the benefits of it, but we can’t make them do that. (Community D) Separation of housing and services To meet the Housing First criteria for separation of housing and services, participants must be admitted to the program without any preconditions or requirements for services use, they must agree to a standard lease, the program must commit to facilitating longterm housing stability, and housing and services should not be collocated (Stefancic et al., 2013). Focus group respondents noted how single-site programs are uniquely situated to help vulnerable Veterans remain housed since staff can intervene on Veterans’ behalf if problematic behaviors arise and work with property managers, with whom they already have a close working relationship, to keep Veterans stably housed: Support is more about keeping people housed but really the [property itself] is better off if people stay 27 housed versus turning folks over, so we realize we’re all kind of working at the same goal. It’s just we come at it from a different kind of perspective. And so being able to talk those through, sometimes we can talk property management into letting some behaviors go for a while because we’re – it’s gonna take time to stabilize versus if that happens one more time they’re gone. It’s like well, no, one more time’s gonna happen. It’s just how can we provide the support to minimize that? (Program D) Given the characteristics of the population typically served by HUD-VASH single-site programs (Montgomery et al., in press) – and the finding in other studies that tenure of housing was positively related to reductions, over time, in behavior that may jeopardize one’s housing (Larimer et al., 2009) – the program’s ongoing commitment to working with participants to assure their housing stability is particularly salient. Staff described two main types of participants in single-site housing: those who used singlesite housing as a stepping stone toward a future goal of independence and those who remained in singlesite housing for the rest of their lives: We have a lot of our Veterans who are senior citizens where they made this step up and now they can relax … And then we got some Veterans who say okay, I’m cleaning myself up. I’m going to get myself ready to get a job and move on next to my career, and move on to bigger and better things. And we work with the Veterans with whatever their goal is. (Program C) Staff reported that continued housing assistance might be necessary for some Veterans. However, for those demonstrating greater knowledge of resources, less need for intensive case management, and increased social supports, graduating from case management could be appropriate: That’s our goal in case management is for them to get to the point where they say, “You know what? I don’t need you anymore … I’m independent … Thank you … I’m going to all my doctor’s appointments. I’m taking my medication. I’m reconnecting. I’ve identified a support system. I don’t need you to come see me anymore.” (Program B) Similarly, for Veterans with a reduced need for additional support services, a goal might be to move from a single-site program to using a scattered-site voucher in the community: There’s those that may still need the subsidy but after a while they’re feeling like they don’t necessarily need all the supports in one place and they’d rather integrate further into a community out in the suburbs or even other parts of [the city], in which case we’ve been able to move them onto some VASH Housing Choice vouchers and let them move into the community. (Community A) Housing First was originally intended to be limited to scattered-site housing units, assuring at least to some degree a distinct separation between a 28 A. E. MONTGOMERY ET AL. participant’s housing and use of supportive services both functionally (i.e. physically separate) and clinically (i.e. one’s needs related to chronic medical conditions or mental health are distinct from housingrelated needs) (Tsemberis, 2010). At each of the single-site programs in this study, separation of housing and services was supported by a distinction in the functions of property management and HUD-VASH case managers. At each site, the property was either owned or managed by a property management company, which collected rent, maintained the property, enforced rules, and addressed issues such as evictions. Supportive services, on the other hand, were the domain of VA staff (i.e. case managers, peer support specialists, nurses) and other contracted service providers located at the site. One site described that, “The separation is built into our structure because we are three separate entities,” describing the roles of VA case management staff, property management, and the mission-driven landlord: Because we are providing services and clinical services, it gets real dicey when you’re trying to handle the money, too, so it’s just better when those are separated. And we do services. And we work with them to help manage any issues that may be preventing you from paying your rent. But we’re not handling the money. So yes, I think it should always be a separation of those two pieces. (Program A) The separation between property management and supportive services was particularly important when issues related to a Veteran’s housing stability arose; the ability to work together to address Veterans’ housing instability from different angles appeared to be effective, which was also identified as a strength of congregate housing projects that were studied as part of the Collaborative Initiative to Help End Chronic Homelessness (Kresky-Wolff, Larson, O’Brien, & McGraw, 2010): We don’t do anything with the rent on the support service side, other than saying “We notice that you’re behind rent and you’re going to be evicted so what’s the issue, what can we work on, how do we do this?” It’s kind of a, I always liken it to good cop/bad cop property management … How can I help you? We need to get this fixed because they’re going to put you out … Then we can work from the support side to say – and that gives us an in-road into some folks who just don’t want any services at all and all of a sudden it’s like yeah, I kind of need you to help me with this and how do I get out of this jam – well, then we can look at what caused the jam in the first place. Where did your money go? (Program D) The separate but complementary roles played by property management and VA case managers was most evident with regards to evictions and enforcement of rules; both sides prioritized maintaining Veterans in their housing and avoiding evictions to the extent possible. The service team and the management team get together, really every week, because we go over any incidents that might have gone on in the building for a week together. As a team, we talk about who possibly may get some type of lease violation or if there’s a necessity for someone to get an eviction notice. But at the same time, even though management may be giving out the eviction notice, services is doing an eviction prevention plan. (Program A) Service philosophy The service philosophy underlying the Housing First approach asserts that participants may choose their own program of services, although there are no requirements for them to accept or participate in psychiatric or substance use services; however, these services must be available and participants must engage with one face-to-face interaction with program staff weekly. Services should be consistent with a focus on recovery and harm reduction and program staff should encourage participants, but not coerce them, to engage in available resources and services (Stefancic et al., 2013). Staff recognized that although the programs offered on-site services, housing was not contingent on the use of services. Staff described Veterans who had very high needs and requested intensive assistance as well as others who required or requested very few services: This is an apartment complex first and foremost … Services were never required from day one. They were always offered. My instructions to staff were always: if someone does not want service, they need to at least get something put under their door every month saying I’m your service provider, I’m available whenever you want, here’s how you contact me. And it’s offered every month. (Program D) However, the choice to use services was somewhat complicated by the location of VA case managers onsite, as many mentioned reaching out for quick check-ins with Veterans even if they had not formally requested services. Those who have been identified as needing additional supports are placed in that acuity and they want the resources. It’s not like we’re knocking down their door like hey, you have to, you have to, you have to. They’re seeking the case managers out … Of course, there are times where maybe there are substance use issues or what not and it could be a gentle reminder with a note slipped under the door as opposed to waiting three or four days for the mail to show up and say hey, worried about you; haven’t seen you in a while. So, there’s no tension there. It’s, the Veterans that I see, it’s receptive. So, and even if there is a period of time where they don’t want services at all, eventually, they come back around. They do. And then if they JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS 29 don’t want services, it’s the constant knock on the door. Hey, worried about you; haven’t seen you in a while and it just makes it more convenient. So, it’s no tension at all. I think it works very, very well for those needing additional services and they know they need additional service so they welcome it. (Community A) therapist, substance use disorder specialist) assigned to a given program or who split their time among programs to augment standard case management. Staff at several single-site programs described how the program morphed over time to include additional service providers focused on housing support: At the same time, “harm reduction focuses on reducing the negative consequences of harmful behaviors related to drug and alcohol abuse … [and] managing potentially harmful consequences of untreated psychiatric symptoms” (Tsemberis, 2010, p. 29), and a key facilitator of single-site programs reported across all sites was the benefit associated with case managers being on-site to provide immediate, ongoing support to Veterans; this was particularly important when Veterans were experiencing a crisis: The VA, over time, has added experts, whether it’s navigators or employment experts … as VASH has expanded to meet the needs of long-term, I think the original focus was to get them housed, but over time, it evolved into, okay, so get them housed. How do they succeed long-term? And more of that additional supports were added within VA. (Program B) We have people, because of their health needs and things going on with them, that we keep a watch … if you don’t see them for a couple of days they need to do a wellness check, that kind of thing. (Program D) Being located where Veterans lived also provided case managers with a more comprehensive view of Veterans’ well-being and progress toward recovery. You leave your office and you go visit people. Don’t sit in your office and let people come to you. You’re visiting their homes. You’re doing your service in the home. It allows you to see the entire environment and what’s going on. (Program D) Service array The array of services provided to participants of Housing First programs should include “housing support, psychiatric treatment, substance use treatment, supported employment, nursing, and services to assist with social integration” (p. 258), delivered either directly or through connection with other services providers to ensure that the program is responsive to different facets of recovery. In addition, crisis response should be available at all times (Stefancic et al., 2013). The single-site HUD-VASH programs provided a variety of supports to assist Veterans in maintaining their housing stability. While VA case managers served as the backbone of this support system, connections with other community resources and VA healthcare provided additional support in helping Veterans reach their recovery goals. VA case management and specialized staff HUD-VASH staffing varied across the programs studied: VA case managers worked at a particular program on given days; one or more dedicated VA case managers were located on-site at the single-site program at all times; and a combination of VA case managers and specialized VA staff (e.g. peer support specialist, nurse, employment specialist, occupational Another single-site program reported bringing in VA specialized nursing staff to address the needs of the medically frail and aging population being served by the program: I’m here … to provide supportive [nursing] services. What that means, it’s like an umbrella of what is really going on. I have a few on my case that I follow-up. It depends on the level of what I’m working with them, like either med management, just teaching them how to use a blood pressure machine and all that. But nothing emergent, except sometimes we get that, too. Like I get called and, can you look at this guy? He doesn’t look right. (Program H) A benefit of having staff on-site was that it often provided a higher level of service for program participants than they might receive in other housing arrangements. For example, having VA social workers on-site facilitated Veterans’ ability to access care and helped with discharge planning when they were admitted to the local VAMC: If they know there’s a social worker that will make sure they get back to the next follow-up appointment or whatever all those things are, we can move them out of inpatient much quicker, which is better for the Veteran and better for … the hospital as a whole. So there’s pretty good communication I think on the different social workers. (Community D) Respondents also described how on-site services were a vehicle to engage Veterans in activities to minimize isolation and an opportunity to assist Veterans in becoming independent, making later community integration easier. They described how they often elicited feedback from Veterans on what they would like to see offered and targeted on-site services to respond to Veterans’ needs, including additional assistance with harm reduction (e.g. Alcoholics Anonymous, Narcotics Anonymous) if Veterans expressed interest: It’s case management with a therapeutic intervention all the way along because that’s how they learn. And you’re really teaching life skills and coping skills and all of that kind of stuff in the process of helping them obtain those basic benefits and those basic needs that just have not been a part of their system for a long time. (Program D) 30 A. E. MONTGOMERY ET AL. Housing First emphasizes the importance of recovery as it relates to a person’s overall well-being (Tsemberis, 2010). Community integration and family reunification were key foci of case management to help Veterans on their paths to recovery: When you’re homeless and you’re living on the street for so long, you usually have lost contact with your family and your loved ones. And when … people come in our facility, if we’re able to reconnect them to their family, then we do. And we were able to reconnect quite a few. And once that happens, sometimes the family says, you know what, you’d be better off coming home with us. (Program A) Staff also described Veterans obtaining education while in single-site programs as a path toward job acquisition and graduation from HUD-VASH: Especially the younger ones, I would say, [live here on a] short-term basis. I want to save. I want to finish my degree. I’m in school. Find employment, save, and then … I’m ready to go out in the community. (Community A) Finally, staff described several possible independent outcomes for program participants, including graduation from the HUD-VASH program (both housing assistance and case management), typically as a result of increased income: I have a Veteran who is a success story. When he came on the program, he was in a different apartment complex with no income. He got a job as a baggage handler part-time, just got a full-time job as a security guard. He’s going to keep his second job, so he’s over income. And he told me yesterday … I don’t need you anymore. I’m doing fine. (Program B) Community connections VA case managers connected Veterans with a range of other supportive services. At some sites, non-VA community resources were co-located at the single-site program, which improved VA staff’s familiarity with the various community-based services available to support Veterans. Case managers connected Veterans with other outside resources including access to benefits and entitlements (e.g. Medicaid) as well as other services in the community such as charity dental care or food pantries: Most of our resources are out from the community. It’s a church that’s offering some kind of payoff or food pantry or some kind of extra service in the community. This was a group that’s not affiliated with the VA. Those are the things that we really, really rely on, those community partners outside of that. (Program B) Staff at programs also described the importance of community integration among the Veterans participating in the single-site program and how they encourage Veterans to volunteer and engage with community organizations and churches. They have a lot of time on their hands so how do you fill it? Well, that’s where you kind of do a lot of the community inclusion and let’s get you connected to this or have you gone to church … That’s been our big push is get them out into what’s in your neighborhood and you’re a value to people. It’s like you’re a value to these organizations looking for help and you’ve got time on your hands. So, those are things, while they have a sense of community here, they also have a sense they’re a part of the community. (Program D) VA healthcare While many services and resources were available at single-site programs, staff emphasized a desire not to replicate services available through the VA healthcare system. Many sites offered shuttles or transportation services to local VA healthcare facilities. Having VA case managers on-site at the single-site programs facilitated Veterans’ ability to access healthcare and supported discharge planning. What I’ve seen is mental health issues, substance abuse issues, they don’t want to be serviced here for those things because this is their home. They want to be able to go to the VA, be able to come home and this be their space. (Program D) Discussion This study explored how HUD-VASH programs apply Housing First principles in the context of single-site PSH. During focus group discussions with HUDVASH staff and community partners, staff championed the Housing First philosophy and reported resourceful ways that these principles were implemented in their local programs. Because several of the Housing First domains cite the importance of integrated housing (housing choice & structure) and the provision of services off-site (separation of housing & services), it was of particular interest in this study to learn how singlesite programs address these issues logistically. Respondents from each program described the importance of client choice in the enrollment process and assuring Veterans that choice remained once they moved into a single-site program; respondents reported working with Veterans to help them obtain a scattered-site voucher, if available, if they chose to leave the single-site program. Separating housing and services in single-site PSH programs may be challenging given that they are physically collocated; respondents clearly described the functional separation of these two pieces of the PSH equation, often accomplished by having separate entities provide the supportive service and property management, clearly delineating the roles of each, and regularly reiterating these distinctions for residents. However, while these two functions were distinct, they also collaborated to address Veterans’ housing JOURNAL OF SOCIAL DISTRESS AND THE HOMELESS instability, which may be more effective than the typical case manager-landlord advocacy for Veterans in scattered-site HUD-VASH given the existing and ongoing relationship between supportive services and property management. While single-site PSH programs may need to be more deliberate about the separation between housing and services, they often have the advantage of having access to more services in terms of both frequency and types (Henwood et al., 2018). Researchers have argued the merit of adapting the Housing First model to meet the specific needs of a particular community or service population while retaining six “ingredients” of Housing First to which program success may be attributed: low-threshold admission policy, harm reduction, eviction prevention, reduced service requirements, separation between housing and case management roles and responsibilities, and strategies to inform and educate consumers (Watson, Orwat, Wagner, Shuman, & Tolliver, 2013; Watson, Wagner, & Rivers, 2013). It is worth noting that these ingredients do not include the criteria that housing be scattered-site. Based on our findings, HUD-VASH single-site programs strive to include each of these ingredients in their programs (although we did not specifically assess strategies to inform and educate consumers). Single-site programs admitted Veterans who had barriers to scattered-site housing due to problematic background characteristics and rental histories and were often well positioned to provide eviction prevention through the distinct yet complementary roles of case management and property management. Single-site programs, then, were welladapted to respond to the needs of those with barriers to housing or more complex medical, mental health, or substance use conditions. However, this study did not assess the perspectives of Veterans living in single-site programs. Therefore, these data are limited in whether Veterans experienced choice in their housing or their use of services. It may be the case, at least in some instances, that services providers may limit or negotiate participants’ choices in such a setting (Juhila, Hall, Gunther, Raitakari, & Saario, 2015). Future research should assess the experiences of people living in single-site Housing First programs in terms of each of the domains reported here, particularly related to housing choice and separation of housing and services. This study is the first to explore how single-site PSH programs articulate the principles of Housing First. The results may not be generalizable to other singlesite programs given specific program requirements or policies imposed by HUD-VASH. In addition, each site had to negotiate ways to express Housing First principles among a number of stakeholders including the public housing authority, local VAMC, property management, and supportive services providers, while keeping in mind the larger community context; the 31 results presented here do not reflect a one-size-fits-all approach to single-site Housing First. Further, the results presented here are not intended to substitute for a formal evaluation of fidelity to the Housing First approach; however, lessons learned from the providers who participated in this study may be instructive for other single-site programs that are navigating how to approach fidelity to Housing First principles. In addition, the present study did not consider the fifth domain identified by Stefancic et al. (2013), which is related to the program structure and includes factors such as priority enrollment for participants with experiences of homelessness as well as serious mental illness or substance use disorders; low participant to staff ratios; weekly meetings with participants; a team approach to responding to participants’ needs and doing so using daily meetings to review and record participants’ status, schedules, and needs; and the incorporation of a peer specialist on staff as well as participants’ input into the program. Focus group participants often described these aspects in terms of how their programs operated but not specifically in response to probes related to programs’ application of Housing First principles. The results from this study have implications for practice, which may be particularly informative for other programs that are attempting to apply a Housing First approach within a single-site context. Specifically, respondents provided examples of how they leverage the independent yet overlapping tasks of case management and property management to ensure functional – if not geographic – separation of housing and services. The primary factor that facilitated successful operation of single-site HUD-VASH programs was having staff on-site to address Veterans’ needs. Given that these programs served high-acuity Veterans, often with complex medical conditions and co-occurring mental health and substance use disorders, having on-site support was critical to housing stability. Program staff described the desire to provide additional services onsite, often related to health needs, particularly for those Veterans who were unable to live fully independently. Additional best practices identified during these visits included working with community service organizations to complement the array of service available to residents (e.g. furniture) and housing single-site programs in mixed-use buildings that may include nonvouchered units, which better reflects the larger community and may facilitate integration. Finally, the present study was not intended to serve as a formal assessment of single-site HUD-VASH programs’ fidelity to a Housing First approach; rather, it described how single-site programs apply Housing First principles in practice. However, given that, by definition, single-site PSH programs violate the principle of separation of housing and services, it is important to consider whether this criterion must be met for 32 A. E. MONTGOMERY ET AL. programs to truly espouse a Housing First approach – should this domain be refined to be consistent with the approach taken by single-site programs or rendered inapplicable altogether? Given that there is an increasing number of single-site PSH units coming online across the country and representatives of the programs studied here were able to articulate some concrete ways that they attempt to separate housing and services, future research should consider potential modification of the Pathways Housing First Fidelity Scale to learn about the variety of ways that separation of housing and services is operationalized and potentially modify the fidelity scale specifically for single-site programs. Disclosure statement No potential conflict of interest was reported by the authors. Funding This work was supported by the U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans. Notes on contributors Dr. Ann Elizabeth Montgomery is an investigator at the VA National Center on Homelessness Among Veterans and the Birmingham VA Medical Center and is an Assistant Professor in the Department of Health Behavior at the University of Alabama at Birmingham School of Public Health. Her research focuses on identifying Veterans at risk of housing instability and interventions to prevent and end homelessness. Dr. Sonya Gabrielian is a psychiatrist and investigator with the VA Greater Los Angeles Health Services Research & Development Center of Innovation and the VISN 22 Mental Illness Research and Educational Center, as well as an affiliated researcher with the National Center on Homelessness Among Veterans. Her research focuses on improving functional outcomes for Veterans engaged in VA housing services. Ms. Meagan Cusack is a project manager with the VA Center for Health Equity Research and Promotion (CHERP), where she coordinates and conducts mixed methods research integrating Veteran and stakeholder voices with secondary data. Dr. Erika L. Austin is an Associate Professor in the Department of Biostatistics at the University of Alabama at Birmingham School of Public Health. Her research focuses on interventions to address homelessness among Veterans and studies using a mixed methods approach. Dr. Stefan G. Kertesz is a physician and health services researcher at the Birmingham VA Medical Center and studies homelessness and housing interventions related to Housing First and Homeless Patient Aligned Care Teams. Ms. Jesse Vazzano is the National Director of the U.S. Departments of Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) program. ORCID Meagan Cusack http://orcid.org/0000-0003-2622-4566 References ATLAS.ti Scientific Software Development GmbH, Berlin. 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