Veterans Outreach and Recovery Program (VORP)

Final Report

P-02281 (11/2018)

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This report is a publication of the Wisconsin Department of Health Services, Division of Care and Treatment Services, Bureau of Prevention Treatment and Recovery. For more information on mental health and substance use services in Wisconsin, visit www.dhs.wisconsin.gov.

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Table of Contents List of Figures ............................................................................................................................................... iv List of Tables ................................................................................................................................................ iv Overview ....................................................................................................................................................... 5 Organization and Management .................................................................................................................... 8

Staffing Model .......................................................................................................................................... 8 Marketing Efforts ...................................................................................................................................... 8

Data and Evaluation ...................................................................................................................................... 9 Homeless Veterans in Wisconsin.............................................................................................................. 9 Evaluation of Primary Goals ................................................................................................................... 11

Identify veterans who experience homelessness and behavioral health disorders .......................... 11 Strategies used to identify, engage, and connect homeless veterans ............................................... 15 Permanent housing status changes for VORP enrollees .................................................................... 17 Health insurance and other benefits.................................................................................................. 18

Evaluation of Secondary Goals ............................................................................................................... 20 Network of treatment contacts ......................................................................................................... 20 Gaps in treatment .............................................................................................................................. 22 Referrals and services ........................................................................................................................ 23 Other resources for mental health and substance use referrals and services .................................. 24 Employment, criminal justice involvement, and social connectedness............................................. 25 Recidivism to homelessness ............................................................................................................... 27

Qualitative Data ...................................................................................................................................... 28 Concerns expressed by program participants .................................................................................... 28 Stories from the field ......................................................................................................................... 28

VORP and Wisconsin’s Opioid Crisis ........................................................................................................... 29 Program Closeout ....................................................................................................................................... 29

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List of Figures Figure 1: Outreach Contacts ....................................................................................................................... 12 Figure 2: People Contacted ......................................................................................................................... 12 Figure 3: Enrollees (Point-In-Time, End of Quarter) ................................................................................... 13

List of Tables Table 1: Veteran Population by County 2015-2017 .................................................................................... 10 Table 2: Annual Point-In-Time Count of Homeless Veterans in Wisconsin ................................................ 11 Table 3: Demographic Characteristics of Enrollees .................................................................................... 14 Table 4: Diagnosis Distribution for VORP Enrollees .................................................................................... 14 Table 5: Domain 1, Identifying Eligible Veterans for VORP ........................................................................ 16 Table 6: Domain 2, Engaging Eligible Veterans for VORP Once They Have Been Identified ...................... 16 Table 7: Domain 3, Connecting Veterans to Services Once They Were Referred (that is, accepting a referral by an outreach and recovery specialist) ........................................................................................ 17 Table 8: Housing Status among Permanently Housed VORP Enrollees ...................................................... 18 Table 9: Health Insurance Benefits Acquired While in VORP ..................................................................... 19 Table 10: Non-Cash Benefits Acquired While in VORP ............................................................................... 19 Table 11: Cash Benefits Acquired While in VORP ....................................................................................... 20 Table 12: Examples from the Network of Treatment Options for Veterans who are Homeless or at Risk of Homelessness ............................................................................................................................................. 22 Table 13: Referrals by Type ......................................................................................................................... 24 Table 14: Services by Type .......................................................................................................................... 24 Table 15: Enrollee Status Changes Across Major Program Indicators ........................................................ 26 Table 16: Return to Homelessness among Transitioned VORP Enrollees .................................................. 28

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Overview The Veterans Outreach and Recovery Program (VORP) was created in September 2014 through a partnership between the Department of Health Services (DHS) and Department of Veterans Affairs (DVA) to support homeless veterans living with mental health and substance use challenges. The program was funded by a three-year, $1.2 million grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). A two-year, $1.2 million supplemental grant from SAMHSA awarded in 2015 supported expansion of the program. The grant funding for the program expired in September 2017. A program for all veterans All former members of the military, no matter their branch, type of service, length of service, and discharge status, were eligible to participate in VORP. The program enrolled 330 men and women, which was more than anticipated. Many others benefitted from contact with program staff. Mostly rural service area The VORP service area covered the northern two-thirds of Wisconsin, a mostly rural area. The program initially provided services in 46 counties. The supplemental grant allowed the program to expand to three more counties for a total of 49. This area was divided into six regions. Veterans helping veterans An outreach and recovery specialist was assigned to each region. Each outreach and recovery specialist was a veteran. Understanding the military culture helped the outreach and recovery specialists earn the trust of VORP contacts and enrollees. Outreach and recovery specialists also used motivational interviewing and trauma-informed care to build non-judgmental relationships with contacts and enrollees in their region. The genuine connections that resulted from the use of these evidence-based approaches allowed the outreach and recovery specialists to provide needed recovery-oriented supports. Health and healing The outreach and recovery specialists worked with county homeless, behavioral health, and veterans groups to identify people who could benefit from the program. Some people only were contacted and given information about local resources. Due to their needs, other people were screened for program enrollment. Once enrolled in the program, the outreach and recovery specialists, supported by a clinical coordinator, ensured the enrollee had stable housing and treatment for their mental health and/or substance use needs. There also was follow-up to ensure that the treatment was continual and effective. Program staff also connected the enrollee to mental health and substance use recovery supports to ensure their success. This report highlights five major gaps in mental health and substance use services for veterans in Wisconsin as identified by the outreach and recovery specialists. Improved quality of life The supports and services provided by VORP allowed enrollees to realize their hopes and dreams.

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• Nearly three-quarters of enrollees with data on housing status were in permanent housing at their latest follow-up interview. Only a quarter of these enrollees were in permanent housing upon enrollment.

• Nearly nine out of 10 enrollees with the largest opportunity to return to homelessness after exiting the program did not return to homelessness after one to two years.

• Over two-fifths of enrollees with data on health insurance acquired health insurance while enrolled in VORP. The program also connected 51 participants with non-cash benefits and 169 participants with cash benefits.

• A third of all enrollees improved in at least one of employment, criminal involvement, or social connectedness outcomes at follow-up.

This report highlights the four primary and five secondary goals of VORP and the extent the program achieved these goals. This report also summarizes information on how the program was organized and managed, as well as some of the lessons learned from staff while implementing the program.

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VORP service area

Region 1 – Counties Ashland Bayfield Barron Burnett Douglas Iron Polk Rusk Sawyer Washburn Region 2 – Counties Florence Forest Langlade Lincoln Marathon Marinette Menominee Oneida Oconto Shawano Vilas

Region 3 – Counties Brown Calumet Door Kewaunee Manitowoc Sheboygan Region 4 – Counties Fond du Lac Outagamie Portage Waupaca Waushara Winnebago Wood

Region 5 – Counties Buffalo Jackson La Crosse Monroe Trempealeau Vernon Region 6 – Counties Chippewa Clark Dunn Eau Claire Pepin Pierce Price St. Croix Taylor

Region 1

Region 3

Region 2

Region 4 Region 5

Region 6

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Organization and Management

Staffing Model The VORP team included a variety of staff positions. Three outreach and recovery specialists were hired initially by DHS due to unexpected barriers in transferring grant funding from DHS to DVA. These staff were eventually transferred to DVA. This group was supported by a clinical coordinator at DHS and a program manager at DVA. In October 2015, under the supplemental grant, DVA hired three additional outreach and recovery specialists and two support positions. One position assisted enrollees with signing up for Social Security and other available benefits. The other position was an operations program associate who assisted with administrative duties and special projects. There was staff turnover during the life of the grant. Position vacancies were covered by other staff until new staff could be hired.

Marketing Efforts DHS DHS created a brochure for VORP that was used to promote the program to potential enrollees; county and tribal behavioral health staff; and providers of homeless, mental health, and substance use services. DHS also promoted VORP on the DHS website, on DHS social media accounts, and at conferences attended by behavioral health professionals. DVA DVA shared information about the program with newspapers in each VORP region. Additionally, DVA used paid advertising in newspapers and shopper publications to promote the program. All veteran and housing organizations in each region, as well as mental health and substance use service providers, were invited to live forums to increase collaboration between VORP and other entities. VORP branded bags with items needed for daily living were purchased and given to homeless veterans. Everything within the bags was stamped with the VORP logo, a number to call to reach VORP staff, and the website for the program. Military coins with VORP contact information also were purchased. The coins were given to VORP enrollees and attendees of special events who may have been homeless veterans to learn about and access community resources.

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Data and Evaluation Performance indicators for VORP were based on SAMHSA’s eight strategic initiatives established in 2014: prevention of substance abuse and mental illness; trauma and justice; military families; recovery support; health reform; health information technology; data, outcomes, and quality; and public awareness and support. The program had four primary goals. • Identify veterans who experience homelessness and behavioral health disorders. • Increase the number of strategies used to address the needs of veterans who experience

homelessness and behavioral health disorders. • Increase the number of participants in permanent housing throughout the life of the program. • Increase the number of participants enrolled health insurance and receiving other benefits.

The program had five secondary goals. • Define gaps in treatment for veterans who experience homelessness and behavioral health

disorders. • Establish a network of treatment providers that makes treatment options more accessible to rural

veterans. • Provide information on housing and mental health or substance use disorder services to all

homeless veterans contacted and ensure that enrollees were connected to either housing or behavioral health services at follow-up.

• Improve employment, criminal justice involvement, or social connectedness outcomes among enrollees.

• Increasing housing stability for enrollees following program exit.

Most of the data presented in this report was obtained through semi-structured interviews with homeless veterans entered into two databases. One of the databases is part of Wisconsin's Homeless Management System (HMIS). This system provides client-level data on people at risk of homelessness or receiving housing services provided by the U.S. Department of Housing and Urban Development. The Institute for Community Alliances manages HMIS for Wisconsin. Staff from the Institute for Community Alliance trained VORP staff to enter data into a behavioral health module in HMIS. The data was reviewed regularly to detect and resolve data entry errors. The second database is the Performance Accountability and Reporting System, a system managed by SAMHSA. Use of this database was required as part of the grant. Outreach and recovery specialists collected and entered data into this system at an individual's enrollment, every six months thereafter, and at the individual's discharge.

Homeless Veterans in Wisconsin Table 1 shows the veteran population across Wisconsin in 2015, 2016, and 2017.

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Table 1: Veteran Population by County 2015-2017

Year

Year 2015 2016 2017 2015 2016 2017

County Count on September 30 County Count on September 30 Adams 2,375 2,317 2,259

Marquette 1,569 1,539 1,508

Ashland 1,384 1,348 1,313

Menominee 299 295 291 Barron 3,738 3,658 3,575

Milwaukee 49,381 47,582 45,832

Bayfield 1,582 1,547 1,512

Monroe 5,217 5,209 5,199 Brown 16,856 16,405 15,959

Oconto 3,201 3,136 3,070

Buffalo 1,008 983 957

Oneida 3,749 3,637 3,526 Burnett 1,822 1,785 1,746

Outagamie 12,248 11,979 11,711

Calumet 2,914 2,854 2,794

Ozaukee 5,137 4,963 4,797 Chippewa 4,952 4,861 4,769

Pepin 581 564 546

Clark 2,066 2,010 1,954

Pierce 2,529 2,485 2,441 Columbia 4,393 4,288 4,185

Polk 3,627 3,553 3,479

Crawford 1,298 1,262 1,226

Portage 4,788 4,703 4,614 Dane 25,336 24,653 23,983

Price 1,318 1,290 1,261

Dodge 6,055 5,901 5,749

Racine 13,143 12,794 12,452 Door 2,451 2,352 2,260

Richland 1,313 1,269 1,226

Douglas 3,854 3,790 3,725

Rock 12,332 12,013 11,693 Dunn 2,877 2,853 2,826

Rusk 1,361 1,321 1,282

Eau Claire 6,776 6,650 6,522

St. Croix 5,449 5,406 5,361 Florence 588 570 553

Sauk 4,667 4,560 4,453

Fond du Lac 7,062 6,866 6,675

Sawyer 1,657 1,627 1,594 Forest 965 935 905

Shawano 3,312 3,233 3,154

Grant 3,189 3,112 3,034

Sheboygan 7,353 7,150 6,949 Green 2,311 2,265 2,220

Taylor 1,471 1,435 1,400

Green Lake 1,400 1,354 1,309

Trempealeau 1,948 1,907 1,867 Iowa 1,581 1,542 1,502

Vernon 2,142 2,100 2,056

Iron 698 676 655

Vilas 2,413 2,345 2,278 Jackson 1,739 1,716 1,691

Walworth 6,774 6,599 6,425

Jefferson 6,151 6,013 5,873

Washburn 1,669 1,635 1,600 Juneau 2,431 2,398 2,363

Washington 8,849 8,616 8,382

Kenosha 10,600 10,457 10,308

Waukesha 22,783 22,038 21,306 Kewaunee 1,364 1,328 1,291

Waupaca 4,598 4,491 4,385

La Crosse 7,787 7,637 7,486

Waushara 2,228 2,184 2,139 Lafayette 984 962 939

Winnebago 12,735 12,448 12,161

Langlade 1,683 1,637 1,590

Wood 6,255 6,087 5,918 Lincoln 2,575 2,497 2,421

Total 383,399 373,606 363,898

Manitowoc 6,004 5,867 5,731

Marathon 9,840 9,587 9,339

Marinette 4,612 4,474 4,341 Source: U.S. Department of Veterans Affairs, National Center for Veterans Analysis and Statistics

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Data on the prevalence of homeless veterans in Wisconsin suggests VORP helped reduce homelessness among veterans and provided supports to those in need. HMIS data suggests that 11% of adults experiencing homelessness in Wisconsin were veterans in 2016. Furthermore, despite decreases in the number of veterans served in emergency shelters, there was a 4% increase in the number of people present in any HMIS data throughout the life of VORP, largely due to the introduction of the program. On a single day in January of each year, the U.S. Department of Veterans Affairs works with volunteers, emergency shelters, veteran transitional housing facilities, and other partners who may be in touch with homeless veterans to identify and count the number of homeless veterans in Wisconsin. Table 2 presents data gathered from these annual point-in-time counts through 2017. The data shows the number of homeless veterans dropped by 21% from 2016 to 2017, possibly due to the services VORP provided to enrollees and contacts. Table 2: Annual Point-In-Time Count of Homeless Veterans in Wisconsin

Year 2017 2016 2015 2014 2013 2012 2011 Count 329 415 534 520 552 539 607

Source: U.S. Department of Veterans Affairs

Evaluation of Primary Goals VORP had four main goals. • Identify veterans who experience homelessness and behavioral health disorders. • Increase the number of strategies used to address the needs of veterans who experience

homelessness and behavioral health disorders. • Increase the number of participants in permanent housing throughout the life of the program. • Increase the number of participants enrolled with health insurance and receiving other mainstream

benefits.

Identify veterans who experience homelessness and behavioral health disorders - People served VORP enrollment totaled 330 people. Program staff also made contact with hundreds of other veterans. All of these veterans were connected with community resources. Enrollees and contacts found out about the program through various sources, including county and tribal veteran service offices, shelters, job centers, day centers, the VA, and housing providers such as Supportive Services for Veteran Families. More information on the strategies used to identify enrollees and contacts is included later in this report. Figure 1 shows the number of contacts with individual people in each quarter of the program. Many of these individuals were contacted more than once. The number of contacts made varied by season, dropping by more than a third in the colder months. The number of people contacted varied less (Figure 2). The rate of outreach contacts and people contacted was slow early in the program and spiked near the second quarter of 2017. Enrollment data presented in Figure 3 also shows a slow start to the program with peak enrollment near the beginning of 2017. Both of these trends reflect implementation challenges related to funding and staffing encountered over the course of the first year of the grant. The

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steep declines in 2017 seen across figures 1, 2, and 3 were likely due to the anticipated ending of the grant and its uncertain future for current enrollees for much of 2017. Figure 1: Outreach Contacts

Source: HMIS Note: Individuals may have been more than once Figure 2: People Contacted

Source: HMIS

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Figure 3: Enrollees (Point-In-Time, End of Quarter)

Source: HMIS

- Enrollee characteristics The characteristics of VORP enrollees were relatively similar to the predicted characteristics of enrollees outlined in Wisconsin’s application for the grant funding. Table 3 shows the predicted number of individuals to be served and the actual numbers of individuals served during the grant period. These figures were based on information gathered by outreach and recovery specialists and entered into HMIS from the 12 months prior to the completion of the program. Total served is consistently higher than the total proposed due to the extension of the grant and additional funds available across reporting periods. One noticeable difference in the data was between the numbers served in the American Indian/Alaska Native and African American populations. This may be due in part to the VORP service area. The service area covered counties in the state that are home to many American Indians. Additionally, the majority of African Americans in the state reside in areas not served by the program. Another more substantial difference in the data was in the “By Age” category. VORP served more veterans under the age of 35 than forecasted.

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Table 3: Demographic Characteristics of Enrollees

Total

Proposed Percentage Total Served Percentage

Direct Services: Number to be served 125 100 330 100 By Race and Ethnicity White 99 79 278 84 African American 16 13 23 7 American Indian or Alaska Native 4 3 27 8 Asian 1 <1 1 <1 Hispanic or Latino 1 <1 1 <1 Two or more 5 4 N/A NA By Gender Female 9 7 37 11 Male 116 93 292 89 Transgender 0 0 1 <1 By Age 35 and Under 15 12 71 22 Over 35 110 88 259 78

Source: HMIS - Distribution of mental health and substance use disorders Table 4 presents data on the distribution of diagnoses among VORP enrollees, which remained fairly similar through the life of the program. VORP had a high percentage of enrollees with a co-occurring mental health and substance use disorders (54%). This may be due in part to VORP’s focus on several high-risk populations: veterans, people experiencing homelessness, and people who live in rural areas. Table 4: Diagnosis Distribution for VORP Enrollees

Diagnosis Percent

Mental Health Disorder 39 Substance Use Disorder 7 Co-Occurring Diagnosis 54 Total 100

Source: HMIS Note: Figures are for all VORP enrollees prior to September 30, 2017.

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Strategies used to identify, engage, and connect homeless veterans Outreach and recovery specialists were encouraged to use traditional and nontraditional approaches to identify, engage, and connect with homeless veterans. Outreach and recovery specialists were trained in street outreach strategies. They also were trained on how to determine the veteran’s needs and how to address those needs through case management and education. VORP collected information on each of the specific strategies used by outreach and recovery specialists to identify eligible homeless veterans, engage them, and connect them to services. For this evaluation report, these strategies have been categorized into three domains. 1. Strategies that identified veterans eligible for VORP. 2. Strategies that engaged these eligible veterans for potential program enrollment. 3. Strategies that connected VORP-enrolled veterans to services to which they were referred by an

outreach and recovery specialist.1 In addition, each strategy was assigned a level of effectiveness by the outreach and recovery specialists (“effective,” “somewhat effective,” or “ineffective”). Tables 5, 6, and 7 present the most commonly listed effective strategies across Wisconsin ranked by their frequency of use by the outreach and recovery specialists for addressing the needs of veterans who experience homelessness. This data was collected in December 2016 and again in December 2017 to arrive at the data summarized in the tables.

1 Analysis of this qualitative data on strategy types followed a directed content analysis approach whereby categorization of strategies were derived deductively from preconceived categories or, in this instance, the three domains of strategies or theoretical perspectives cited in the VORP grant application and evaluation plan.

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Table 5: Domain 1, Identifying Eligible Veterans for VORP

1. Build relationships with local veterans service organizations, for example, Disabled American Veterans, Veterans of Foreign Wars, and the American Legion.

2. Word of mouth.

3. Build relationships with and receive referrals from veteran service providers, for example, Supportive Services for Veterans Families.

4. Build relationships with and receive referrals from veteran service providers, for example, county veterans service officers.

5. Place pull tab flyers with VORP contact information at places frequented by the homeless, for example, bus stops and coffee shops.

6. Spend time at local homeless shelters to meet with veterans.

*Identified by at least six of the eight outreach and recovery specialists as effective. Total strategies used by outreach and recovery specialists was 26.

Table 6: Domain 2, Engaging Eligible Veterans for VORP Once They Have Been Identified

1. Provide homeless kits as well as hats, blankets, water bottles, meals ready to eat, and other handouts.

2. Discuss in detail the program and network of referrals that can help with housing, employment, etc., with the client.

3. Use resources as incentives (bus passes, gas cards to fill cars).

4. Have conversations of like experiences (veteran-to-veteran) to get them to open up.

*Identified by at least seven of the eight outreach and recovery specialists as effective. Total strategies used by outreach and recovery specialists was 12.

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Table 7: Domain 3, Connecting Veterans to Services Once They Were Referred (that is, accepting a referral by an outreach and recovery specialist)

1. Provide an in-person introduction of veterans to staff of helper agencies (Supportive Services for Veteran Families, Veterans Housing and Recovery Project, etc.).

2. Call the referral service agency with the veteran so a connection is made and all parties are on the same page (treatment, housing, employment, Social Security, etc.).

3. Provide needed transportation for appointments whenever possible (medical appointments, meetings with community corrections officers, job interviews, appointments to view housing options, etc.).

4. Provide bus passes or pre-paid gas cards, if these resources could aid VORP consumers in making it to their referral service agency appointments.

5. Call the referral service agency to notify them the veteran will be coming down to vouch for client and speed up the process of connecting veterans with referrals.

6. Call a referral service agency to explain a veteran's need for services and find out next possible steps to addressing these needs and then have the veteran call the agency to complete these steps.

*Identified by at least seven of the eight outreach and recovery specialists as effective. Total strategies used by outreach and recovery specialists was 11.

Permanent housing status changes for VORP enrollees A stable and safe place to live is important for long-term recovery from behavioral health concerns. The housing status of VORP enrollees was tracked regularly. An enrollee’s status at their latest follow-up (most recent) interview date was the indicator of this goal. An enrollee’s housing situation was considered to have improved if the enrollee was not permanently housed upon enrollment and listed as permanently housed at their latest follow-up status update. At the end of the program, 271 VORP enrollees had valid follow-up data on housing (Table 8). In general, housing outcomes for VORP enrollees improved through time. Among these enrollees, 193 (71 %) reported being in permanent housing at their latest follow-up, only 65 (24%) of these enrollees were in permanent housing upon enrollment. This is a 196% increase in the number of VORP enrollees who were in permanent housing at follow-up when compared to the number in permanent housing at enrollment. Although the number of VORP enrollees who had been in the program for 12 or more months is substantially less than those who have spent any time in VORP (72 versus 271, respectively), there were still increases among this group in obtaining permanent housing. Specifically, there was an increase from 14 (19%) to 60 (83%) enrollees in permanent housing. This is a 329% increase in permanent housing among those previously not in permanent housing. In summary, more than two-thirds of VORP enrollees who did not have permanent housing upon enrollment were able to find housing after enrollment.

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Table 8: Housing Status among Permanently Housed VORP Enrollees

Duration from Enrollment to Latest Follow-up

Any 3 Months 6 Months 9 Months 12 Months Count % Count % Count % Count % Count %

In Permanent

Housing

At Enrollment 65 24 62 24 50 24 28 22 14 19 At Follow-up

193 71 187 74 159 75 102 80 60 83 Total Participants with

Follow-up Data 271 100 254 100 212 100 127 100 72 100 Source: HMIS Health insurance and other benefits All VORP enrollees participated in an intake interview or needs assessment conducted by program staff. This interview included a review of the enrollee’s eligibility for benefits (cash and non-cash) and whether they were receiving all benefits in which they met the eligibility criteria. Program staff helped enrollees connect to all benefits in which they were eligible, but not receiving. Data collected in HMIS on health insurance carried by VORP enrollees suggests that many VORP enrollees in need of health insurance were connected to this benefit while enrolled in the program. Out of the 329 enrollees with valid data, 282 (86%) reported data on health insurance acquired before or during enrollment in VORP. Of these people, 119 (42%) acquired health insurance while in VORP. The large majority of these people received Veterans Administration medical services (Table 9). Of the people who acquired health insurance after their VORP enrollment, 72 (61%) did not report having any health insurance prior to their enrollment.

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Table 9: Health Insurance Benefits Acquired While in VORP

Benefit Type Percent

Veteran's Administration Medical Services 51

Medicaid or Medicare 38

Indian Health Services Program 3

State Children's Health Insurance Program 2

Employer Provided Health Insurance 2

Other 1

Private Pay Health Insurance 1

Health Insurance Obtained Through COBRA <1

Total 100

Source: HMIS Data from HMIS suggests that several VORP enrollees were connected with non-cash benefits while enrolled in the program (Table 10). Out of the 329 enrollees with valid data on non-cash benefits, 141 (43%) reported receiving some type of non-cash benefit before or during enrollment in the program. Of these people, 51 (36%) acquired these benefits while in VORP. The large majority of these people received Supplemental Nutrition Assistance Program benefits as did the majority of people reporting receiving non-cash benefits prior to program enrollment. Of the people who acquired non-cash benefits after their VORP enrollment, 34 (67%) reported having any non-cash benefits prior to their enrollment. Table 10: Non-Cash Benefits Acquired While in VORP

Non-Cash Benefit Type Percent

Supplemental Nutrition Assistance Program (FoodShare) 92

Section 8, public housing, or other ongoing rental assistance 6

Special Supplemental Nutrition Program for WIC 2

Total 100

Source: HMIS Data from HMIS suggests that several VORP enrollees were connected with cash benefits while enrolled in the program (Table 11). Out of the 329 enrollees with valid data on cash benefits, 271 (82%) reported receiving some type of cash benefit before or during enrollment in the program. The large majority of these people received earned income (50%). Of these people, 169 (62%) acquired these benefits while in VORP. Of the people who acquired cash benefits after their VORP enrollment, 80 (47%) did not report having any non-cash benefits prior to their enrollment. Among those who received cash benefits prior to program enrollment, VA service-connected disability compensation was the most common pre-VORP cash benefit (35%) and only 20% of any of these cash benefits were earned income.

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Table 11: Cash Benefits Acquired While in VORP

Cash Benefit Type Percent

Earned Income 53

Social Security Disability Insurance 13

VA Service-Connected Disability Compensation 13

Supplemental Security Income 6

VA Non-Service Connected Disability Pension 5

Other 3

Pension or Retirement Income from Another Job 2

Child Support 2

Retirement Income From Social Security 1

Missing 1

Temporary Assistance for Needy Families 1

No Financial Resources <1

Unemployment Insurance <1

Total 100 Source: HMIS

Evaluation of Secondary Goals VORP was created to make mental health and substance use treatment and recovery services more accessible to veterans living in mostly rural areas. It sought to do this through five secondary goals. • Establish a network of treatment providers that makes treatment options more accessible to rural

veterans. • Define gaps in treatment for veterans who experience homelessness and behavioral health

disorders. • Provide information on housing and mental health or substance use disorder services to all

homeless veterans contacted and ensure that enrollees were connected to either housing or behavioral health services at follow-up.

• Improve employment, criminal justice involvement, or social connectedness outcomes among enrollees.

• Increase housing stability for enrollees following program exit. Network of treatment contacts The outreach and recovery specialists completed lists of treatment needs and made connections with treatment options in every county they served. The focus was on identifying and connecting with service providers for low income, rural veterans, including VA medical centers, VA community-based outpatient clinics, county behavioral health departments, and private providers. This work resulted in a database of providers that could be used to help homeless veterans statewide. The outreach and recovery specialists connected veterans with behavioral health needs to the appropriate level of care in their areas.

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The work establishing a treatment network also included meetings with veteran service organizations, including the Veterans of Foreign Wars and American Legion. Outreach and recovery specialists learned about the services available through these groups, including Heat for Heroes and mentorship programs. Outreach and recovery specialists educated service providers on how to identify veterans in need of treatment, the resources available for veterans with mental health and substance use needs, and how to make referrals for these services. Table 12 provides a list of the most frequent treatment provider types and some examples of these providers as they existed in the complete list of VORP agency contacts. The full list suggests VORP was able to provide referrals and connections to services able to address the various mental health and substance use needs of enrollees and other contacts.

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Table 12: Examples from the Network of Treatment Options for Veterans who are Homeless or at Risk of Homelessness

Most Frequent Provider Types Examples of Providers

Food Assistance

Neighborhood Food Pantry–Clark County, Working Community Surplus–Sheboygan County, St. Bernard Congregation–Brown County, Rib Lake United Methodist Church Food Pantry–Taylor County

Housing Assistance

Veterans Assistance Foundation–Portage County, Trempealeau County Housing Authority–Trempealeau County, Indian Head Community Action Agency–Burnett County, New Community Shelter–Brown County

Aging and Disability Resources Aging and Disability Resource Center–Calumet County, Ho-Chunk Nation Tribal Aging Unit–Jackson County, Marinette County Elderly Services–Marinette County

Health and Human Services

Florence County Department of Health–Florence County, Bay Area Mental Health Center, Inc.–Bayfield County, Jackson County Department of Health and Human Services–Jackson County, Brown County Coalition for Suicide Prevention–Brown County, Aurora Sheboygan Memorial Medical Center, Mental Health–Sheboygan County

Employment Assistance

Menominee Job Center College of Menominee Nation–Menominee County, Pepin County Job Center–Pepin County, Oneida Tribe of Indians of Wisconsin–Oneida County, LE Phillips Career Development Center–Chippewa County

Transportation Assistance Arms of Angels–Brown County, New Freedom Volunteer Driver Program–Chippewa County, Door Tran, Inc. –Door County, Marathon County Transportation Program–Marathon County

Assistance Specifically for Veterans

County Veteran Service Office–Dunn County, Tribal Veteran Service Officer–Oneida Tribe, Outagamie Ladysmith VFW Post–Rusk County, Supportive Services for Veteran Families–Fond du Lac County

Source: Complete list of VORP agency contacts Gaps in treatment Five major gaps in mental health and substance use services were identified during this program. First, there is a lack of detoxification services in Wisconsin. Program staff often experienced waitlists when attempting to secure a detoxification stay. More detoxification services are needed for those who are suffering from alcohol or benzodiazepine withdrawal. While hospital emergency rooms can admit a person in situations of life threatening withdrawal, they lack the expertise of detoxification facilities. Because of this, hospitals tend to discharge individuals once they are stable, as opposed to conducting extensive discharge planning that would include the needed follow-up substance use disorder treatment. Program staff found that extra planning and discussion around continuing treatment prior to

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discharge from detoxification services was imperative to success for homeless veterans with an alcohol use disorder. Second, detoxification services are unwilling to admit individuals in withdrawal from opioids because the withdrawal is seen as non-life threatening. This lack of support through withdrawal likely pushed some homeless veterans seeking to quit opioids to abuse other substances to lessen the effects of the painful withdrawal. Having access to detoxification services would likely reduce the abuse of these other substances. Third, there is a lack of residential treatment services for substance use disorder. This shortage led to waitlists for services. Ideally, someone with chronic alcohol use who completes detoxification would go directly to a residential substance use disorder program, unless they have a need for inpatient services. Unfortunately, for VORP enrollees, it often was the case that an individual would complete detoxification and could not go directly to residential treatment due to waitlists, even when it was the recommended level of care for the enrollee. When an individual does not have a support network, the wait for treatment after detoxification is difficult. This may result in a return to substance abuse and a readmission to detoxification services. While VORP was sometimes unable to provide proper residential treatment for people leaving detoxification services, support provided from an outreach and recovery specialist likely helped lessen the impact of this gap in treatment. Moreover, because all outreach and recovery specialists were veterans themselves, they could provide better support to VORP participants based on their own understanding of the challenges facing veterans. Fourth, only one of the substance use residential service providers in Wisconsin allows residents to smoke cigarettes. Cigarette use was common among VORP participants. The no smoking rules in place at substance use residential service providers dissuaded VORP participants from attending needed residential treatment. Fifth, there is a lack of cultural competency among treatment providers in Wisconsin. Many direct services staff were not veterans. Over time, VORP program staff identified veterans among service providers. Whenever possible, VORP program staff directed participants to these services. For example, one substance use residential facility has two therapists who are veterans. One of these therapists served as the counselor for VORP participants at their facility. While progress was made during the grant cycle in training mental health and substance use providers on how to work with veterans, more work needs to be done. Referrals and services VORP sought to provide information on housing and mental health and substance use disorder services to all homeless veterans contacted. Enrollees were also screened for these disorders. Data from HMIS provides a summary of housing and mental health and substance use disorder referrals (Tables 13) and services (Table 14), as well as the many other services, treatment options, and referrals VORP participants and contacts may have received. Counts in these tables represent the multiple referrals or services an individual may have received while in contact with VORP. Only services directly funded through VORP are reported in Table 14. As such, this data substantially undercounts actual services VORP participants may have received. Services may have been supported through other funding resources, such as Medicaid.

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Table 13: Referrals by Type

Referral Type Region

Totals I II III IV V VI

Housing/Shelter/Hotels/Motels 56 54 97 49 62 76 394 Employment 11 17 86 20 23 13 170 Mental Health Assessment and Treatment 1 34 85 21 6 15 162 Food 0 12 135 4 0 2 153 Case/Care Management 8 28 54 52 4 3 149 Transportation 19 3 84 13 1 2 122 Health Care 0 11 73 17 1 3 105 Outreach Programs 2 5 59 3 1 6 76 Substance Use Disorder Intervention Programs 3 6 29 10 11 10 69 Social Security Disability Insurance 9 13 19 16 6 1 64 Social Development/Enrichment/Mentorship 1 2 43 7 0 0 53 Money Management 0 2 23 3 0 0 28 Legal Services 3 10 9 3 0 0 25 Educational Programs 1 2 6 8 0 0 17 Totals 114 199 802 226 115 131 1587

Source: HMIS, December 2017 Notes: This data includes duplicate clients. For example, an individual may have been referred to three employment agencies. This will show in the report three times.

Table 14: Services by Type

Service Type Region

Total I II III IV V VI

Case/Care Management 333 501 312 368 536 468 2518 Transportation 37 38 25 69 175 3 347 Mental Health Assessments 3 16 6 2 13 4 44 Mental Health and Substance Use Inpatient/Outpatient 3 0 4 5 7 5 24 Food Provided Directly by VORP 1 5 3 4 0 0 13 Total 377 560 350 448 731 480 2946

Source: HMIS, December 2017 Notes: Only the services directly funded through VORP are reported in this table. This data does not include services referred to and supported through other funding resources. This data includes duplicate clients. For example, an individual may have received cases management three times. This will show in the report three times. Other resources for mental health and substance use referrals and services Outreach and recovery specialists offered education to providers of homeless services on the importance of exploring the mental health or substance use disorder needs of their clients. This was a factor in VORP’s success. Many homeless programs serving veterans focus on basic needs such as

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housing, food, and employment, rather than the behavioral health of their clients. In some instances, individuals can be disqualified from these programs due to their mental health or substance use issues. There was a lack of funds to provide emergency shelter and emergency financial assistance to veterans. To fill in this gap, DVA successfully applied for an Otto Bremer Trust Grant. This grant allowed DVA and six counties in the VORP service area to partner with the American Red Cross and the Salvation Army. Through these arrangements, VORP provided assistance for such things as first month’s rent, security deposits, and hotel stays. Participants waiting to get into a home that would be available within days or waiting for residential treatment benefited greatly from this effort. VORP also partnered with the Couleecap and Newcap homeless programs. Couleecap serves western Wisconsin. Newcap serves northeastern Wisconsin. VORP helped these organizations understand military culture and supported case management services for veterans served by these programs. The partnerships allowed for VORP participants enrolled in the Couleecap and Newcap programs to use housing funds from these programs. Employment, criminal justice involvement, and social connectedness DHS and DVA set a goal that half of all VORP enrollees would demonstrate improvement in employment, criminal justice involvement, or social connectedness at follow-up. Table 15 summarizes data across the major indicators for this goal from the enrollee’s admission to their latest follow-up. • “Employed?” indicates whether a person was employed full- or part-time. • “Involved in Crime?” is a single, combined measure of whether, in the past 30 days, a VORP

participant had been arrested or committed a crime. • “Socially Connected?” is a single, combined measure of whether, in the past 30 days, a VORP

participant: o Attended self-help groups for recovery that were not affiliated with a religious or faith-based

group. o Attended any religious or faith-based recovery self-help groups. o Attended meetings of organizations that support recovery other than the organizations

described in the previous questions on recovery self-help groups. o Had any interaction with family or friends that were supportive of their recovery.

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Table 15: Enrollee Status Changes Across Major Program Indicators

Status Admission Follow-Up or Discharge

Count % Count % Employed?

Yes 42 13 106 33 No 284 87 219 67 Total 326 100 325 100

Involved in Crime?

No 294 89 306 93 Yes 36 11 24 7 Total 330 100 330 100

Socially Connected?

Yes 244 74 220 67 No 86 26 110 33 Total 330 100 330 100

Source: SAMHSA’s Performance Accountability and Reporting System Further analysis of the data in Table 15 provides a picture of improvements from program admission to latest follow-up interview. Sixty-four enrollees became employed while in VORP. This is 20% of the total 330 VORP enrollees, and 24% of the 284 enrollees who started the program unemployed and, thus, could have seen improvements in employment. Twelve enrollees abstained from criminal activity while in the program after they had reported involvement in crime in the past 30 days upon program admission. This is 4% of all VORP enrollees, or 33% of the 36 enrollees who started the program with criminal justice involvement upon enrollment. Data on the reported number of times a person was arrested or committed a crime in the 30 days prior to their initial interview also reveals that, among people involved in criminal justice upon program enrollment, 48 instances of criminal justice involvement occurred in the 30 days prior to admission. For this same measure, only 32 instances of criminal justice involvement occurred at latest follow-up or discharge, which translates to 16 fewer arrests or commissions of a crime or a 33% reduction in criminal activity. Social connectedness among VORP enrollees did not show improvement while in the program. Twenty-four fewer enrollees were socially connected in their latest follow-up interview. This represents 7% percent of all VORP enrollees, or 29% of the 86 enrollees who started the program without social connectedness. Data on the reported number of times a person either attended a self-help group or had an interaction with family or friends that are supportive of their recovery reveals that, among people socially connected upon program enrollment, 731 instances of attendance or connection occurred in the 30 days prior to admission. For this same measure, only 500 instances of social connection occurred at latest follow-up or discharge, which translates to 231 fewer instances, or a 32% reduction in social connections. This unexpected result may be due in part to VORP participants finding other supports through the program outside of self-help groups.

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A combined measure of employment, criminal justice involvement, and social connectedness revealed that 100 VORP enrollees (33%) improved in at least one of these three areas while in the program. This is 37% of the 267 people who, upon program enrollment, were unemployed, involved in crime, or unconnected socially. While these findings may suggest VORP did not perform to the expected level for addressing the needs of participants, VORP participants often had complex needs and received a variety of services and resources to address those needs. Improvements in these major areas may not yet have occurred for some VORP participants. Furthermore, examining more intermediary measures of program performance, such as substance use disorder treatment completion rate or functional improvements, may be more appropriate evaluations of the performance of a program such as VORP. This evaluation was not performed for VORP. Recidivism to homelessness DHS and DVA set a goal that 80% of VORP participants in housing at program exit will remain in that type of housing and not return to homelessness. HMIS tracks client-level data on people at risk of homelessness or receiving housing services as provided through the U.S. Department of Housing and Urban Development. The requirement to track and report on any and all people receiving services for homeless people regardless of their involvement with VORP provides a source of data for tracking VORP participants who may return to homelessness in any Department of Housing and Urban Development-funded program. Using this HMIS data, a conservative measure of returns to homelessness was calculated among the 165 enrollees who transitioned out of VORP to a permanent housing destination2 and returned to a program that serves people who are homeless3 (Table 16). Enrollees may have transitioned or exited from VORP as early as March 14, 2016, or as late as December 31, 2017. This, combined with the latest current follow-up window of data, which goes through April 15, 2018, means that there are various follow-up periods of recidivism that vary depending on when an enrollee exited the program. Enrollees who transitioned from VORP were examined across those who had 12 to 24 months, six to less than 12 months, and three to less than six months of follow-up, or time for a return to homelessness to occur. Among enrollees with the largest opportunity to return to homelessness, those who had 12 to 24 months following program transition, 87% did not return to homelessness and, for each of the other cohorts, 96% of people did not return to homelessness. Overall, 94% of VORP enrollee remained in

2 Permanent housing destinations defined by the U.S. Department of Housing and Urban Development included in analysis were Housing and Urban Development Exchange—moved from one Housing Opportunities for Persons With AIDS funded project to another with permanent housing; owned by client, no ongoing housing subsidy; owned by client, with ongoing housing subsidy; permanent housing (other than rapid re-housing) for formerly homeless persons; rental by client, no ongoing housing subsidy; rental by client, with grant and per diem Transition in Place housing subsidy; rental by client, with other ongoing housing subsidy; rental by client, with rapid re-Housing or other equivalent subsidy, rental by client, with Veterans Affairs Supportive Housing subsidy; staying or living with family, permanent tenure; or staying or living with friends, permanent tenure. 3 Returns to homelessness were defined by returns to destinations defined by the U.S. Department of Housing and Urban Development as street outreach, emergency shelter, transitional housing, safe haven, or permanent housing project.

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permanent housing through the examined follow-up periods; well beyond those people surpassing the program’s goal. Table 16: Return to Homelessness among Transitioned VORP Enrollees

Follow-Up Period (Months)

People in Permanent Housing at Exit

People Returned to Homelessness

Count % Count % 3 to less than 6 51 31 2 4 6 to less than 12 74 45 3 4 12 to 24 40 24 5 13 All Periods 165 100 10 6

Source: HMIS

Qualitative Data VORP staff routinely asked participants about their program concerns. Stories also were collected. Concerns expressed by program participants • There were obstacles and long waiting times for services through counties, VA, and private

insurance. • There was a lack of alcohol detoxification services in many areas. • There was a lack of opioid withdrawal management services in many areas. • There was a lack of understanding among providers of the issues facing veterans. • There was a lack of familiarity among county and private insurance service providers of VA services

available and eligibility policies. Stories from the field VORP staff maintained a log of stories from the field. This log includes stories of participants being housed, finding employment, securing benefits, and developing supportive relationships through recovery. The following is a summary of three stories from this log. A survivor of multiple suicide attempts was supported by VORP. He admitted that his struggle with a substance use disorder impacted his quality of life. He had lost his job, housing, and social supports. After enrolling in VORP, he was connected to housing at a boarding house. He completed chores around the home to cover the cost of his room. It was a one-week stay. However, during this time, VORP staff connected the man to his county veterans service officer to discuss other benefits and services available to him. He received financial assistance for permanent housing from the Center for Veteran Issues. He enrolled in FoodShare. He was connected to the Wisconsin Department of Workforce Development for help finding a job. He obtained clothing and other supplies through Goodwill. He received a Walmart gift card to pay for phone minutes and other supplies. Today, he is earning $17 an hour as a part-time woodworker, a job he loves. He says his well-being is the best it has been in years. An outreach and recovery specialist contacted a college in his area to connect students studying nutrition services with VORP enrollees. The students discussed healthy eating habits and budget-friendly food-buying strategies with the newly housed enrollees. College staff would also go into the home of

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the veteran with the outreach and recovery specialist and cook a meal together with that veteran. This occurred every week for a few weeks with each veteran. An outreach and recovery specialist noticed abandoned bicycles being picked up by police in his area. He asked them what they do with them. He was told that if no one has reported them as missing they are destroyed. He asked if a VORP enrollee could have the bikes to be destroyed. The enrollee wanted to fix bicycles for homeless veterans to provide them a way to get to and from work. The police department agreed to provide the bike. The outreach and recovery specialist found a church willing to donate space in its basement for the VORP enrollee to work on the bikes. The outreach and recovery specialist helped connect veterans to the bikes.

VORP and Wisconsin’s Opioid Crisis Two men and one woman enrolled in VORP lost their lives to opioid overdoses. Due to these deaths and the high number of enrollees diagnosed with an opioid use disorder, outreach and recovery specialists participated in additional trainings that included information on how to identify a person addicted to opioids, levels of care available, and where and how to get help as well as examples of case management scenarios. Many enrollees with substance use disorders reported VORP and the connection to their outreach and recovery specialist helped them reclaim their lives and begin their lives of recovery.

Program Closeout Enrollment in VORP ended March 30, 2017, six months prior to the scheduled grant closing date of September 30, 2017. Shortly before the scheduled grant closing date, SAMHSA awarded the program a grant extension through December 31, 2017, for both the original and enhancement grants. There was no additional funding associated with these extensions. However, the extensions allowed the program to use left-over funds to continue activities for three more months. Outreach and recovery specialists used this time to transition remaining enrollees to other services and supports. They also continued their work identifying veterans in need of help and connecting these veterans to resources in their communities. Efforts to educate service providers on the importance of understanding military culture so they could better work with veterans continued during this time. DVA requested state funding in 2018 to expand VORP to all 72 Wisconsin counties. This effort was successful.