Developing and Implementing a Common Referral Form for Temporary Housing Providers

By Shawn Liu, National Homeless Program Manager, Homeless Programs Office

April 11, 2024

Introduction

Homelessness, particularly unsheltered homelessness, is one of the most dangerous situations an individual can experience. Although VA’s goal for every homeless Veteran is stable, permanent housing, temporary housing is often a necessary first step on that path. When a Veteran expresses interest in moving to an emergency shelter or transitional housing program, VA must be ready to provide a solution as quickly as possible, ideally on the same day. If not, the Veteran will remain unhoused longer, and the window of opportunity to help the Veteran move toward permanent housing may close.

VA medical centers (VAMCs) have noted that lengthy referral forms can be a barrier to quickly placing homeless Veterans into temporary housing. For example, one VAMC noted that providers routinely referred Veterans to the local non-VA-funded community shelter because it used a 1-page referral form, whereas their local GPD provider’s referral was 12 pages long.

Having different referral forms for different community providers may increase the time it takes for a Veteran to move from unsheltered to sheltered while also taking staff time that could be better used addressing the Veteran’s clinical needs. This is particularly the case for VAMCs that have many community partners providing temporary housing.

Facing both these issues in Orlando, Florida, homeless program staff took concrete steps to modify their existing policies and procedures to simplify their processes, resulting in improved outcomes for Veterans. In addition to streamlining the referral process, the practice also maximizes the chances that homeless Veterans, particularly those who are unsheltered, can get same-day access to temporary housing.

Practice overview

Staff at the Orlando VAMC worked with 9 GPD grantees to create a 2-page common referral form that can be completed once and submitted to all grantees whose services meet the individual Veteran’s needs.

The common GPD referral was inspired by a similar one adopted more than a decade ago for Orlando’s Health Care for Homeless Veterans Contract Residential Services (CRS) providers. The GPD efforts came later for several reasons: there were significantly more GPD grantees compared to CRS providers; GPD grantees offered services in 5 counties across 3 different VA service sites, while CRS providers were in 3 counties covered by a single service site; and local VAMC control over CRS contracts as compared to GPD grants.

Background and context

The push toward developing a common GPD referral form at the Orlando VA started in 2018 when the U.S. Department of Housing and Urban Development (HUD) enacted new rules about coordinated entry (CE) systems. The CE rules were first codified by HUD in 2012 in response to the initial U.S. Interagency Council on Homelessness (USICH) publication of Opening Doors: Federal Strategic Plan to Prevent and End Homelessness in June 2010. Under the 2012 rules, HUD required each local Continuum of Care (CoC) to establish and operate a CE process to increase the efficiency of local crisis response systems and prioritize people most in need of assistance.

Between 2012 and 2017, as HUD learned more about what made CE systems most effective, it was determined that additional requirements were necessary. The new requirements provided more clarity on the fact that temporary housing providers, such as VA’s GPD grantees, were part of the local CE system and needed to conform to its practices, which included the use of standardized assessment processes that gathered “only the information necessary to determine the severity of need and eligibility for housing and related services.” Therefore, while a comprehensive CE assessment may be a phased process, employing different tools at different stages, the information gathered should only be what was necessary for an admission decision for transitional housing.

While not specific to the CE process, it is also relevant to note that reducing the information requested from Veterans when assessing and referring them for services conforms to the principles of trauma-informed care. The experience of homelessness is in itself a traumatic event, and many homeless Veterans have experienced trauma before, during, and after their military service. Reducing the amount of information requested from Veterans during this difficult and stressful time can help minimize the possibility of re-traumatization and increase trust between the Veteran and VA staff.

Developing the new common referral form

In 2018, a team of homeless program leaders at VA Orlando began holding meetings with the GPD grantees to educate them about the new requirements, starting with the grantees in their largest CoC area and gradually expanding to the others. Initially, they discussed the need for a common referral from a conceptual standpoint, emphasizing its consistency with the CE requirements. They enlisted Technical Assistance Collaborative to help educate the providers about the flow of the CE system. As the meetings progressed, they began to discuss the specifics of a common referral form in 2019, with the team’s GPD liaisons leading the effort. Due to staff transitions and the onset of the COVID-19 public health emergency, the process was paused for more than a year but was renewed in the summer of 2020.

Before the common referral form was developed, Orlando’s GPD provider referrals ranged from 2 pages to more than 10. Consequently, a vital component of the process was building consensus among the grantees about what information was truly necessary for an admission decision. First, the team collected all the referral forms and noted their common elements. Second, they clustered other elements into themes: physical health, mental health, employment history, etc.

In subsequent meetings with the grantees, they discussed in detail why other elements were needed and how the information was used. Significantly, they differentiated between information necessary at intake and information that could be gathered from VA staff, particularly the GPD liaison, after the Veteran had been admitted. These discussions determined the minimum number of elements that all the grantees could agree upon. After the group completed a draft of the new referral form, Orlando VAMC initiated a 5-month pilot with some GPD grantees to gather feedback and fine-tune it before the general rollout in June 2021.

Considering the COVID-19 pause in early 2020, the entire process was completed over approximately 18 months. In addition to streamlining the process for its then-current grantees, the common referral has also proved beneficial when new grantees have come on board. When a new grantee was approved in 2023, the organization provided its referral form to the Orlando VAMC. However, the VAMC shared its existing practice and added the grantee to the common referral form.

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Conclusion

Practice outcomes

When Orlando VAMC developed the common GPD referral form, its primary goal was to streamline the process for both Veterans and the providers referring them to GPD sites. This resulted in decreased waiting times for Veterans and a higher percentage of Veterans being admitted to a GPD site on the same day of the referral.

Additional considerations for homeless program leaders

As homeless program leaders at other VAMCs consider embarking on a process improvement

project to create a common referral form for their GPD or CRS providers, the following points could contribute to the success of their efforts.

Invite all stakeholders to the table

The Orlando team intended to develop a common referral form to support the direct relationships between the VAMC and its GPD grantees. However, the project also affected the area’s entire CE system. Therefore, engaging their CoC agency teams and case conferencing facilitators was important. VAMCs that embark on similar efforts should include these partners in the discussions.

Anticipate and address reluctance to change current practices

The Orlando VA team encountered hesitation from several grantees when developing a common referral form. Some did not thoroughly understand the CE process or GPD’s role. Some initially saw the proposed change as an intrusion into their organization’s autonomy. Some insisted that every question on their existing referral forms was necessary to make an informed admission decision.

Other VAMCs should anticipate possible points of resistance and be prepared to address them thoroughly and thoughtfully.

Enhance your team’s skills in process improvement

When the project began at the Orlando VA, one of the team’s GPD liaisons had recently completed Lean Belt training, which proved helpful to its success. Although specific training is not necessary to make this kind of organizational change, they recommend that VAMC homeless program leaders cultivate a culture of continuous improvement within their teams by encouraging staff to participate in process improvement training and rewarding process improvement ideas and efforts.

Show up for partners if issues arise after admission

Before the common referral form was implemented, grantees raised a concern regarding what to do if serious issues arose after admission, or if it was determined that the Veteran’s needs made him or her inappropriate for the placement. To help alleviate the impact on the partner in these cases, the Orlando team holds their GPD liaisons and homeless program supervisors to a high standard of care: a VA staff member is on-site at the grantee a minimum of once per week and up to 4 days per week to ensure that grantees feel adequately supported. VA staff address clinical issues and facilitate alternate placements when deemed necessary. Although significant on-site presence is already the expectation for VA staff concerning GPD grantees, VAMCs must be prepared that an increased number of same-day admissions may require a correspondingly increased on-site presence.

Provide ongoing education for staff and community partners

An unforeseen consequence of adopting the common referral form was that both internal VAMC staff and community partners who referred to GPD would sometimes refer to all nine sites in the hopes of securing a bed quickly. However, not all Veterans are suitable for every type of bed offered, and sometimes a Veteran would be accepted at a site and others would be unaware. To reduce occurrences of this scattershot approach, the Orlando team implemented and continues to hold monthly training for new staff and partners to review the different types of beds available (e.g., low demand, bridge housing, service-intensive) and to discuss which are most appropriate for individual Veterans. Other VAMCs should note that ongoing training will be essential.

For more information, please contact HomelessVets@va.gov.