Office of Research & Development

VA RESEARCH QUARTERLY UPDATE
This Issue: Ensuring High-Quality Care | Table of Contents: Fall 2016 | Download this issue

Spotlight on Career Development

Improving services for homeless Veterans


Dr. Jack Tsai's research focuses on improving services for Veterans affected by homelessness and mental illness. . <em>(Photo by Robert Lisak)</em>>
Dr. Jack Tsai's research focuses on improving services for Veterans affected by homelessness and mental illness. . (Photo by Robert Lisak)

Dr. Jack Tsai's research focuses on improving services for Veterans affected by homelessness and mental illness. (Photo by Robert Lisak)

Dr. Jack Tsai is a clinical psychologist at the VA Connecticut Healthcare System and an investigator for VA's New England Mental Illness, Research, Education, and Clinical Center (MIRECC) and Pain Research, Informatics, Medical Comorbidities and Education (PRIME) Center. He is also an assistant professor of psychiatry at Yale School of Medicine, and co-director of the Yale Division of Mental Health Services Research. He received his Ph.D. from Purdue University and completed a National Institute of Mental Health fellowship at Yale University. Tsai's work involves addressing the needs of homeless populations, improving understanding of PTSD and recovery from the condition, and evaluating psychosocial services for adults with severe mental illness. His HSR&D Career Development Award focuses on improving services for homeless Veterans.

VARQU: Tell us about your Career Development project.
Tsai: With support from VA, I have been able to study perhaps the most important homeless program for Veterans, HUD-VASH [Housing and Urban Development—VA Supportive Housing]. The HUD-VASH program provides independent, permanent housing to homeless Veterans. It does that by offering Veterans a voucher that helps pay their apartment rent and supportive case management that helps them live independently. The program is also unique because it is a collaboration between two federal agencies. My project focuses on improving the HUD-VASH program in several ways.

What I've discovered is that many homeless Veterans are incredibly isolated. In fact, one of the most common complaints from Veterans in the HUD-VASH program is that they are lonely. HUD-VASH case managers visit Veterans in their homes. There are Veterans who never leave their house, and the case manager's visit is the only social interaction they ever have. So, I thought, this is really a problem, since so much of our lives is about social connection.


Social worker Karen Ablondi, a research associate with Dr. Jack Tsai's team, meets with Veteran Thomas Scherrer as part of a pilot program to teach money management to clients of the HUD-VASH program. <em>(Photo courtesy of Jack Tsai)</em>
Social worker Karen Ablondi, a research associate with Dr. Jack Tsai's team, meets with Veteran Thomas Scherrer as part of a pilot program to teach money management to clients of the HUD-VASH program. (Photo courtesy of Jack Tsai)

Social worker Karen Ablondi, a research associate with Dr. Jack Tsai's team, meets with Veteran Thomas Scherrer as part of a pilot program to teach money management to clients of the HUD-VASH program. (Photo courtesy of Jack Tsai)

Another problem is that there are times the HUD-VASH program managers are issued a large number of housing vouchers all at once, and often there aren't enough case managers to go around. There is quite a lot of upfront work that's needed in order to use the vouchers, such as finding an apartment, getting the apartment inspected, and moving Veterans in. There just aren't enough case managers to efficiently deal with these waves of housing vouchers.

I recognized these were two issues with the HUD-VASH program, so I developed a new case-management model for the HUD-VASH program called Group-Intensive Peer Support (GIPS). Basically, the GIPS model offers group case management. In group case management, case managers see multiple Veterans at one time, which saves the managers' time, and Veterans don't rely only on the case managers, but receive peer support from fellow Veterans. Peer support involves having other Veterans mentor them, advise them about the best places to live away from negative elements, and even help each other move in.

Instead of spending time driving to individual Veterans, case managers see groups of Veterans in community spaces, borrowed spaces in churches, VA facilities, HUD buildings, even in vans. We heard wonderful stories of Veterans helping each other out with furniture and getting together to support one another. Besides these anecdotes, because this was a scientific project, we empirically evaluated the GIPS model. We found that, compared with other HUD-VASH programs that did not implement the model, the GIPS model was associated with greater social integration among Veterans, and it enabled case managers to have more time to perform different activities.

We've promoted the GIPS model to other VAs with some success, and several have adopted this approach. Our next challenge is to conduct a randomized controlled trial of the GIPS model at multiple sites, and we have been exploring various ways to do that.


How do you think the results of this project will benefit Veterans?
The project highlights a way for Veterans to help one another and also to combat the loneliness that can occur when you live by yourself independently. Part of the loneliness that Veterans feel reflects a greater feeling in American society. Sociologist Robert Putnam wrote about this in his famous book Bowling Alone, in which he documented the interesting phenomenon that more Americans are bowing alone and are no longer on bowling teams.

I think Veterans may even be more susceptible to this loneliness. Soldiers in the military were part of a tight, cohesive unit living on bases with an even larger military family and many were displaced from their hometowns. As a result, after they left the military, they often have difficulty integrating back into civilian life. This matters because a great deal of research has shown that social support buffers the effect of stress. Those with histories of substance abuse or mental illness can relapse because of a lack of social support, and because they do not have an adequate support system.

Dr. Jack Tsai meets with MIRECC colleagues Drs. Mehmet Sofuoglu (left) and Robert Rosenheck (right). <em>(Photo by Robert Lisak)</em></em>
Dr. Jack Tsai meets with MIRECC colleagues Drs. Mehmet Sofuoglu (left) and Robert Rosenheck (right). (Photo by Robert Lisak)

Dr. Jack Tsai meets with MIRECC colleagues Drs. Mehmet Sofuoglu (left) and Robert Rosenheck (right). (Photo by Robert Lisak)


You have done a great deal of other work on behalf of the homeless Veterans population, and on behalf of seriously mentally ill Veterans. Can you describe a few highlights of the studies you have participated in?
Much of my work has involved helping people think about and pay attention to what can be done to support the long-term independence of Veterans. For example, Housing First is now the dominant approach to housing Veterans. The idea is that homeless Veterans should be provided immediate access to independent housing instead of asking them to "prove" themselves through first living in more supervised environments and graduating eventually to independent housing.

I've been known to ask, "If housing is first, then what's second?" We've done several studies showing that providing housing to Veterans helps them stay housed, but it does not have a dramatic effect on many other aspects of their lives, such as their mental health, substance abuse issues, employment, and social connections.

Many people have talked about how great the Housing First model is, but I think getting Veterans housed is just the first step, and in fact, much of the real work is what happens after they have been housed. Are they able to keep their housing? Do they know how to manage their money? Do they find employment and contribute to society meaningfully in the ways they want to? Do they connect with others, find love, and live full lives so they not only exit homelessness but become productive citizens?

We are currently piloting a money-management program to help HUD-VASH Veterans learn how to budget their money, do things like build credit, and gain financial literacy. Some Veterans have never had a checking account, or don't know how to responsibly track their bills. This is an exciting project that's going on now.

VA has long been a leader in homelessness research and services. Here, an outreach worker participates in the 2015 Point-in-Time Homeless Count in Washington, D.C. <em>(Photo by Robert Turtil)</em>
VA has long been a leader in homelessness research and services. Here, an outreach worker participates in the 2015 Point-in-Time Homeless Count in Washington, D.C. (Photo by Robert Turtil)

VA has long been a leader in homelessness research and services. Here, an outreach worker participates in the 2015 Point-in-Time Homeless Count in Washington, D.C. (Photo by Robert Turtil)

Another intervention-type project that is really interesting is the concept of medical-legal partnerships. Medical-legal partnerships bring lawyers and VA health care providers together to help Veterans. Many homeless Veterans and Veterans with severe mental illness have civil legal problems that can impact their recovery, such as evictions, child support payments, and challenges obtaining disability benefits.

Housing First doesn't help with those, and these legal problems can impede long-term recovery. At some VAs, there are actually lawyers that run legal clinics on VA grounds, which is really unique. VA clinicians can just walk down the hall and refer Veterans to a lawyer. We're doing a study right now, funded by the Bristol-Myers Squibb Foundation, that's studying the effect of these VA medical-legal partnerships to help homeless and at-risk Veterans with their recovery. I've submitted a request for a VA Merit grant to further study this innovative model.


How have these findings affected, or how do you hope they will affect, the way in which VA provides care to these Veterans?
Homelessness is really a multifaceted problem. It's often seen as just a financial problem, but there are often so many other factors involved. If you think about what you or I would do if we became homeless tomorrow, we would probably be able to tap various resources to help us exit homelessness. We might have friends and family to help us, job skills and contacts that could help us find a job if we lost our job, and the know-how to avail ourselves of public resources like unemployment or disability benefits, welfare, and other programs. So part of my work is helping homeless Veterans build up these resources to permanently end their homelessness.

VA is really an incredible health care system, because it provides comprehensive care. There are programs that provide medical care, mental health care, and dental care—and there are also programs to help Veterans obtain education and employment, and to develop social skills. It's an ideal place for my kind of research because the kind of services I am talking about are somewhat outside the traditional medical model and address social determinants of health.

There's a growing movement [in VA] toward multidisciplinary care and addressing social determinants of health, and my work has taken advantage of the support that exists for these movements. I hope my work continues to help VA consider ways to expand the comprehensive care the department provides, as we recognize that social conditions like homelessness and many medical and mental health conditions are influenced by psychosocial factors, for which we can develop services.

What are your plans for the next phase of your research career?
I am very grateful for my VA Career Development Award, because it has allowed me dedicated time for research, and to explore a career path within the VA. I'm passionate about working with Veterans. What's special about the VA Career Development Award compared to other career development awards, such as the National Institute of Health's K-award, is that if you are a clinician, you can remain engaged in providing direct VA clinical services some of the time. I have a fear of being in an ivory tower and doing research and evaluating programs that is detached from the real VA world. So it's been good that I've been able to stay connected to direct care, proving therapy, and seeing Veterans in clinical care.

I'm not exactly sure what's next for me, but I think I want a position that allows me time to do research, and to also stay connected to direct clinical care. There may be some administrative-type roles that will allow me to do that. VA's Career Development Award is also unique in that it guarantees at least a five-eighths VA position after the award ends.

In terms of my research, I definitely plan to continue examining innovative ways to address age-old difficult problems such as homelessness and trauma. Besides projects like the money-management program and medical-legal partnership projects I mentioned, I am also exploring the use of technology. It turns out that many Veterans, including those who are homeless or have severe mental illness, have smartphones and use computers. These technologies represent new ways to reach, engage, and treat Veterans. We are currently piloting computerized treatments for insomnia among Veterans with severe mental illness and those with posttraumatic stress disorder.

There are so many exciting lines of research in the VA, and such a large network of VA researchers, that I always feel like there's not enough time in the day to do all the projects I want. I can't imagine not being part of this great health care system.


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