We Can Prevent, Not Just Treat, Homelessness Among Veterans

Co-authored by Rishi Manchanda, MD, MPH, Lead Physician - Homeless Patient Aligned Care Team, Greater Los Angeles VA System, @rishimanchanda and Megan Sandel, MD, MPH, Medical Director of the National Center for Medical-Legal Partnership @megansandel

There are many problems our nation's veterans face as a result of serving our country that we must be prepared to treat when they return home. But homelessness should not be one of them; it is something that should never happen in the first place.

This Veterans Day, 50,000 veterans will sleep in shelters or on our streets. That number is down 23 percent between 2009 and 2013, thanks in part to the U.S. Department of Veterans Affairs' (VA) investment in additional mental health counseling and subsidies for permanent housing from the VA and the U.S. Department of Housing and Urban Development. But to get this number to zero, we have to stop thinking about homelessness as something we treat and start approaching it as something we can prevent. It will take recognizing the varying factors at the source of homelessness, cultivating a new kind of team - one that includes attorneys - to address those factors, and getting creative in developing cross sector partnerships.

Each year, the VA surveys homeless veterans, VA staff and community service providers about the most significant unmet needs homeless veterans face. This survey reveals that homelessness is about so much more than the lack of a place to sleep or even underlying mental health issues. Often an unaddressed legal problem triggers homelessness.

In the VA's most recent survey, homeless Veterans reported needing legal help with evictions and foreclosures, outstanding criminal warrants and fines, child support issues that garnish wages, and a discharge status from the military that prevents employment. Homeless Veterans also reported needing legal help to access public benefits, secure guardians or fiduciaries, clear up bad credit, and expunge criminal records. Each of these barriers to employment and income jeopardize long-term housing.

Similar to mental health issues, when legal issues go "untreated," they get worse and can affect every area of someone's life. These legal problems can also threaten to derail the success of other housing interventions as well as the well-intentioned efforts of healthcare and social service providers to help. Take the VA's housing voucher program as an example. If a veteran has a bad credit score or lacks basic amenities like a refrigerator to furnish a rental property, she can be disqualified from using a voucher. And a homeless veteran's inability to pay first, last and security deposit - a requirement that stands for most landlords - can also disqualify her from using a voucher. These barriers can make it that much harder for a homeless veteran to get a home. And since stable, healthy housing is a prerequisite for good health, these barriers pose challenges to a healthcare system charged with the responsibility of helping Veterans lead honorable, healthy lives.

But each of the situations described above can be resolved with the help of an attorney. And done early enough, legal interventions can assist with employment, boost income, and protect existing housing before a veteran becomes homeless, and ensure that other interventions like a housing voucher work. But understanding the connection between legal problems and homelessness is the first step. How do we translate this knowledge to effective, preventive interventions?

In recent years, an upstream approach known as "Medical-Legal Partnership" has arisen to help at-risk populations by combining and leveraging the strengths and resources of healthcare and civil legal aid providers. To date, 262 healthcare institutions in 36 states have implemented this approach.

We have an opportunity to bring the legal aid and VA healthcare systems - which each hold critical pieces of the puzzle - together in a real way that looks at the whole person. Legal assistance is often the intervention needed, but traditionally, people do not typically seek out a lawyer unless they are in crisis, like when they have already been evicted. Alternatively, people frequent their healthcare institutions with much more regularity, providing healthcare with greater ability to detect problems more upstream.

The good news is that the VA has made significant steps in this direction. The VA encourages its medical centers, outpatient clinics and Vet Centers to provide space for civil legal aid providers to address the legal needs of veterans; currently, 43 VA healthcare facilities provide office space for on-site civil legal services. That is a great start, but it needs to go further. We need more integration and wider adoption of this upstream approach.

We can start by training VA healthcare providers to screen for potentially harmful legal issues as part of their care for veterans at risk of homelessness. And we can do more to ensure that every VA healthcare facility has a strong medical-legal partnership, forged with local, nonprofit civil legal aid agencies where not only are appropriate referrals made for services, but where civil legal aid is offered on-site, where communication between healthcare and legal teams is constant, and where both sides work together to improve policies that impact the lives of Veterans who are homeless or at-risk of homelessness.

As we pause today to honor the men and women who have served our country with parades and speeches, and as you look through the compelling appeals you have no doubt received from Veterans' organizations, stop and ask yourself, can the medical-legal partnership approach work in your community? What other upstream solutions can help prevent homelessness? And what will it take from you, and from all of us, to make them happen?