Housing First and the Risk of Failure: A Comment on Westermeyer and Lee (2013).

Over the last 5 years, community policies in response to homelessness have shifted toward offering permanent housing accompanied by treatment supports, without requiring treatment success as a precondition. The US Department of Veterans Affairs (VA) has embraced this "Housing First" approach. A 2013 report sounds a contrarian note. In a 16-person quasi-experimental study, 8 veterans who entered VA's permanent supportive housing did poorly, whereas 8 veterans who remained in more traditional treatment did well. In this commentary, we suggest that the report was problematic in the conceptualization of the matters it sought to address and in its science. Nonetheless, it highlights challenges that must not be ignored. From this report and other research, we now know that even more attention is required to support clinical recovery for Housing First clients. Successful implementation of Housing First requires guidance from agency leaders, and their support for clinical staff when individual clients fare poorly.

Making housing first happen: organizational leadership in VA's expansion of permanent supportive housing.

BACKGROUND: While most organizational literature has focused on initiatives that transpire inside the hospital walls, the redesign of American health care increasingly asks that health care institutions address matters outside their walls, targeting the health of populations. The US Department of Veterans Affairs (VA)'s national effort to end Veteran homelessness represents an externally focused organizational endeavor. OBJECTIVE: Our aim was to evaluate the role of organizational practices in the implementation of Housing First (HF), an evidence-based homeless intervention for chronically homeless individuals. DESIGN: This was an interview-based comparative case study conducted across eight VA Medical Centers (VAMCs). PARTICIPANTS: Front line staff, mid-level managers, and senior leaders at VA Medical Centers were interviewed between February and December 2012. APPROACH: Using a structured narrative and numeric scoring, we assessed the correlation between successful HF implementation and organizational practices devised according to the organizational transformation model (OTM). KEY RESULTS: Scoring results suggested a strong association between HF implementation and OTM practice. Strong impetus to house Veterans came from national leadership, reinforced by Medical Center directors closely tracking results. More effective Medical Center leaders differentiated themselves by joining front-line staff in the work (at public events and in process improvement exercises), by elevating homeless-knowledgeable persons into senior leadership, and by exerting themselves to resolve logistic challenges. Vertical alignment and horizontal integration advanced at sites that fostered work groups cutting across service lines and hierarchical levels. By contrast, weak alignment from top to bottom typically also hindered cooperation across departments. Staff commitment to ending homelessness was high, though sustainability planning was limited in this baseline year of observation. CONCLUSION: Key organizational practices correlated with more successful implementation of HF for homeless Veterans. Medical Center directors substantively influenced the success of this endeavor through their actions to foster impetus, demonstrate commitment and support alignment and integration.

VA's expansion of supportive housing: successes and challenges on the path toward Housing First.

OBJECTIVES: The U.S. Department of Veterans Affairs (VA) is transitioning to a Housing First approach to placement of veterans in permanent supportive housing through the use of rental vouchers, an ambitious organizational transformation. This qualitative study examined the experiences of eight VA facilities undertaking this endeavor in 2012. METHODS: A multidisciplinary team interviewed facility leadership, midlevel managers, and frontline staff (N=95 individuals) at eight VA facilities representing four U.S. regions. The team used a semistructured interview protocol and the constant comparative method to explore how individuals throughout the organizations experienced and responded to the challenges of transitioning to a Housing First approach. RESULTS: Frontline staff faced challenges in rapidly housing homeless veterans because of difficult rental markets, the need to coordinate with local public housing authorities, and a lack of available funds for move-in costs. Staff sought to balance their time spent on housing activities with intensive case management of highly vulnerable veterans. Finding low-demand sheltering options (that is, no expectations regarding sobriety or treatment participation, as in the Housing First model) for veterans waiting for housing presented a significant challenge to implementation of Housing First. Facility leadership supported Housing First implementation through resource allocation, performance monitoring, and reliance on midlevel managers to understand and meet the challenges of implementation. CONCLUSIONS: The findings highlight the considerable practical challenges and innovative solutions arising from a large-scale effort to implement Housing First, with particular attention to the experiences of individuals at all levels within an organization.

Sexual orientation disclosure to health care providers among urban and non-urban southern lesbians.

Concerns regarding sexual orientation disclosure to health care providers have been suggested as a barrier to care which may account for documented differences in the health care utilization of lesbians relative to heterosexual women. This study explored the correlates of sexual orientation disclosure to health care providers among 934 lesbian women living in urban and non-urban areas of the South. Psychosocial resources, such as self-esteem, social support, and mastery, along with several lesbian-specific experiences (proportion of lesbian, gay, bisexual, or transgender friends, access to the lesbian, gay, bisexual, or transgender community, degree of being "out"), were all independently associated with greater likelihood of having disclosed to a health care provider. Internalized homophobia and lesbian-related stigma decreased the likelihood of disclosure. Lesbians living in non-urban areas were significantly less likely to have disclosed than women in urban areas, suggesting that disclosure may present a special concern for populations in non-urban areas.

Sexual orientation, partnership formation, and substance use in the transition to adulthood.

Evidence suggests that lesbian and gay young adults use substances more frequently than their heterosexual peers. Based on the life course perspective, we argue that this difference may be due to the unavailability of marriage as a turning point in the lives of lesbian/gay young adults. We use data from a nationally representative sample of youth (N = 13,581, 52.4% female, 68.6% white, ages 18-26) to examine sexual orientation differences in substance use and explore whether these differences vary by romantic partnership formation in young adulthood. We find that the formation of more serious partnerships (e.g., cohabitation, marriage) is associated with less frequent substance use among heterosexual young adults, though this pattern does not hold for lesbian and gay young adults. We conclude that the partnership options available to lesbians and gay men do not provide the same health-protective benefits that marriage does for heterosexuals.

Health behaviors and health care utilization of southern lesbians.

PURPOSE: Lesbian women are more likely to experience negative physical and mental health outcomes compared with heterosexual women, although most research on this population has relied on small convenience samples. This study compared health behaviors and health care utilization among lesbian women living in the South to representative subsamples of women from the general population. METHODS: We conducted a Web-based survey of 1,141 self-identified lesbian women aged 19 and older living in the South. We compared descriptive results from our study to the U.S. Centers for Disease Control and Prevention's Behavioral Risk Factor Surveillance System. We also calculated adjusted logistic regression models to further explore correlates of Southern lesbian women's physical and mental health. MAIN FINDINGS: Southern lesbians were less likely to be in poor physical health, but more likely to experience recent depression than women in the general population. Lesbians reported more risky health behaviors relative to other Southern and non-Southern women. Southern lesbians and other Southern women experienced similar barriers to routine health care, including lack of health insurance, not having a regular provider, and having to forgo care owing to cost. Many of these health behaviors and barriers to care were associated with poor physical and mental health among Southern lesbians. CONCLUSION: Southern lesbians' patterns of health behaviors and utilization of care may place them at increased risk for negative health outcomes relative to the general population.

Age differences in the correlates of problematic alcohol use among southern lesbians.

OBJECTIVE: Research has demonstrated a high frequency and intensity of alcohol use among lesbian women. This work explores age differences in risk factors for problematic alcohol use among self-identified Southern lesbians. Risk factors of interest include depression, general stress, and three measures of sexual minority stress (i.e., experiences of discrimination, lesbian/gay-related stigma, and internalized homophobia). METHOD: We analyze data from the Lesbian Social Life study, which recruited 1,141 self-identified Southern lesbians for participation in an anonymous Web-based survey. We present results from a series of regression models predicting scores on the CAGE scale, a self-reported measure of problematic alcohol use. Results are reported separately by age group (19-29, 30-49, >or=50). RESULTS: Frequent and intense alcohol use was most common among lesbian women ages 19-29. Depression and stress were the most consistent psychosocial correlates of problematic alcohol use, although these patterns varied by age. Each of the minority stress measures was associated with problematic alcohol use, although no clear age-related pattern appeared. CONCLUSIONS: Our findings suggest that depression and stress are strong predictors of problematic alcohol use among lesbians, which is comparable to previous findings in heterosexual populations. Additional research is needed to understand how the association between sexual minority stress and problematic alcohol use changes across the life course.

Ethnic differences in the correlates of mental distress among homeless women.

BACKGROUND: Homeless women experience high rates of mental distress. We sought to determine whether ethnic differences exist in the relationship between the predisposing and enabling domains of the Gelberg-Andersen Behavioral Model for Vulnerable Populations and mental distress. METHODS: We selected 821 homeless women in the Los Angeles area using a representative probability sampling design and invited them to participate in face-to-face interviews. The sample was 67% African American, 17% Hispanic, and 16% White. RESULTS: We identified a number of ethnic differences in the correlates of mental distress. Being partnered or married was associated with greater distress among African American and White women, and experiencing competing needs was predictive of distress for African Americans and Hispanics. CONCLUSION: A variety of factors contribute to mental distress among different ethnic groups of homeless women; these differences should be considered in the development of culturally appropriate services designed to address mental health problems among homeless populations.

Correlates of HIV-related stigma among HIV-positive mothers and their uninfected adolescent children.

The purpose of this study was to examine the degree and impact of HIV-related stigma among HIV positive mothers and their uninfected children. One hundred eighteen HIV-infected mothers and their uninfected early- and middle-adolescent children (mean age=13 years) participated in a study of maternal mental and physical health and child school performance and psychological distress. Mothers and a subset of children (to whom the mother's HIV status had previously been disclosed) were administered a series of questions to measure stigma related to the mother's HIV status. Mothers reporting high levels of HIV-related stigma scored significantly lower on measures of physical, psychological, and social functioning. Mothers' levels of depression were also significantly higher when their levels of stigma were higher. No significant differences were found in children's depression by perceived level of stigma; however, adolescents who perceived high levels of stigma because of their mothers' HIV status were more likely to participate in delinquent behavior, compared with those reporting low HIV-related stigma. The experience of stigma had consequences for many aspects of well-being among the HIV-infected mothers. While their children were aware of and perceived stigma, they appeared to be affected primarily in the realm of delinquent behavior.