Improving a Sanctioned Homeless Encampment for Veterans During COVID-19 Through Multilevel Partnerships
Abstract
A veteran-clinician-researcher partnership—the Care, Treatment, and Rehabilitation Service (CTRS)—enabled quality improvement within a U.S. Department of Veterans Affairs–sanctioned homeless encampment created in response to the COVID-19 pandemic. Although the differing concerns of clinicians and operational leaders led to challenges in defining CTRS’s goals and quality metrics, partnering with frontline social work and peer staff (N=11) and veterans (N=21 of 381 CTRS participants) and considering their feedback resolved those differences. Multilevel partnerships improved care within the encampment, leading to the development of an encampment medicine team (providing onsite integrated health care) and a veteran engagement committee (providing feedback).
HIGHLIGHTS
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The U.S. Department of Veterans Affairs developed a novel sanctioned encampment for veterans experiencing unsheltered homelessness during the COVID-19 pandemic.
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Multiple partnerships were leveraged to improve care for veterans in this setting.
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An encampment medicine team, which provided primary and mental health care at the encampment, and a veteran engagement committee were created via partnerships among internal and external stakeholders.
In April 2020, the COVID-19 pandemic prompted leadership at the U.S. Department of Veterans Affairs (VA) Greater Los Angeles Healthcare System (VAGLA)—a tertiary care facility in Los Angeles—to create a first-of-its-kind emergency safe camping environment for veterans experiencing homelessness (VEHs). This initiative—the Care, Treatment, and Rehabilitation Service (CTRS)—allowed veterans to shelter outdoors in a low-barrier sanctioned tent encampment on VA grounds. Many reasons existed for starting CTRS. First, for VEHs, this pandemic has posed profound health risks and curtailed access to services (1). Second, Los Angeles County has the largest unsheltered population in the nation, with approximately 63,700 Angelenos, including 3,700 veterans (2), living outdoors or in other places not meant for sleeping. Finally, when other shelter options closed in response to the pandemic, veterans increasingly congregated in tents adjacent to VAGLA, necessitating a quick response. In this context, CTRS provided a safe camping option, including onsite hygiene facilities (e.g., toilets, showers, handwashing stations, masks, and laundry) and three meals a day, for VEHs who chose not to live in existing VA transitional housing. Moreover, research suggested that the outdoor nature of encampments lessens the risk for COVID-19 transmission (3). Although the rationale for CTRS was clear, no paradigms for sanctioned encampments at other VA facilities existed. Emergency funds for COVID-19 initiatives were allocated to start CTRS, and staff were borrowed from other overstretched VA programs. Furthermore, the emergency initiative’s scope and goals—beyond providing temporary housing, food, and hygiene resources—were poorly defined.
Given CTRS’s novelty, its staff and leadership desired iterative quality improvement (QI). At program inception, low veteran enrollment and poor staff morale were identified as problems that would benefit from stakeholder-informed improvements. Yet, CTRS was seen as a model that had the potential to be used within and outside VA to respond to COVID-19 and future disease epidemics or to accommodate VEHs who prefer low-barrier settings. To enable QI, VA operational leaders tapped an existing partnership between VA and the University of California, Los Angeles (UCLA): the UCLA-VA Center of Excellence (CoE) for Training and Research in Veteran Resilience and Recovery, developed to engage in community-based participatory research and training that improves care for VEHs with mental illness. A CoE-CTRS partnership evolved, guided by an implementation framework that prioritizes an equitable relationship and shared knowledge exchange between academic research teams (e.g., the QI team) and the community (e.g., CTRS’s staff and VEHs) (4). In this column, we outline partnership processes (i.e., relationship building with partners and individual stakeholders) shaped by this framework, built to enable QI in CTRS, and funded and initiated by the CoE and VAGLA’s homeless program.
Context
CTRS began as an emergency initiative of VAGLA’s homeless program, which serves more VEHs than any other VA system in the United States and offers robust mental health, general medical, and social services in brick-and-mortar settings. In addition to providing a safe encampment that lowered COVID-19 transmission risk, CTRS addressed the long-standing needs of a subgroup of VEHs whose preferences and goals may not align with traditional VA emergency housing resources (5). Although the number of CTRS staff varied, at least two full-time social workers and two full-time veteran peer specialists were reassigned to CTRS from other homeless services in the initiative’s first year, enabling a program capacity of 100 VEHs per night. A preventive medicine physician was also reassigned to work full-time at CTRS for the first 7 months to provide high-level care management. CTRS first offered VEHs tents that could be pitched in VA parking lots, then moved VEHs to tents on raised platforms in a grass field with 24/7 security monitoring. VEHs had access to supportive services, COVID-19 surveillance, chaplain services, occupational therapy, and onsite urgent care from VA primary care providers (twice per month) (6). Mental health and other health care services were offered virtually (via tablets provided onsite) or in brick-and-mortar clinics on the colocated VA campus. Because many VEHs participating in CTRS historically had difficulty engaging with VA, services were aligned with VA’s definition of patient-centered care, which views a veteran’s goals as central to health care treatment. From April 1, 2020, through October 1, 2021, a total of 381 veterans took part in the CTRS initiative (see the online supplement to this column) (7).
Partnership Processes
CoE QI scientists partnered with CTRS leadership to develop a user-informed project to improve processes, partnerships, and relationships that affect VEHs’ use of VA services; document care experiences reported by VEHs; and enhance features of CTRS associated with positive care experiences. Although the results of the project are outside this column’s scope, the steps taken to achieve these aims involved brokering multiple interdisciplinary stakeholder partnerships (4) and engaging in shared decision making.
Relationship Building
QI efforts began with two doctoral-level medical anthropologists from the CoE introducing the project and its aims to CTRS’s staff and VEHs. From September 2020 to October 2021, anthropologists conducted ethnographic fieldwork during more than 55 visits to the encampment, spending approximately 3 hours per visit. They held semistructured interviews with VEHs (N=21) and participated in daily activities (e.g., engaged in informal conversations, helped with camp admissions, pitched tents, and attended recreational activities). Their contemporaneous field notes documented conditions and lived experiences. The QI team observed everyday routines from diverse perspectives and how VEHs and staff responded to each other, which helped the team understand the experiences and preferences of VEHs and staff and facilitated comparisons among these groups.
To learn how to improve staff morale and retention, the anthropologists conducted semistructured interviews with current and former staff (N=11). These interviews revealed that frontline CTRS social workers and peer specialists wanted to engage in QI and systems-level decision-making processes (beyond their traditional roles). As a result, the CTRS social work supervisor became a critical partner to the QI team, enabling increased buy-in for QI.
Multilevel Partner Communication
The anthropologists reviewed their field notes together each week to ensure that they consistently documented successes, challenges, and other updates during rapid-cycle improvement processes. They worked with CoE QI scientists to lead six onsite town halls with VEHs during CTRS’s first year. During these town halls, the anthropologists shared observations, engaged VEHs in interpreting ethnographic data, and solicited input on ways to improve CTRS (4). VEHs received gift cards as compensation for their time. Eventually, a veteran engagement committee was formed that is managed by veteran peer specialists with lived experience of homelessness; the committee meets weekly to provide feedback to CTRS staff and management. Numerous QI interventions (e.g., a veteran-led art group, improvements to food service and quality, recreational activities) have ensued.
One month after the first field visit, the CoE initiated videoconference QI meetings attended by interdisciplinary CoE scientists (physicians, psychologists, social workers, anthropologists, other social scientists, data analysts), the CTRS social work supervisor, and CTRS’s lead veteran peer specialist, as well as VA primary care, mental health, and homeless program leadership. The QI team used this weekly venue to share syntheses of ethnographic findings, engage key partners in interactive discussions, and discuss CTRS’s rapidly evolving dynamics. These meetings enabled the QI team to rapidly relay feedback to key partners, such as VAGLA leadership, and field queries and requests regarding VA administrative data—for example, to validate or enhance findings regarding VA service utilization (e.g., rates of visits attended vs. no-shows), diagnosed mental health conditions of VEHs at the encampment, COVID-19 testing frequency, and more. Meetings provided a forum in which problems of interest to VEHs that were often overlooked by staff and administration could be shared (e.g., misalignment between dietary preferences and food served or lighting that disturbed VEHs when they tried to sleep). These meetings also led to important onsite safety initiatives, such as COVID-19 vaccination clinics.
Use of Partnerships to Enable QI
To enable high-quality, stakeholder-engaged QI, the QI team fostered partnerships at multiple levels. As the anthropologists cultivated relationships with frontline CTRS social workers and peer specialists, they invited to weekly QI meetings all staff, who in turn became active participants in QI (beyond their typical scope). Facility leadership from VAGLA’s homeless program and mental health service grew interested in QI efforts. When the QI team undertook relevant rapid-cycle improvements to onsite mental health services, behavioral health leadership became important partners in developing, testing, and improving innovations. Each month, at a QI meeting attended by homeless program leadership, QI team members presented salient findings from field visits and partner communication efforts and identified areas needing improvement. Homeless program leadership, frontline CTRS staff, and VEHs at the encampment consistently expressed gratitude for their partnership with a QI team that spanned this VA system and its academic affiliate. These partnerships were critical for enacting change at CTRS and facilitated staff buy-in and participation.
Process Improvement Resulting From Partnership
From the outset, perspectives differed regarding CTRS’s goals, such as whether the initiative should seek to provide transitional housing, a low-barrier clinical program, or a temporary emergency shelter. Many homeless program partners viewed CTRS as a way to provide an emergency shelter that connected VEHs with alternative forms of housing. Because the CTRS encampment described in this column is located on a VA campus, the initiative’s social workers encouraged VEHs to visit on-campus brick-and-mortar clinics for health care or attend virtual appointments in their tents via tablets the program provided. For the first 7 months, in addition to onsite urgent care (twice per month), an onsite preventive medicine physician was available weekly to meet with VEHs, provide referrals to care, and provide COVID-19 prevention services (e.g., hygiene education and COVID-19 testing). VA and CoE scientists agreed that having a sanctioned encampment of the most vulnerable veterans on VA grounds meant that the VA was responsible for providing more opportunities to access onsite health care and supportive services.
The CoE anthropologists’ semistructured interviews and field notes showed that CTRS staff and VEHs discussed the challenges of accessing primary and mental health care through face-to-face appointments (e.g., difficulty tolerating waiting rooms, preference not to be treated in walled settings, distrust of health care professionals) and virtual visits (e.g., digital illiteracy). VEHs expressed their desire for more convenient services. For example, one veteran with disabilities said of his difficulties accessing care, “[CTRS is] making us fend for ourselves [by sending us to the hospital] . . . I’m medically disabled. I can’t go walk to work.” VEHs also regularly worried about psychiatric symptoms exhibited by some of the VEHs in the encampment and wished for better mental health care. Another veteran discussed how streamlined services offered at the encampment would facilitate better housing outcomes: “If you streamline [services] . . . it would definitely make living here a little bit easier, and maybe, if you’re more comfortable and you don’t have to worry . . . you can move on with your life . . . like getting an apartment.”
These data, which highlighted the need and desire for primary and mental health care delivery within the encampment, were presented to multilevel stakeholder partners, including VEHs. The QI team leveraged its partnership with the University of Southern California Keck School of Medicine Street Medicine team (another academic affiliate) to deliver training sessions to CTRS staff on street medicine practices. Plans for an encampment medicine team—whose members would use methods adapted from street medicine—emerged from these findings and were supported by CTRS staff and VEHs, CoE stakeholders, VAGLA clinicians, and national VA homeless program leadership.
To plan for the encampment medicine team, VA stakeholders from primary care and the Mental Health Intensive Case Management program—the VA’s assertive community treatment team that provides intensive field-based services and case management for veterans with serious mental illness (i.e., veterans with a psychotic illness or bipolar disorder who meet criteria for VA’s National Psychosis Registry)—were invited to the QI meetings. Together, they iteratively developed an encampment medicine approach, launched in October 2021, that addressed the high rates of substance use disorder, serious mental illness, medical complexity, and social vulnerability among VEHs at the camp. One of the challenges of the partnership was the conflicting visions for CTRS. Social work staff envisioned CTRS as a program to provide temporary shelter for VEHs, whereas medical providers viewed CTRS as a program to provide a place for veterans to access care (7). QI meetings fostered discussions and compromises that were informed by VEHs’ input. Productive outcomes included the medical team both assisting social workers with patients with behavioral issues and encouraging patients to work with social workers on their housing plans. These collaborations allowed space for both visions, enabled by open communication across groups.
Conclusions
Multilevel partnerships were essential to improving care for VEHs in a sanctioned homeless encampment. An academic team engaged with frontline staff and VEHs to foster relationships, develop structured communication pathways, and design stakeholder-informed solutions to problems (e.g., encampment medicine and a veteran engagement committee). In part due to veterans’ positive reception of CTRS, the initiative recently transitioned from an emergency program to a program funded under VA’s permanent supportive housing umbrella. Tiny shelters (8×8-foot lockable cabins with electricity, heat, and air conditioning) have replaced the tents. When programs are built rapidly, such as during pandemic or other emergency conditions, multilevel partnerships are particularly valuable in driving stakeholder-informed improvements. We urge other systems engaged in rapid innovation for vulnerable populations to develop QI work groups that partner with patients, providers, and administrators to improve care, although we recognize that our enriched setting allowed us to engage in partnerships more nimbly than is sometimes possible in other contexts. Regardless, providers and patients in new programs are often eager to share their perspectives; in settings with fewer resources, concerted efforts to develop QI partnerships that reflect the voices of these stakeholders may be made, although involving some researchers (e.g., anthropologists) may be infeasible. In academic VA settings, embedded QI scientists are well positioned to partner with vulnerable patients to enable practical, iterative improvement of health and social services.
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References
1.
Wood LJ, Davies AP, Khan Z: COVID-19 precautions: easier said than done when patients are homeless [letter]. Med J Aust 2020; 212:384–384.e1
2.
Henry M, de Sousa T, Roddey C, et al: The 2020 Annual Homeless Assessment Report (AHAR) to Congress: Part 1: Point-in-Time Estimates of Homelessness. Washington, DC, Department of Housing and Urban Development, 2021
3.
Weed M, Foad A: Rapid scoping review of evidence of outdoor transmission of COVID-19 [preprint]. MedRxiv 2020. DOI:
4.
Carman KL, Dardess P, Maurer M, et al: Patient and family engagement: a framework for understanding the elements and developing interventions and policies. Health Aff 2013; 32:223–231
5.
Gruenewald DA, Doan D, Poppe A, et al: “Meet me where I am”: removing barriers to end-of-life care for homeless veterans and veterans without stable housing. Am J Hosp Palliat Care 2018; 35:1483–1489
6.
Owens T, Ewing D, Devera M, et al: Housing for health in the Veterans Affairs Greater Los Angeles tent community. Ann Fam Med 2022; 20:281
7.
Kalofonos I, McCoy M, Altman L, et al: A sanctioned encampment as a strategy for increasing homeless veterans’ access to housing and healthcare during the COVID-19 pandemic. J Gen Intern Med (Epub June 20, 2023). doi
Information & Authors
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Published In
History
Received: 25 July 2022
Revision received: 7 March 2023
Accepted: 9 June 2023
Published online: 26 July 2023
Published in print: January 01, 2024
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Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
Funding was provided by a pilot grant from the UCLA-VA Center of Excellence for Training and Research in Veteran Resilience and Recovery (to Drs. Altman and Gabrielian) and by a fiscal year 2022 intramural award from the National Center on Homelessness Among Veterans (to Dr. McCoy).These views represent the opinions of the authors and not necessarily those of the VA Greater Los Angeles Healthcare System, the UCLA-VA Center of Excellence for Training and Research in Veteran Resilience and Recovery, or UCLA.
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