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
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.
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 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
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
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
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
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
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