Implementing a One Team Approach to
Ending Veteran Homelessness in VA Southern Nevada

By Colleen Reilly, Special Assignment, and Shawn Liu, National Homeless Program Manager, Homeless Programs Office

July 10, 2024

VA’s end goal is always to place homeless Veterans in safe, stable, permanent housing using a housing-focused approach that addresses the needs and preferences of each individual Veteran. However, VA cannot and does not do this alone. VA medical centers (VAMC) rely on thousands of community partners who conduct outreach, provide temporary and permanent housing, offer short— and long-term financial support, and much more.

Coordinating efforts can be challenging, considering the number of partners, the breadth of services they offer, and the varying ways they track and share information about homeless Veterans in their communities. In April 2024, HPO published the first iteration of the One Team Approach Implementation Toolkit, which was developed to provide guidance, templates, and tools for implementing a One-Team approach locally.

It is well understood that VAMCs are in different stages of this implementation. Most followed some aspects of the One Team guidance before it was formally named and the toolkit was created. VA Southern Nevada was an early adopter of many One Team practices and, like some other VAMCs, has benefited from technical assistance to help them implement new approaches. Their work has improved Veterans’ outcomes and deserves consideration for adoption by other VAMCs.

Practice overview

The VA Southern Nevada Homeless Programs team has implemented a high level of collaboration with their community partners, provides same-day access to interim housing in most cases, and employs innovative practices regarding their by-name list (BNL), outreach, and case conferencing.

Enhanced community collaboration

When VA announced its 38,000 Permanent Housing Placement National Challenge in 2022, VA Southern Nevada homeless program staff began working with the Technical Assistance Collaborative, Inc. (TAC) to increase communication and collaboration among VA and its community partners. These partners included the local Continuum of Care (CoC), the Southern Nevada Regional Public Housing Authority (PHA), Supportive Services for Veteran Families (SSVF) providers, Grant Per Diem (GPD) providers, Contracted Residential Services (CRS) providers, community outreach teams, and community shelters. They implemented a monthly meeting including all partners to discuss VA and community priorities with all partners to discuss VA and community priorities and goals, questions, and issues that arise, provide education and support to each other, and reinforce their shared mission to end Veteran homelessness by focusing on specific aspects of their community priorities. Notably, with the help of their TA partners, all meetings emphasize a coordinated and interdependent community approach rather than a VAMC-directed one.

Table 1: Community Meetings

Meeting	Frequency	Particpants
Las Vegas Community Call	Monthly	VA, CoC, PHA, SSVF, GPD, CRS, community shelters, HUD field office
SSVF	1-2x monthly	VA, SSVF, SSVF regional coordinator
Housing Leadership	1-2x monthly	VA, SSVF, GPD/CRS site leaders
BNL/Outreach/Case Conferencing	2x monthly	VA and community staff doing street outreach (includes a Veteran with lived experience of homelessness)
Housing Specialists	2x monthly	VA HUD-VASH housing specialist, PHA landlord liaison, SSVF housing navigators & rapid re-housing staff

VA Southern Nevada also created a messaging and communications workgroup, which includes staff and leaders from both VA Southern Nevada and SSVF grantees, along with their TAC partners, to ensure consistent messaging about programs and services among community stakeholders. The group develops and disseminates one-pagers about programs, talking points for landlords, etc.

The team emphasizes that increased collaboration with community partners has laid the foundation for introducing new ideas and practices to better serve homeless Veterans. Because VA Southern Nevada and its partners communicate frequently, they ensure that their priorities are clear and well-known to all. Therefore, when they or a partner introduces something new, they do it against the backdrop of these priorities and can come to an agreement quickly.

Same-day access to interim housing

VA Southern Nevada has three GPD providers and two CRS providers offering a total of 408 beds for temporary housing. At the same time, they help homeless Veterans enroll in appropriate permanent housing programs and seek permanent housing. However, this was not always the case. About a decade ago, the VAMC and community pushed to acquire more interim housing beds, knowing that this was a key strategy for progressive engagement with Veterans on their path to permanent housing.

Having many vacant beds inherently leads to easier same-day placement—on a given day, between 4 and 10 beds typically become available to accommodate new Veterans. However, team members also note that Veterans do not “apply” for interim housing but are referred directly by the VAMC or community outreach staff after a clinical assessment to determine which transitional housing program is most appropriate for the Veteran’s individual needs. GPD and CRS providers only decline to enroll a Veteran in very limited circumstances, such as a previous episode of violence at the facility.

Notably, during the unsheltered surge completed by six VAMCs from November 2023 through January 2024, VA Southern Nevada took an additional step to maximize the possibility that the most vulnerable unsheltered Veterans could move into interim housing the same day they were engaged. CRS provider Salvation Army and GPD provider U.S. VETS agreed to hold one bed each for an unsheltered Veteran referred by the VA Southern Nevada outreach team or a community partner outreach team until 1:00 p.m. rather than offer these on a first-come-first-served basis. The team noted that the ongoing close collaboration between the VAMC and its interim housing providers facilitated this quick shift, as the partners understood the priority and readily agreed to the change. VA Southern Nevada is coordinating with the partners on whether to make the change permanent.

BNL management, outreach, and case conferencing

VA Southern Nevada owns the BNL in their community, which comes from the Homeless Management Information System (HMIS). Veterans are added to the BNL when they check in with their HMIS identification card to a local shelter or have contact with an outreach team and state that they are Veterans. The VA Southern Nevada program specialist screens the list to confirm that the listed individuals are Veterans and then refers the names to the staff at the local VA Community Resource and Referral Center (CRRC). From there, several staff members review HMIS, the Veteran’s VA electronic health record, Joint Legacy Viewer, and HOMES and attempt to contact the Veteran at the last known phone number. They may also reach out to community contacts who have had recent contact (e.g., the HMIS case manager if one is noted in the system). If these efforts are unsuccessful, they often put out a public alert for community providers asking them to contact CRRC if they encounter the Veteran.

In late 2023, VA Southern Nevada augmented this process by assigning each Veteran on the BNL to a member of its outreach team, who is responsible for attempting to locate the Veteran and bring them into services. Because the team has historically had many interim housing beds and HUD-VASH vouchers available, finding the Veteran is the primary challenge; once they can do so, they can generally temporarily house the Veteran very quickly and start the process for permanent housing.

The VA Southern Nevada outreach team collaborates very closely with community outreach teams. As noted above, all outreach teams meet once every two weeks to strategize locating the Veterans on the BNL and complete case conferencing. They have developed a schedule for visiting areas homeless Veterans are known to frequent, and they often visit the locations together. This level of coordination enhances their ability to locate homeless Veterans and address their needs and preferences to develop an individualized plan for services.

An excellent example of this collaboration is the development of VA Southern Nevada’s Veteran Outreach Response Team (VORT), comprising VAMC, SSVF, and GPD/HCHV outreach staff. When community outreach teams refer unsheltered Veterans through HMIS, a VORT staff member attempts to follow up with the Veteran within 48 hours. In addition to leveraging the power of many to repeatedly engage with Veterans experiencing homelessness and provide services, this also demonstrates the entire community’s dedication to locating and housing every homeless Veteran, which is essential to building trust.

Conclusion

Practice outcomes

Adopting the practices outlined above has enhanced the ability of VA Southern Nevada, in partnership with the entire community, to reach more homeless Veterans, enroll them in programs and services, and place them in permanent housing.

The benefits are well illustrated in VA Southern Nevada’s results from the unsheltered surge. The team surpassed its targets by a wide margin with respect to all three of the measures: outreach engagement with unsheltered Veterans, same-day interim housing access, and permanent housing intervention enrollment.

Table 2: VA Southern Nevada Results from Unsheltered Surge

Category	Subcategory	Number
Outreach Engagement with Unsheltered Veterans	Target	150
	Outcome	180
Same-Day Interim Housing Access	Target	50
	Outcome	180
Permanent Housing Intervention Enrollment	Target	70
	Outcome	108

In addition, the number of unsheltered homeless Veterans on the BNL maintained by VA Southern Nevada is now the lowest it has been since 2020. This is a direct result of the collaborative outreach efforts among VAMC and community outreach teams.

Additional considerations for homeless program leaders

As homeless program leaders at other VAMCs determine their paths to implementing the One Team approach, the following considerations could contribute to the success of their efforts.

Investments in community partner relationships pay off

The overall goal of One Team implementation is to establish a collaborative, community-wide approach to identify, locate, and house homeless Veterans as quickly and efficiently as possible. This can only be achieved if all partners know the homeless Veterans in their communities, know each other’s goals, priorities, and capabilities, and trust that they will support one another in their efforts. Regular communication is essential to furthering this goal. Although all community partners share responsibility in the efforts, VAMC leadership may be necessary to establish the needed level of communication.

Although this can be challenging to accomplish, the payoff is tangible. For example, the VA Southern Nevada team noted that when they proposed setting aside beds for vulnerable Veterans referred by outreach teams during the unsheltered surge, partners who provided temporary housing in the community were eager to assist in furthering their shared goals. The buy-in was immediate because these goals had been frequently and consistently communicated over time to all community partners. VAMC homeless program leaders can help ensure similar results by continually investing in the relationships with their community partners.

A consistent, collaborative outreach presence is key to building trust with Veterans

Some homeless Veterans feel ambivalent about engaging with services for varying reasons. Perhaps they have had one or more negative experiences or believe that the services offered will not meet their needs and preferences. In this case, building trust through progressive engagement is essential. Although the VA Southern Nevada outreach team comprises just four staff members, they and their community outreach teams maintain a consistent schedule for outreach in various locations frequented by Veterans, which enables them to build rapport and trusting relationships. When a Veteran has an established relationship with an outreach worker, whether VAMC or community staff, they will likely have less ambivalence about coming into services. Other VAMCs, in partnership with community outreach teams, can work toward adopting consistent, collaborative efforts to build trusted relationships with homeless Veterans in their area.

Technical assistance can boost your VAMC’s efforts

When they received their area’s first Calendar Year Homeless Program Goals in 2022, the VA Southern Nevada team knew that adaptations to some of their processes could help them meet them. They reached out immediately for TAC, which proved invaluable. TAC partners continue to provide helpful guidance and participate in several regular meetings with community partners to add expertise. If you could similarly benefit, contact HPO leaders to connect you with technical assistance.

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

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