Homeless Programs Office (HPO) Unsheltered Surge: Policy and Practice Recommendations for Effectively Serving Unsheltered Veterans

By Masaki Hirayama, Health Systems Specialist, and Shawn Liu, National Homeless Program Manager, Homeless Programs Office

June 3, 2025

Introduction

This white paper summarizes the results of the U.S. Department of Veterans Affairs’ (VA) unsheltered surge efforts in fall 2023 and winter 2024. It offers policy and practice recommendations to serve unsheltered homeless Veterans more effectively.

Unsheltered Veteran homelessness

Homelessness is a traumatic experience with destructive effects, and it should be rare, brief, and non-recurring. Unsheltered homelessness, i.e., sheltering in a place that is not meant for human habitation, is particularly harmful to a person’s health. Unsheltered homeless Veterans have more significant health challenges than those who are sheltered, increasing their vulnerability to negative health outcomes. Due to this, the mortality rate of unsheltered homeless Veterans is three times higher than the sheltered homeless cohort. Despite concerted efforts to connect unsheltered Veterans to interim housing services, such as emergency shelters and transitional housing, 44% of homeless Veterans were unsheltered during the 2023 Point-in-Time (PIT) Count.

Priority to Action: Supporting Veterans’ Whole Health, their caregivers, and survivors.

In September 2022, VA announced its health care priorities – six key areas of focus for the next few years. These included:

• Priority 1: Hire faster and more competitively.
• Priority 2: Connect Veterans to the soonest and best care.
• Priority 3: Service Veterans with military environmental exposures.
• Priority 4: Accelerate VA’s journey to a high reliability organization.
• Priority 5: Support Veterans’ whole health, their caregivers, and survivors.
• Priority 6: Prevent Veteran suicide.

In support of Priority 5: Support Veterans’ whole health, their caregivers, and survivors, the Homeless Programs Office (HPO) within the Veterans Health Administration (VHA) established a key action to reduce the number of unsheltered Veterans in America by 15% by September 2024, when compared to the 2020 PIT Count.

To accomplish this key action, in fall 2023, HPO planned and carried out six “unsheltered surge” efforts across the country.

Practice overview

Unsheltered surges

A surge is a set of strategies and collaborative efforts meant to maximize the use of resources to achieve a relatively short-term goal. The goal of VA’s unsheltered surge was to reduce the overall number of unsheltered Veterans in a VA Medical Center’s (VAMC) catchment area. This surge effort specifically focused on engaging unsheltered Veterans and linking them directly to temporary (i.e., emergency shelter or transitional housing) and permanent housing options.

While VAMC homeless programs focus on ending homelessness among all Veterans in their day-to-day operations, these surge efforts were meant to place a time-limited focus on a specific, high-priority subpopulation – unsheltered Veterans. The key was working to make a direct, measurable impact on the unsheltered Veteran population within a defined period with a defined set of practices and coordinated efforts.

The six VAMCs chosen were Bay Pines, Florida; Los Angeles, California; Las Vegas, Nevada; Long Beach, California; San Diego, California; and Seattle, Washington. They were selected based on factors including the number of unsheltered Veterans in the area, performance outcomes and vacancy rates of VA interim housing, and Housing and Urban Development VA-Supportive Housing (HUD-VASH) voucher utilization rates.

As part of their participation, each VAMC was expected to:

• Conduct outreach and engagement to unsheltered Veterans in the community (e.g., at encampments, parking lots, doorways, underpasses, and abandoned buildings).
• Provide same-day access to interim housing: Grant and Per Diem (GPD), Health Care for Homeless Veterans (HCHV) Contract Residential Services (CRS), community shelters, or Supportive Services for Veteran Families (SSVF) Emergency Housing Assistance (EHA).
• Provide direct linkage to permanent housing interventions.

Expectations

These expectations apply and reinforce VA’s One Team Approach, an integrated approach to deliver homeless programs and services that provide an agile and comprehensive response to prevent and resolve Veteran homelessness.

Each VAMC had the discretion to set its approach, duration, and outcome targets for engagement with unsheltered Veterans, same-day access to interim housing placement for unsheltered Veterans, and permanent housing enrollment for unsheltered Veterans. Five of the VAMCs implemented efforts spanning several weeks, while one held a one-day surge event.

Timeline of events

In November 2023, a kickoff call was held with the six VAMCs and their regional Network Homeless Coordinators (NHCs) to explain the purpose and design of the surge effort. Each VAMC was given a planning toolkit with detailed background information and worksheets to plan their surge effort with local community providers. In addition, targeted technical assistance from HPO was offered to address VAMC-specific issues. HPO staff held mid-surge and after-surge meetings with each VAMC and their NHC to answer questions and review outcomes. Every VAMC submitted an after-action report with actual outcomes and the VAMC’s reflections from the experience. In February 2024, the HPO senior leaders met with the six VAMCs and respective NHCs to review their progress, outcomes, challenges, and successes, and for VAMCs to share ideas and resources.

Outcomes

Successes and challenges

Overall Successes	Overall Challenges
Enhanced outreach efforts	Competing priorities
Increased community engagement coordination	Limited access and barriers to interim housing
Improved case conferencing	Data integration
Improved data tracking accountability	Limited resources

Duration, performance targets, and outcomes

Element	Bay Pines	Los Angeles	Las Vegas	Long Beach	San Diego	Seattle	Total
Duration	12/13/23	12/1/23-1/31/24	12/1/23-1/24/24	11/20/23-1/23/24	11/14/23-1/5/24	11/20/23-1/31/24
Engagement Target	15	75	150	30	60	38	368
Engagement Outcome	18	87	180	61	72	107	525
Interim Housing Target	12	50	50	20	40	15	187
Interim Housing Outcome	9	7	180	22	45	1	264
Permanent Housing Target	8	20	70	28	50	38	214
Permanent Housing Outcome	1	31	108	108	52	35	335

Practice considerations

Selected VAMCs initially felt burdened by having to plan and execute another initiative. However, by the end of the surge effort, the overall feedback was positive. Participation in the unsheltered surge effort presented each VAMC with an unexpected opportunity to re-evaluate and reset its outreach approach. By design, VAMCs were compelled to communicate and coordinate efforts and resources with their community partners/providers to target and serve unsheltered Veterans as One Team. Additionally, the surge effort spotlighted some existing community challenges and created a platform for VAMCs and their communities to prioritize a path toward change.

Recommendations

Based on the review of the surge effort’s process and outcomes, HPO identified four practice or policy recommendations for effectively serving unsheltered Veterans and one process improvement recommendation for staff safety.

• Recommendation 1: Enhance outreach efforts outside of hospitals, Community Resource and Referral Centers (CRRCs), service centers, clinics, or other office-based settings.
• Recommendation 2: Establish or enhance relationships with community providers to conduct outreach and case conferencing more intentionally, efficiently, and collaboratively.
• Recommendation 3: Review and improve local processes to reduce barriers to housing and dedicate resources to support same-day access to interim housing and permanent housing programs for unsheltered Veterans.
• Recommendation 4: Improve local data collection methodologies to identify and track all unsheltered Veterans within the catchment area to ensure we can continue to engage Veterans.
• Recommendation 5 (Process Improvement): Review methods VAMCs use to foster staff safety while conducting outreach in the community.

Additionally, HPO recommends that VAMCs consult technical assistance where available and necessary. This includes their NHCs and/or HPO staff, who can provide support, guidance, and clarification to continue the momentum in housing Veterans when VAMCs and local providers are unable to resolve a disagreement, have different interpretations of program requirements, identify a need for the community or an individual, or any other barrier.

Recommendation 1

Theme: VAMCs that expanded their geographic outreach areas were able to identify and engage unsheltered Veterans who would not typically be present in an office setting.

Practice Recommendation: VA outreach teams should prioritize community-based outreach to engage unsheltered Veterans where they are; the onus is on the provider to locate and initiate contact, not the Veteran. Through this practice, access is not prioritized on a first-come, first-served basis. Instead, equal access is given to Veterans who cannot come to a clinic, are hesitant to initiate contact, or are unaware of service locations.

By meeting Veterans where they are, outreach teams can build rapport through progressive engagement, motivational interviewing, and consistent presence with Veterans who are hesitant to seek services, believe they are ineligible, do not know where to go, or have given up on the process. If staffing is a concern, HPO recommends that VAMCs and community providers pool their resources to develop an interim staffing plan to continue prioritizing outreach in the community.

Recommendation 2

Theme: VAMCs that coordinated outreach with non-VA teams maximized limited staffing resources and the geographic area(s) covered, which enabled them to reach more unsheltered Veterans.

Practice Recommendation: HPO recommends that VAMCs establish weekly meetings (more, if needed) with non-VA providers to coordinate and assign mutually agreed-upon outreach areas. Through this intentional and efficient approach, staff can agree upon the area(s) to target and assign staff to avoid duplication and missed areas. Staff can also share information about newly formed areas for outreach or areas that no longer have unsheltered Veterans. Regular collaborations could aid in identifying Veteran “hot spot” areas for individuals and groups as well as the use of tracking tools to re-engage Veterans who have declined services in the past or have repeatedly returned to homelessness.

Also, through this collaborative approach, outreach teams can diversify the pool of subject matter experts, such as licensed clinicians, peer specialists, substance use counselors, and chaplains, each contributing a unique approach and perspective. This team diversity can be integral to engaging unsheltered Veterans who may be more hesitant to accept services. Increased coordination improves trust and rapport among all service providers and demonstrates the One Team approach, with VAMC and community providers united in their efforts.

Theme: VAMCs with clearly established communication channels with community providers were able to build trusting relationships that improved case conferencing and Veteran outcomes.

Practice Recommendation: VAMCs and community providers should regularly engage in creative discussions regarding the unique needs of their community’s unsheltered Veteran population. In the One Team approach, it is crucial that all providers own a piece of the Veteran’s individual service plan to equally share responsibility in transitioning the Veteran to permanent housing, including defining each provider’s roles and responsibilities to avoid duplication and gaps in efforts. Collaborative discussions improve case conferencing and enhance the sense of trust and interdependence among team members. In addition, VAMC staff can provide ongoing education and orientation about VA homeless programs, eligibility, and the scope of services.

Case conferencing includes validating a Veteran’s eligibility for VA homeless programs and supportive services so a Veteran can be offered the best possible pathway to permanent housing. Case conferencing should be utilized until the pathway to permanent housing is successful. This will include discussion around both program eligibility and prioritization of resources based on individual emergent needs. If a Veteran is reluctant to pursue a housing option, staff shall continue building trust and rapport with the Veteran through consistent visits and continuously offering available resources. Communities are encouraged to embrace collaborative efforts, creative thinking, and innovative ways to end the episode of homelessness for each Veteran.

Recommendation 3

Theme: VAMCs that had regular conversations with their GPD and HCHV providers about barriers to same-day interim housing placements for unsheltered Veterans and collaborated on local improvement plans for access achieved an improved sense of camaraderie and experienced positive results.

Recommendation: HPO recommends that VAMC staff initiate and engage in frequent communication with HCHV contractors and GPD grantees to openly discuss local policies and processes (e.g., eligibility criteria, program requirements, enrollment processes, etc.) that create or worsen barriers to same-day access. These conversations provide an opportunity to review and challenge local policies that can be changed. This is an opportunity to model the reciprocal nature of the One Team approach and demonstrate how transparent discussions can be mutually beneficial and build camaraderie.

As an example of reviewing local policy, one VAMC reported that providers routinely refer Veterans to the non-VA funded community shelter because it uses a one-page referral form, while the referral form for the local GPD grantee is 12 pages. Having experienced this barrier, another VAMC responded that it had worked with its GPD providers to create a brief, common referral form to streamline access.

Ongoing collaborative discussions enable more same-day placements, which are essential to the most vulnerable Veterans. Staff can also address clinical concerns quickly and better monitor the flow of Veterans moving from interim housing into permanent housing, which frees up beds for more unsheltered Veterans.

Theme: VAMCs that negotiated the dedication of a number of same-day interim housing beds by GPD and HCHV programs were able to agree upon a mutually beneficial prioritization system.

Recommendation: VAMCs and their community partners/providers should consider whether the demand for local resources warrants a mutually agreed-upon prioritization policy for dedicated same-day access beds. Working together on policies is another way to build trust between VAMCs and their providers. Additionally, when an unsheltered Veteran agrees to interim housing enrollment, an outreach team member can be assured a bed will be available immediately, which is critical to building trust with the Veteran.

For example, one VAMC and its community providers agreed upon a new prioritization system in which priority was given to referrals from VAMC and community outreach teams. Under the new policy, the VAMC agreed to release unused beds in the early afternoon to self-referred unsheltered Veterans, sheltered homeless Veterans, and other homeless Veterans.

Theme: Discuss the possibility of a streamlined, universal Public Housing Authority (PHA) application/intake process.

Recommendation: HPO recommends VAMCs partner with their PHAs to assess, streamline, and reduce barriers to their intake process, which should include a focus on referral packets. HPO further recommends a focus on streamlining processes across PHAs within a VAMC’s catchment area to ensure uniformity of the process from the referral for a voucher to leasing. Some examples include a universal referral packet and acceptance of self-certification of income by all PHAs. Similar to how VAMCs identified some GPD and HCHV referral forms as a barrier to access, VAMCs commented that the different PHA applications/intake packets can also be a barrier. Having streamlined forms increases accessibility and the likelihood of engaging Veterans through the voucher issuance process. One VAMC commented that one of their HUD-VASH Boot Camp goals was to create a universal PHA intake packet. Although the VAMC reports pushback from the PHAs, they are continuing to collaborate and work through the process.

Recommendation 4

Theme: VAMCs that utilized the VA Homeless Operations Management and Evaluation System (HOMES), the Homeless Management Information System (HMIS), and a manual tracker for data collection had better success continually engaging unsheltered Veterans and connecting them to services.

Recommendation: VAMC teams should utilize HOMES assessments and a manual tracking tool to account for unsheltered Veterans’ statuses. While the HOMES pre-assessment does not capture unsheltered status, the full HOMES assessment does. It also documents how contact for the interview was initiated and specifies Veterans who are engaged in the community versus those who come to the hospital/clinic or CRRC. However, this field does not populate on the HOMES Operational Report 6 (OR6), so doing a pre- or full assessment may not be the most effective way to build rapport with hesitant Veterans. HMIS, a local information technology system used by VA- and non-VA-funded providers, is another important source for identifying and tracking unsheltered Veterans.

Supplementing HOMES and HMIS with a simple manual tracking tool until a Veteran is entered into one or both data systems contributes to a comprehensive, high-quality by-name list (BNL) and HOMES census by taking account of the Veterans. The tracking tool can be simple, such as a spreadsheet of names, locations, strengths, and barriers, and it can be shared among relevant VA and non-VA providers via encrypted emails (refer to Routine Use #30 for data sharing rules). A tracking tool enables teams to fully account for all unsheltered Veterans in the VAMC catchment area in real time and monitor program enrollment, progress, and barriers.

Theme: Continuums of Care (CoC) that tracked all homeless Veterans and their progress from homelessness to permanent housing and their outcomes optimized care coordination and outcomes on individual and system levels.

Recommendation: Having a regularly updated BNL is important to capture who is being engaged, eligibility status, location, services offered or denied, etc. The BNL can give the community insight into the process from engagement to program enrollment and/or denial to review and improve the homeless response system. This data illustrates individual trends, successes, barriers, reasons for declining services, existing community service gaps, reasons for program denial, and other important markers of a Veteran’s and a community’s progress.

Recommendation 5

Theme: It is important to minimize and address the risks to staff when conducting community-based outreach. Safety concerns should not deter staff from enhancing community outreach work. It is important for program supervisors and staff to know what has worked at other VAMCs and how they can supplement existing safety protocols.

Recommendations for VAMCs: VAMCs should review local safety plans/protocols and competencies for community-based providers and all available safety resources to ensure staff safety while conducting outreach in the community. The local Disruptive Behavior Committee (DBC) should be actively engaged in discussions concerning the safety of homeless staff. The DBC reviews reports of disruptive behavior, evaluates risk, assists with strategies to optimize safety, and serves as a safety resource for leadership and staff. Staff preparedness is one key element in optimizing safety. Education and training are tailored to each staff member’s duties. Staff working in the community should receive training in verbal interventions and personal safety skills. HPO also recommends that VAMC staff consider conducting outreach in pairs or groups and assigning identified roles, such as the client engager and the observer. Lastly, VAMCs are encouraged to explore their VAMC counterparts’ effective safety procedures and other safety tools, such as current technology tracking systems.

Recommendations for HPO: HPO is exploring effective safety practices and is working with the Prevention and Management of Disruptive Behavior (PMDB) Office to ensure VAMC homeless programs have the proper levels of PMDB training. HPO is also working to unify the message and training regarding utilizing the Disruptive Behavior Report system for community visits. Additionally, a podcast series on safety while working in the community has been created and is available in TMS. Also, in June 2024, HPO will host a national safety webinar through which HPO will reiterate existing safety trainings and podcasts on PMDB for community-based workers. It is recommended that all VAMC homeless programs staff attend this webinar and utilize the available training.

Conclusion

Unsheltered homelessness is a traumatic and dangerous experience that should be prevented whenever possible and limited to a brief duration when it occurs. Applying these recommendations could significantly impact VAMC homeless programs and their community partners, allowing them to serve unsheltered Veterans more effectively.

The design of the unsheltered surge effort provided VAMCs and community providers an opportunity to review the accessibility of programs and services, prioritization systems, and barriers at a system level. In the end, every provider’s commitment to providing resources and presence enhanced the local One Team approach and generated creative and innovative strategies.

With dedicated and unified resources, including staff, interim housing beds, permanent housing interventions, data tracking tools, and collaborative case management, this powerful One Team comprised of VAMCs and community providers can successfully reduce the number of unsheltered Veterans.

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