Coordinated Exit: Providing Services to All Veterans Exiting Homeless Programs, Regardless of Destination

By Shawn Liu, National Homeless Program Manager

August 12, 2021

Introduction

The VHA Homeless Programs Office identifies and disseminates innovative practices in homeless program operations. The VA Central Ohio Health Care System has been identified as a site with an innovative practice for providing effective follow-up and re-engagement services for currently and formerly homeless Veterans.

While the coronavirus pandemic has led to the development of many new and innovative approaches to engage Veterans in the community, it has also surfaced new challenges and gaps in service coverage. At the onset of the pandemic in March 2020, and consistent with guidance provided by the Centers for Disease Control and Prevention (CDC), the VHA Homeless Program Office directed homeless programs across VA to decrease routine or non-emergent face-to-face encounters with Veterans.

Fearing the negative impact on the quality of services provided to Veterans experiencing homelessness in Columbus, OH, the VA Central Ohio’s Healthcare for Homeless Veterans (HCHV) Outreach Team worked swiftly to strengthen collaboration and case review processes with other VA homeless programs and non-VA community providers. As they developed new case coordination processes, they quickly identified significant and systematic gaps related to follow-up care for Veterans who exited housing programs, regardless of their housing destination. Concretely, there was a lack of clarity among VA Central Ohio homeless program staff and community partners regarding who was responsible for caring for Veterans who were not enrolled in any homeless programs following a program exit. As it is common for individual programs and individual agencies to simply “move on to the next client”, when community-wide homeless service systems do not have proactive policies and procedures to re-engage former clients following program exit, these clients are often left behind. At VA Central Ohio, this lack of clarity was further exacerbated as programs shifted away from face-to-face encounters and towards telephone and video contacts. To help address these systemic gaps, in August 2020, the HCHV Outreach Team created the Coordinated Exit Model.

Practice Overview

Post-discharge follow-up procedures for Veterans exiting VA and non-VA homeless programs is critical for ensuring that no Veterans “fall through the cracks”.

The Coordinated Exit Model was developed to ensure that every Veteran in the community, regardless of health care eligibility, who exited any homeless program, regardless of exit destination, had a Responsible Provider charged with providing follow-up care or to reengage them in services. The model also aimed to reduce future episodes of homeless by ensuring that all Veterans entering housing had their needs met and knew who to call if future housing crises occurred.

While the HCHV Outreach Team already had a process to review the community’s by-name list (BNL) on a weekly basis to track Veterans experiencing homelessness and to assign them a Responsible Provider based on community-wide criteria, Coordinated Exit added a stronger focus on Veterans exiting from homeless programs. For currently and formerly homeless Veterans already enrolled in a VA or non-VA homeless program, the decision was simple: a case manager from that program was designated as the Responsible Provider. For currently homeless Veterans not enrolled in any programs, the HCHV Outreach Team was designated as the Responsible Provider. In HMIS, these Veterans were often identified with exit destinations coded as “No Exit Interview,” “Place Not Meant for Human Habitation,” or “Don’t Know.” Lastly, for Veterans residing in a temporary housing placement, such as a rooming house or unleased with family or friends, or who were permanently housed and no longer receiving any case management services, the HCHV Outreach Team was also designated as the Responsible Provider. However, follow-up services for these Veterans were often light touch in intensity, exploring Veteran comfort and confidence with their housing placement and identifying any additional needs to obtain or sustain independent housing.

When the HCHV Outreach Team picked up a Veteran for Coordinated Exit follow-up services, they often reached out to the Veteran via telephone or video teleconference (when available). In rare instances, contact was made through face-to-face encounters using appropriate personal protective equipment and following CDC guidelines for physical distancing. For currently homeless Veterans, these contacts provided opportunities for re-engagement and re-referral to housing programs along with referrals for other services such as transportation, food, employment, and VHA health care. While there was a major focus on Veterans not enrolled in homeless programs but who were still homeless, for Veterans who exited to permanent housing destinations, Coordinated Exit allowed the HCHV Outreach Team to better understand what needs these Veterans still had and to effectively case plan strategies to ensure that these Veterans did not fall into homelessness again. Many of the needs identified focused on recent unemployment, housing placement dissatisfaction, financial hardships, utility assistance needs, and food insecurity.

Reviews of the Veteran’s VHA electronic health record and service activity in other available databases (i.e., Homeless Management Information System, VA Homeless Operations Management and Evaluation System) made up a significant portion of time spent by the HCHV Outreach Team on Coordinated Exit. The review process served to identify the Responsible Provider, better understand needed health care and supportive services resources, and detect patterns of homelessness for individual Veterans to identify potential interventions or case plan ideas. Through these efforts, staff were often able to proactively address Veteran needs. Additionally, during these chart reviews, the HCHV Outreach Team routinely found errors in the community’s BNL data such has incorrect housing dates, exit destinations, and Veteran status. An unexpected benefit of the Coordinated Exit Model was the opportunity to correct these errors, both improving data quality while also making it easier to connect Veterans to resources in the future.

In January 2021, as the HCHV Outreach Team deepened their understanding of barriers that Veterans served through Coordinated Exit faced, they identified “shelter bans” as a major obstacle. If someone had a “health and safety” shelter ban, they are banned from all community-based shelters in Columbus indefinitely. This indefinite, community-wide ban dramatically hindered Veteran motivation for reengagement in services. The HCHV Outreach Team often advocated for bans to be modified, advocated for Veterans to be connected to hotels for emergency shelter through the Supportive Services for Veteran Families (SSVF) program, or conducted more in-person outreach.

Impact

Within the first month of starting Coordinated Exit, the HCHV Outreach Team began to see reductions in the time Veterans spent homeless as well as reductions in the the frequency of recurrent homelessness for Veterans tracked on their community’s BNL. Of the 54 Veterans who exited any homeless program in September and October 2020, all had a Responsible Provider and received Coordinated Exit follow-up services. Additionally, of the 15 Veterans who exited to permanent housing and received Coordinated Exit follow-up services in September and October 2020, as of May 2021, all were still successfully housed, and none were enrolled in SSVF prevention services. To continue to evaluate the effectiveness of Coordinated Exit services, the HCHV Outreach Team is planning to conduct six-month follow-ups and periodic chart reviews of housed Veterans with the goal to prevent recurrent homelessness.

Conclusion

For the Columbus homeless service system, implementing Coordinated Exit led to greater visibility into system trends, a deeper understanding of the impact of shelter bans on client engagement, better quality data, and increased community collaboration and partnership. For their Veterans served, having a Responsible Provider helped those who remained homeless continue on the path to housing and helped those who exited homelessness stay connected to supports to keep them housed.

We would like to thank the dedicated staff at VA Central Ohio for sharing their practice with us. For more information, please contact HomelessVets@va.gov.