VVA Testimony VVA Testimony
VVA Testimony

Statement
Of
VIETNAM VETERANS OF AMERICA  

Submitted by

Marsha (Tansey) Four, RN
Chair,
VVA Woman Veterans Committee

Before the

House Veterans Affairs Committee

Regarding
National Commitment to End Veterans’ Homelessness

June 3, 2009

 

Good morning Mr. Chairman, Ranking Member Buyer, and distinguished members of the House Veterans Affairs Committee. Thank you for giving Vietnam Veterans of America (VVA) the opportunity to offer our comments on the National Commitment to End Veterans’ Homelessness.

Homelessness continues to be a significant problem for veterans. Among male homeless veterans those of the Vietnam Era are still of the highest percentage, although it is decreasing. Among women veterans this percentage is highest for those of the peace time era after Vietnam and before Gulf War I. In part this is due to the fact that until the end of the Vietnam Era, woman, by law, were only able to make up 2% of the Active Duty Force. The VA estimates about one-third of the adult homeless population have served their country in the Armed Services. Newly released population estimates suggest that about 131,000 veterans are homeless on any given night and perhaps twice as many experience homelessness at some point during the course of a year.

Homelessness has varied definitions and many contributing factors. Among these factors are PTSD, a lack of job skills and education, substance abuse and mental-health problems. The homeless require far more than just a home. A comprehensive, individualized assessment and a rehabilitation/treatment program are necessary, utilizing the “continuum of care” concept. Assistance in obtaining economic stability for a successful self-sufficient transition back into the community is vital.

Although many need help with permanent housing, some require housing with supportive services, others need long-term residential care and some, in reality, will chose to remain in their homeless life situation. Will homeless veterans cease to exist…I’m not sure that is possible. But I do believe that if we continue to work on the issues together in a concerted, cohesive, and collaborative fashion, committed to the mission, and investing our energies, seeking to understand the needs of the veterans and developing programs that meet those ever changing needs, we will succeed in providing the best we can to those homeless veterans who recognize our passion and commitment to them, while holding on to a hope that may have almost disappeared. Some have not trusted in a long time and we have to prove we can be trusted with their lives and that their lives are worth the saving.

 

VA HOMELESS GRANT & PER DIEM PROGRAM

The VA’s Homeless Grant & Per Diem Program has been in existence since 1994.  Since then, with this investment made by the VA, thousands of homeless veterans have availed themselves of the programs provided by community-based service providers.  In some areas of this country, the VA, community-based service providers, and local governments work successfully in a collaborative effort to actively address homelessness among veterans.  The community-based service providers are able to supply much needed services in a cost-effective and efficient manner.  The VA recognizes this and encourages residential and service center programs in areas where homeless veterans would most benefit.  The VA HGPD program offers funding in a highly competitive grant round.  VA credits HGPD and VA outreach for the drop on the number of homeless veterans previously mentioned from 250,000 to as low as possibly 131,000. VVA also believes that the expansion of the Homeless Veterans Reintegration Program (HVRP), used in tandem with the above cited programs, has helped homeless veterans and formerly homeless veterans obtain and retain employment, thus stabilizing their financial and emotional situation, enabling them to keep off the street. HUD VASH with its VA case management will certainly provide a great asset for those veterans who need to maintain a closer connection with services.

However, VVA and providers are concerned that the long term effects of the current Global War On Terrorism will produce a significant impact on the number of homeless from this new generation of veterans. The unemployment rate will “heap on” increased difficulties adding to the spectrum of difficulties and stress that compounds life’s burdens often leading to homelessness.

VVA believes that the VA Homeless Grant and Per Diem program is vital to the efforts being made to confront and attack the disgrace of homeless veterans in this country. Its impact on the reduction of the number of homeless veterans in America is profound. VVA also believes that the VA’s increased partnership with local government agencies has played a significant role in bringing the plight of these veterans to the forefront in communities across this nation. And no one can deny the powerful role that non-profit agencies have played in providing the manpower, services, and assistance that brings an added heart and soul to the programs of the VA Homeless Grant and Per Diem initiative. But small nonprofits do face difficulties along the way.

At times it is not easy for nonprofit agencies to forestall debt in attempting to accomplish the mission of its homeless programs. For some it is the financial challenge of the “reimbursement” method utilized by VA. According to the understanding of some nonprofits that use the accrual basis for accounting, the agency is expected to incur an expense and then pay the expense before it can invoice the expense for reimbursement. As an example: a $20,000 food expense is incurred in June, the invoice is due in thirty days so it is paid in July. Then the agency can invoice VA in August for the July paid bill and get reimbursed by maybe mid to late September. In real life, nonprofits cannot front the expenses for over two months before reimbursement. It is impossible unless it uses its line of credit which then incurs an interest expense that can’t be charged off anywhere.

Another situation that proves challenging for non-profit grant recipients is meeting the requirements of proven expenses in order to justify an increase in the per diem rate if they are not receiving the highest amount available under the law. These agencies must justify the need for an increased per diem rate based on the program expenses as indicated on the previous fiscal year’s annual audit. Therefore the non-profit agency must over spend money in order to increase the program expenses so that a need for the increased per diem rate can be identified and justified. Non-profit agencies exist on nearly bare bones dollars and spending beyond their budgets is nearly impossible. All programs are budget driven and they work as close to the budget as possible in order to remain solvent. So therein lays the dilemma in attempting to increase its per diem rate. This process is limiting to program function, enhancement, and staffing levels.

Some federal agency and private grant funders structured their financial awards in such a way that the budgeted dollars for the coming year are projected, requested, and available on a monthly basis. This budget is then approved as the cap for the projected program year and no more than those funds are made available. It seems that this per diem payment structure should be investigated. It also appears to be more “user” friendly, less complicated, and more feasible for the grant recipient. One of the resounding questions that non-profit agencies have is, “Why aren’t these programs seen as a “fee for service” operation instead of a reimbursement?” It would be so simple to set aside the allowable per diem rate for the number of beds in a program on an annual basis and permit the nonprofits to draw down on this amount on a monthly basis equal to the number of beds occupied for the month. It’s pretty hard to imagine that any one wouldn’t think that $34.40 per day is the best bargain in town to provide housing, care and treatment for a veteran. The amount of work and the staff time required to accommodate the current system is a drain on the entire system to include that of the VA. This request would require a change to the law but is one for which we would ask be fully investigate and considered and VVA would like to have further discussion on this topic.

OUTREACH

One of the front line outreach programs funded by VA HGPD is the Day Service Centers, sometimes referred to as Drop In Center. These centers reach deep into the homeless veteran population that are still on the streets and in the shelters of our cities and towns. Under the VA HGPD program they receive per diem at rates based on an hourly calculation per diem ($4.30) for the actual time that the homeless veteran is actually on site in the center. This amount may cover the cost of the coffee and food that they receive but it does not come close to paying for the professional staff that must provide the assistance the veterans need long after they leave the facility. As one can well imagine the needs of these veterans are great and demand enormous amounts of time, energy, and manpower in order to be effective and successful. It is for this reason, the lack of available funding, that many service centers for homeless veterans have closed or could never open even after being funded by VA HGPD. This is a tremendous loss to the outreach efforts so important in connecting the homeless veterans with the VA.

The reality is that most city and municipality social services do not have the knowledge or capacity to provide appropriate supportive services that directly involve the treatment, care, and entitlements of veterans. It is for this reason that these homeless veterans’ service centers are so vital. These service centers need help and a re-vitalization in order to be re-instituted as the effective outreach tool that they were designed to be. VVA believes that it is possible to create “Service Center Staffing/Operational” grants, much like the VA “Special Needs” grants, already in existence. It would not be setting precedence. VVA supports and seeks legislation to establish Supportive Services Assistance Grants for VA Homeless Grant and Per Diem Service Center Grant awardees.

CONSOLIDATION OF VA HGPD PROJECTS

In the past, some successful VA HGPD residential programs identified a need for increased bed space due to the number of veterans requesting admission. These programs requested additional beds under a “Per Diem Only” (PDO) grant process and were awarded the ability to increase their overall program beds. Here’s where it gets tricky. Since the original grant and the PDO grant were awarded at different times they have separate “project numbers” While it is the same program with the same expenses, though increased in capacity and costs, they are required to divide out by percentage the number of beds under each project number in all reporting process. This is also required in requesting the per diem rates for the program. Not only is this a very time consuming process on the reporting side, it can be detrimental to the program in that not only does each project number end up with two different per diem rates for the same program, all expenses for the program on the bookkeeping side of the agency have to be calculated by percentage. VVA believes that if a single program has two different project numbers based solely on an approved expansion, that program should be treated as a whole and the two projects numbers should be merged. To do so would allow an agency to function in a more efficient manner, have access to an appropriate and true per diem structure, and reduce the paper work for even the VA HGPD offices. VVA request that this issue also have further discussion because any changes may also require legislation.

WOMEN VETERANS

Women comprise a growing segment of the Armed Forces, and thousands have been deployed to Iraq and Afghanistan. This has particularly serious implications for the VA healthcare system because the VA itself projects that by 2010, over 14 percent of all veterans utilizing its services will be women.

The nature of the combat in Iraq and Afghanistan is putting service members at an increased risk for PTSD. In these wars without fronts, “combat support troops” are just as likely to be affected by the same traumas as infantry personnel. They are clearly in the midst of the “combat setting”. No matter how you look at it, Iraq is a chaotic war in which an unprecedented number of women have been exposed to high levels of violence and stress. Nearly 200,000 female soldiers have been deployed to Iraq and Afghanistan…this compared to the 7,500 who served in Vietnam and the 41,000 who were dispatched to the Gulf War in the early ‘90s. The death and casualty rates reflect this increased exposure.

There have been few large-scale studies done on the particular psychiatric effects of combat on female soldiers in the United States, mostly because the sample size has been small. More than one-quarter of female veterans of Vietnam developed PTSD at some point in their lives, according to the National Vietnam Veterans Readjustment Survey conducted in the mid-‘80s, which included 432 women, most of whom were nurses. (The PTSD rate for women was 4 percent below that of the men.) Two years after deployment to the Gulf War, where combat exposure was relatively low, Army data showed that 16 percent of a sample of female soldiers studied met diagnostic criteria for PTSD, as opposed to 8 percent of their male counterparts. The data reflect a larger finding, supported by other research that women are more likely to be given diagnoses of PTSD, in some cases at twice the rate of men.

Matthew Friedman, Executive Director of the National Center for PTSD, a research-and-education program financed by the Department of Veterans Affairs, points out that some traumatic experiences have been shown to be more psychologically “toxic” than others. Rape, in particular, is thought to be the most likely to lead to PTSD in women (and in men, where it occurs). Participation in combat, though, he says, is not far behind.

Much of what we know about trauma comes primarily from research on two distinct populations – civilian women who have been raped and male combat veterans. But taking into account the large number of women serving in dangerous conditions in Iraq and reports suggesting that women in the military bear a higher risk than civilian women of having been sexually assaulted either before or during their service, it’s conceivable that this war may well generate an unfortunate new group to study – women who have experienced sexual assault and combat, many of them before they turn 25.

Returning female OIF and OEF troops also face other crises. For example, studies conducted at the Durham, North Carolina Comprehensive Women’s Health Center by VA researchers have demonstrated higher rates of suicidal tendencies among women veterans suffering depression with co-morbid PTSD. And according to a Pentagon study released in March 2006, more female soldiers report mental health concerns than their male comrades: 24 percent compared to 19 percent.

VA data showed that 25,960 of the 69,861 women separated from the military during fiscal years 2002-06 sought VA services. Of those seeking VA services 35.8 percent requested assistance for “mental disorders” (i.e., based on VA ICD-9 categories). Of these, 21 percent was for post traumatic stress disorder or PTSD, with older female vets showing higher PTSD rates. Also, as of early May 2007, 14.5 percent of female OEF/OIF veterans reported having endured military sexual trauma (MST). Although all VA medical centers are required to have MST clinicians, very few clinicians within the VA are prepared to treat co-occurring combat-induced PTSD and MST. These issues singly are ones that need address, but concomitantly create a unique set of circumstances that demonstrates another of the challenges facing the VA. The VA will need to directly identify its ability and capacity to address these issues along with providing oversight and accountability to the delivery of services with qualified therapists and clinicians in this regard. All of these issues, traumas, stress, and crises have a direct effect on the women veterans who find themselves homeless.

HOMELESS WOMEN VETERANS

While the overall number of homeless veterans is decreasing, and rather significantly over the past few years, the number of women veterans in this population is rising. When it was reported that there were 250,000 homeless veterans, 2% were considered to be female, roughly 5,000. Of the current estimate of 131,000, approximately 4-5% are women veterans, which can be as high as 6,550. Striking, however, is the fact that the VA also reports that of the new homeless veterans (OEF/OIF), they are seeing this is as high as 11% for woman veterans.

It is believed that this dramatic increase is directly related to the increased number of women now in the military (15% - 18%). About half of all homeless veterans have a mental illness and more than three out of four suffer from alcohol or other substance abuse problems. Nearly forty percent have both psychiatric and substance abuse disorders. Homeless veterans utilize the entire VA the same as any other eligible group of veterans. Therefore all delivery systems and services offered by the VA have an impact on homeless veterans, as do they on it.

The VA must be prepared to provide services to these former service members in appropriate settings. 

One of the confounding factors with homeless women veterans is the sexual trauma many of them suffered during their service to our nation. Few of us can know the dark places in which those who have suffered as the result of rape and physical abuse must live every day. It is a very long road to find the path that leads them to some semblance of “normalcy” and helps them escape from the secluded, lonely, fearful, angry corner in which they have been hiding.

Not all residential programs are designed to treat mental health problems of this very vulnerable population. In light of the high incidence of past sexual trauma, rape, and domestic violence, many of these women find it difficult, if not impossible, to share residential programs with their male counterparts. They openly discuss their concern for a safe treatment setting, especially where the treatment unit layout does not provide them with a physically segregated, secured area. They also discuss the need for gender-specific group sessions.

Reports also indicate that in mixed gender residential programs, women remain fearful, isolated, stifled, and unsafe. This rises from a number of fronts. Women have had very different experiences from male veterans not only in the military but after also. Some women live as victims of extremely violent pasts. They have been used, abused, and raped. They trust no one. They fear that any day it could happen again. They are suspicious and paranoid.

Some women have sold themselves for money, taking part in unimaginable activities in order to pay for food, a bed, or drugs. Some have reported being sold for sex at the age of three. They wake up everyday, remembering what they did, encased in total humiliation and guilt. They have given away very own children…this they also live with for the rest of their lives.
In order to survive on the streets or stay alive moving from house to house or bed to bed, they can become callused, aggressive, and develop attitude. This behavior can often be a means to remain safe, or to keep predators at bay. In light of the nature of some of their personal and trauma issues, and the humiliation and guilt they must endure, how can anyone expect these women veterans to open up to therapy and profit from mixed gendered group therapy. While some facilities have found innovative solutions to meet the unique needs of women veterans, others are still lagging behind.  VVA requests that all residential treatment areas be evaluated for the ability to provide and facilitate these services, and that medical centers develop plans to ensure this accommodation.

SPECIAL NEEDS GRANTS

The first funded programs utilizing this tremendous asset legislated by Congress came on line in late 2004…early 2005. The grants were developed to provide additional grant funding, in addition to VA per diem, for programs that were designed to attend to the needs of homeless veterans that were especially challenging. This special funding included six categories of homeless veterans: chronically mentally ill, the frail elderly, terminally ill, or women and women with children. While my comments will address specifically the grants for women veterans, in general, they can be reflective of the advantage that these funds provide to all the special needs population.

The need for women specific programs is easy to understand if we take it to the basics. First: there is a powerful need on the part of many of the women to avoid men due to the percentage of them who have suffered physical, emotional, and sexual abuse at the hands of men. Second: we believe that successful programs are those that provide an atmosphere where the veteran can remain focused on themselves and their recovery, be it from addiction or mental health problems. If a program is mixed gendered the veterans have a tendency to “focus” on or involve themselves with others that may be detrimental to their most successful program outcomes.

While I speak on behalf of VVA, I am employed by The Philadelphia Veterans Multi-Service & Education Center, a small nonprofit agency with a nearly thirty year history of working exclusively with veterans. I am its Program Director for Homeless Veteran Services and also serve as the Program Director for the Mary E. Walker House, its thirty bed transitional residence for homeless women veterans. This program was awarded one of the first Special Needs Grants. The Walker House opened its doors on January 3, 2005. It is the largest women veteran specific program funded under VA Grant and Per Diem in the country and accepts applications from anywhere in the country. To date we have had applications from 13 Veteran Integrated Service Networks (VISN) and admitted women from 10 VISNs.

To date 145 women veterans have chosen to live at the Walker House. While they are able to stay for up to two years, last fiscal year their average length of stay was 305 days.

Since there are so few women veteran specific long term residential programs from which to collect data for research, I suspect much of my comments will not be scientifically proven. But I venture to say that anyone who has work with a female veteran population will support what I have personally experienced.

The reality of the day to day operation of a program such as The Mary E. Walker House is complex far beyond imagination. It demands a rechargeable battery of patience and a readily available sense of humor in order to personally survive the challenges that await daily. The work can be exhaustive, in part due to the qualities and characteristics of this gender population, and in part due to the complexity and multiplicity of presenting problems, issues, histories, debt, legal and court issues, employability, and diagnoses of each woman.

As the Director of Homeless Services for the agency, I had years of experience with a ninety-five bed transitional residence for male veterans. Few women would enter because it was so highly populated with men. It was not imagined that an exclusively women veterans program would function or demand much more than we were used to providing in the men’s program. We had not factored into the equation the fact that with so few locations available for this gender specific population…women who fit no where else in the system, women who were considered “too sick” for general homeless programs, or those who could not survive in other available mixed gender programs. These factors may exaggerate our program findings, but if the women veterans of our program are a true cross-section of the complicated and complex situations faced by homeless women veterans as a specific cohort, then I say that without the assistance of the Special Needs Grants, we could never find enough resources to fulfill our mission in their regard.

Their needs are profound as you can see from some of our demographics.
Of those women admitted to the Mary E. Walker House:

Age: 4% under 25; 21% under 40; 51% under 50; 24% under 65.

Era of Service: VN Era – 10%; Peace Time – 54%; Persian Gulf – 26%; OEF/OIF – 2%; GWOT – 8%

Service Connected Disability: 36%

Drug and Alcohol Recovery: 89%

Sexual Trauma: Childhood – 37%; Pre/Post military – 42% MST – 63%; multiple categories – 48%; Combined MST and other sexual abuse – 80%

Domestic Violence: 46%

Mental Health: PTSD – 51%; Bipolar – 26%; Adjustment Disorder – 10%; Personality Disorder – 12%; Self Harm – 12%; Cognitive Disorder – 5%; Schizophrenia – 6%; Depressive Disorder – 50%; OCD – 5%; also includes Borderline personality disorder, Histrionic disorder, Narcissism, Suicidal Ideation, and Paranoia.

Medical Issues: these are wide and varied, include every system of the body to include stroke, cardiac, GYN, diabetes, orthopedics, pulmonary, and endocrine to name a few.

At times, the Mary E. Walker House could be viewed as a Seriously Mental Ill (SMI) program. Through the coordinated and team effort of reviewing the applications, if the woman veteran meets our eligibility criteria and if we feel we are able to bring assistance we will not deny admission, no matter how difficult or extraordinary the situation. Some of our women have actually qualified for the VA Mental Health Intensive Case management Program (MHICM) and were placed in MHICM upon discharge. This program and others like ours did not have the necessary and appropriate level of professional staff to address the needs of these women they would continue to flounder. The foresight of the Special Needs Grant Program to include the ability of the local VA Medical Center to request additional grant funding for itself has allowed for an expansive infusion of dedicated staff and treatment components. This element is vital and must not be lost in the future. These enhancements have elevated the special needs programs into a new dimension of partnership between the VA with HGPD awardees. The Special Needs Grants give recognition to the challenges faced by these defined groups of homeless veterans.

Per Diem alone could never meet the demand for staffing and program components to effectively and successfully reach into the complexity of their situations. Without the Special Needs Grants, programs such as ours, which fill an enormous gap in the system for women veterans and other special needs populations, would fail these veterans. They would ultimately be lost again, perhaps forever. VVA is in support of the renewal of these grants when they must be considered in 2011.

HOMELESS WOMEN VETERANS AND MILITARY SEXUAL TRAUMA (MST) RESIDENTIAL PROGRAMS

Military sexual trauma is not exclusive to women veterans while percentages are higher in the VA for women veterans the actual numbers are fairly even. Because we have such a high incidence of this trauma in the homeless women veteran population and in some instances it is the reason they are homeless I bring forward the follow discussion.

The VA has given increasingly more attention to the issue of MST. Professional staff have been trained, specialist in this arena of treatment have been hired. Counselors are located in the Vet Centers. But clearly the need is not decreasing. VVA believes more emphasis must be made on the qualification and certification of those providing this treatment and that more residential gender specific/MST specific programs should be initiated.

Military Sexual Trauma (MST) residential programs do exist within the VA. However, if the list of these programs is studied it can be noted that not all are specific to MST. Some are PTSD programs that have an element of MST. Others are not gender specific. And we believe there is only one male specific - MST specific residential program in the country at Bay Pines VA Medical Center in Florida. We have been given to understand that these programs report that they are meeting capacity needs because they can accommodate admissions without a waiting list. VVA believes this is an illusion and may be true because they do keep a rolling waiting list. Some women veterans are waiting months to make access to these programs after they have been referred and have made application. During this waiting period these veterans run the very real risk of relapse or crisis. Another detriment to applying to these few and far between programs is not only the application wait time but the distance a veteran must travel to receive this intensive residential treatment program. This travel can incur a significant cost to the veteran and if they happen to be within the homeless population it can be prohibitive. VVA would encourage the VA to establish a gender specific - MST specific residential program located within every VISN in the country and that there be allowances for the male veterans in an alternating gender specific program component. VVA feels this may well contribute to the elimination of homelessness among specific cohorts of homeless veterans. We also feel that it may play a proactive role in the prevention of homelessness.

VVA was very encourage by the President interest and commitment on the issue of zero tolerance for homeless veterans, while we will work in support of the President desire to end homeliness among all veterans, this will proved be a very challenging under taking for all those who are working in the arena. I thank you for providing me the opportunity to speak with you today. This concludes my testimony. I will be pleased to answer any questions you may have at this time.

VIETNAM VETERANS OF AMERICA PRIVATE
Funding Statement
June 3, 2009

The national organization Vietnam Veterans of America (VVA) is a non-profit veterans membership organization registered as a 501(c) (19) with the Internal Revenue Service. VVA is also appropriately registered with the Secretary of the Senate and the Clerk of the House of Representatives in compliance with the Lobbying Disclosure Act of 1995.

VVA is not currently in receipt of any federal grant or contract, other than the routine allocation of office space and associated resources in VA Regional Offices for outreach and direct services through its Veterans Benefits Program (Service Representatives). This is also true of the previous two fiscal years.

For Further Information, Contact:
Executive Director for Policy and Government Affairs
Vietnam Veterans of America.
(301) 585-4000, extension 127

 

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