Category Archives: GAO

Surge Seen in Number of Homeless Veterans

Surge Seen in Number of Homeless Veterans

 Oldtimer’s Comment:  I’ve seen a number of these types of articles.   Although the estimates vary depending on the subject area from 400 to about 1500, the word on the street is that the returning soldiers from Iraq and Afghanistan are showing up in shelters much faster than in previous wars.  The problem stems from higher rates of PTSD and TBI (traumatic brain injury) which still take too long to diagnose, and which are resulting from the combined effect of IED’s and higher survival rates.    The VA has long under diagnosed these problems and only recently, after much heat, begun to actively pursue it. 

Photo by Jeff Swensen for The New York Times
Frederick Johnson, a veteran of the Iraq war, lives in temporary housing provided by the V.A. after spending a year on the streets.

By ERIK ECKHOLM

WASHINGTON, Nov. 7 – More than 400 veterans of the Iraq and Afghanistan wars have turned up homeless, and the Veterans Affairs Department and aid groups say they are bracing for a new surge in homeless veterans in the years ahead.

 

Photo by Brendan Smialowski for The New York Times
Joe Williams lives in a homeless shelter in Washington.

Experts who work with veterans say it often takes several years after leaving military service for veterans’ accumulating problems to push them into the streets. But some aid workers say the Iraq and Afghanistan veterans appear to be turning up sooner than the Vietnam veterans did.

“We’re beginning to see, across the country, the first trickle of this generation of warriors in homeless shelters,” said Phil Landis, chairman of Veterans Village of San Diego, a residence and counseling center. “But we anticipate that it’s going to be a tsunami.”

With more women serving in combat zones, the current wars are already resulting in a higher share of homeless women as well. They have an added risk factor: roughly 40 percent of the hundreds of homeless female veterans of recent wars have said they were sexually assaulted by American soldiers while in the military, officials said.

“Sexual abuse is a risk factor for homelessness,” Pete Dougherty, the V.A.’s director of homeless programs, said.

Special traits of the current wars may contribute to homelessness, including high rates of post-traumatic stress disorder, or PTSD, and traumatic brain injury, which can cause unstable behavior and substance abuse, and the long and repeated tours of duty, which can make the reintegration into families and work all the harder.

Frederick Johnson, 37, an Army reservist, slept in abandoned houses shortly after returning to Chester, Pa., from a year in Iraq, where he experienced daily mortar attacks and saw mangled bodies of soldiers and children. He started using crack cocaine and drinking, burning through $6,000 in savings.

“I cut myself off from my family and went from being a pleasant guy to wanting to rip your head off if you looked at me wrong,” Mr. Johnson said.

(…)  Read more about Fredrick at the link above

Poverty and high housing costs also contribute. The National Alliance to End Homelessness in Washington will release a report on Thursday saying that among one million veterans who served after the Sept. 11 attacks, 72,000 are paying more than half their incomes for rent, leaving them highly vulnerable.

Mr. Dougherty of the V.A. said outreach officers, who visit shelters, soup kitchens and parks, had located about 1,500 returnees from Iraq or Afghanistan who seemed at high risk, though many had jobs. More than 400 have entered agency-supported residential programs around the country. No one knows how many others have not made contact with aid agencies.

More than 11 percent of the newly homeless veterans are women, Mr. Dougherty said, compared with 4 percent enrolled in such programs over all.

Veterans have long accounted for a high share of the nation’s homeless. Although they make up 11 percent of the adult population, they make up 26 percent of the homeless on any given day, the National Alliance report calculated.

Oldtimer’s comment:   My studies show that homeless male veterans make up 43% of the homeless male population, far in excess of what would be expected.

According to the V.A., some 196,000 veterans of all ages were homeless on any given night in 2006. That represents a decline from about 250,000 a decade back, Mr. Dougherty said, as housing and medical programs grew and older veterans died.

Oldtimer’s comment:  Oops!  That is a deliberately misleading statement.   A GAO report states that the drop from 250,000 a decade ago was due to a major change in how homeless veterans are counted.   While it is true that our older veterans are dieing off, many more veterans are joining the ranks of the homeless and make up for it.  There has been no real decline, and actually there has been a steady increase in the percentage of homeless veterans vs the overall population of veterans.

The most troubling face of homelessness has been the chronic cases, those who live in the streets or shelters for more than year. Some 44,000 to 64,000 veterans fit that category, according to the National Alliance study.

On Wednesday, the Bush administration announced what it described as “remarkable progress” for the chronic homeless. Alphonso R. Jackson, the secretary of housing and urban development, said a new policy of bringing the long-term homeless directly into housing, backed by supporting services, had put more than 20,000, or about 12 percent, into permanent or transitional homes.

Oldtimer’s comment:  I’m not sure where these numbers come from.  It appears the HUD secretary is talking about all chronic homeless, not just veterans.   20,000 is 12% of 166,000, which is about right for the chronic homeless for the entire homeless population. To get a feel for progress among veterans, see the following two paragraphs.

Veterans have been among the beneficiaries, but Mary Cunningham, director of the research institute of the National Alliance and chief author of their report, said the share of supported housing marked for veterans was low.

A collaborative program of the Department of Housing and Urban Development and the V.A. has developed 1,780 such units. The National Alliance said the number needed to grow by 25,000.

Mr. Dougherty described the large and growing efforts the V.A. was making to prevent homelessness including offering two years of free medical care and identifying psychological and substance abuse problems early.

Oldtimer’s Comment:  ‘Bout Time!

(…)

How many homeless youth are there?

How many Kids are Homeless?

There is a  Congressional Research Service (CRS) Report to Congress with information on this subject titled Runaway and Homeless Youth: Demographics, Programs, and Emerging Issues which was published in January 2007.  This link is to their 37 page report. 

I think they are being honest when they say this:

The precise number of homeless and runaway youth is unknown due to their residential mobility and overlap among the populations. Determining the number of these youth is further complicated by the lack of a standardized methodology for counting the population and inconsistent definitions of what it means to be homeless or a runaway.

Estimates of the homeless youth population range from 52,000 to over one million.  Estimates of runaway youth – including “thrownaway” youth – are between 1 million and 1.7 million.

Part of the problem of counting homeless youth is that they often avoid shelters and more or less hide in inaccessable areas where they avoid counters.  Some hide out with friends, others take to the woods and alleys, even the rails.  You may have seen an earlier post of mine (Homeless Youth Project) where loose groups of homeless youth ride the rails around the country.  Youth that do come into contact with census counters are reluctant to admit that they are homeless.    

The 52,000 to over 1 million estimates are based on a series of counting attempts through the decades.    A 1987 GAO report estimated 52,000 to 170,000 homeless on any one night.  CDC’s 1992 National Health Interview Survey of youth ages 12 to 17 determined that 5% of those they surveyed had been homeless during some part of the prior year.  That estimate came to more than a million youth that experienced homelessness during that year.

The latest federal survey was conducted by NISMART – (National Incidence Studies of Missing, Abducted, Runaway and Throwaway Children) which was conducted in 1999.  That study found that 1.8 million youth under age 18 left home or were asked to leave home in 1999 (at some time during the year). 

The NISMART-2 study for 1999 shows that:

1.8 million youth under age 18 experienced homelessness

68% were between the ages of 15 and 17 (1,224,000)

32% were 14 or younger (612,000) 

20% reported sexual abuse in the home (360,000)

33% reported family conflict in the home (600,000)

there were about an equal number of males and females

57% were White, 17% Black, 15% Hispanic

about 11,000 were runaway foster children

more than half left home for more than 1 to 6 days

30% traveled 1 to 10 miles from home

30% traveled 11 to 50 miles from home

nearly 99% were returned to their homes

That leaves more than 18,000 that never came back that year.

Another study, reported by Jan Moore,  Unaccompanied and Homeless Youth Review of Literature (1995-2005)  ,  reported 1 million to 1.3 million homeless youth.   I reported on this study earlier, see How many of the Homeless are Youth? 

Also see a forum report I presented in 2006 on the Cobb Faith Partnership site titled:  Homelessness Among Children and Youth – Basic Facts in which 1.35 million homeless children are reported homeless in a given year, according to the National Law Center.    The numbers seem to be centering around 1.3 million with a spread of 300,000 either way.   I feel that the numbers probably fluctuate wildly on any given day in any given year, much like trying to get the average level of a raging river.

Factors Influencing Homelessness and Leaving Home:  Youth most often cite family conflict as the major reason for their homelessness or episodes of running away. A literature review of homeless youth found that a youth’s relationship with a step-parent, sexual activity, sexual orientation, pregnancy, school problems, and alcohol and drug use were strong predictors of family discord.  14% of Foster kids that age out of the system experience homelessness the first year and 25% at sometime overall.   Another report shows 20%.

Of those callers who used the National Runaway Switchboard (a federally-sponsored call center for youth and their relatives involved in runaway incidents) one third attributed family conflict as the reason for their call.  Runaway and homeless youth also describe abuse and neglect as common experiences.  Over 20% of youth in the NISMART-2 reported being physically or sexually abused at home in the prior year
or feared abuse upon returning home.

Congress has funded 102 million dollars for three federal funded programs:

Basic Center Program: To provide outreach, crisis intervention, temporary shelter, counseling, family unification, and after care services to runaway and homeless youth under age 18 and their families.

Transitional Living Program: To support projects that provide homeless youth ages 16 to 21 with stable, safe longer-term residential services up to 18 months (or longer if the youth has not reached age 18), including counseling in basic life skills, interpersonal skills building, educational advancement, job attainment skills, and physical and mental health care. 

Street Outreach Program: To provide street-based outreach and education, including treatment, counseling, provision of information, and referrals for runaway, homeless, and street youth who have been subjected to or are at risk of being subjected to sexual abuse and exploitation.

Those are the facts on homeless youth, the best that I can report at this time.   You can select whatever set of data suits your purpose, but it appears the most current data comes in somewhere between 1 and 1.8 million kids that experience homelessness in any given year, centering around 1.3 million youth.  

There is no good estimate as to how many that amounts to on any given night, but if you are one of those kids, it is way too many. 

Those are our kids out there

Some Special Links:

Click to see all Oldtimer Speaks Out homeless youth articles (35 so far).

Click here if you came here to find Oldtimer’s articles on Homeless Veterans (75 so far)

Grace and Peace,

Oldtimer

GAO Testimony – DOD and VA

Transition Field Unit staffingGAO Testimony – DOD and VA

This is a troubling situation.  We have our kids off at war and they become severely injured, physically and mentally.   Our country has pulled out all stops to provide the best possible care for them and still we have problems.  Due to the protective gear and terrific and speedy medical care, thankfully more and more are surviving.  This shift in the severity and long term recovery needs requires major adjustments in our programs for treatment and rehabitation, for our benefits and compensation programs.  The cause and effect has driven the case loads and delays out of sight at the expense of our wounded heroes.

The good news is that that there is a scramble going on to correct these problems as soon as possible. There are people in high places capable of fixing the problem that have a heart for our heroes and are working very hard to fix the problems.  There are people in our VA and in militray trauma centers that are just as frustrated as we are.  There is a continuum of care mentality for our soldiers starting at the battlefield and continuing through our VA system. There are programs under development to reduce the time required to make determinations before our heroes get the treatment and benefits they need.

The bad news is there are still more than 150,000 cases more than 6 months old among the pending 600,000 cases in the VBA system, and we have no idea how old these cases really are.  The GAO found that new programs designed to correct the problems are not yet fully off the ground and there are severe staffing problems in key places, both on the active duty side and the veteran side of the picture. It appears to me that some of it is due to needing to move physicians from one program to staff another, leaving both under staffed. 

(Download Here)

What the GAO found

Warrior Transition Unit

Challenges have emerged for staffing the Warrior Transition Unit in which servicemembers are assigned to three key staff – a physician care manager, a nurse care manager, and a squad leader. For example, as of mid-September 2007, over half the U.S. Warrior Transition Units had significant shortfalls in one or more of these critical positions. In addition the number of recovery coordinators and how many servicemembers each would serve have yet to be determined.

Transition Field Unit staffing

This table shows that in actuality we have only 35% perminent staffing for these teams.  More than 450 of the existing staff (19%) have been borrowed from elsewhere, likely reducing the staff, already short, in othere facilities.   The table below shows where those with less than 50% staffing are located. 

 Staffing problem locations

PTSD and TBI 

Three independent review groups examining the deficiencies found at Walter Reed identified a range of complex problems associated with DOD and VA’s screening, diagnosis, and treatment of TBI (Traumatic Brain Injury) and PTSD, signature injuries of recent conflicts. Both conditions are sometimes referred to as “invisible injuries” because outwardly the individual’s appearance is just as it was before the injury or onset of symptoms. In terms of mild TBI, there may be no observable head injury and symptoms may overlap with those associated with PTSD. With respect to PTSD, there is no objective diagnostic test and its symptoms can sometimes be associated with other psychological conditions (e.g., depression).

TBI and PTSD chart
 
This table outlines what is being implimented (or planned) for handling TBI and PTSD better.   However, according to Army officials and the Independent Review Group report, obtaining qualified health professionals, such as clinical psychologists, is a challenge, which is due to competition with private sector salaries and difficulty recruiting for certain geographical locations. 

Data Sharing

In addition, the Dole-Shalala Commission noted that while VA is considered a leader in PTSD research and treatment, knowledge generated through research and clinical experience is not systematically disseminated to all DOD and VA providers of care.

Data Sharing

This table shows the efforts being taken to improve the data sharing between organizations. 

Disability Evaluations

As GAO and others have previously reported, providing timely and consistent disability decisions is a challenge for both DOD and VA. To address identified concerns, the Army has taken steps to streamline its disability evaluation process and reduce bottlenecks.   To address identified concerns, the Army has taken steps to streamline its disability evaluation process and reduce bottlenecks. The Army has also developed and conducted the first certification training for evaluation board liaisons who help servicemembers navigate the system. To address more systemic concerns, the Senior Oversight Committee is planning to pilot a joint disability evaluation system. Pilot options may incorporate variations of three key elements:

(1) a single, comprehensive medical examination;

(2) a single disability rating done by VA; and

(3) a DOD-level evaluation board for adjudicating servicemembers’ fitness for duty.

DOD and VA officials hoped to begin the pilot in August 2007, but postponed implementation in order to further review options and address open questions, including those related to proposed legislation.

Fixing these long-standing and complex problems as expeditiously as possible is critical to ensuring high-quality care for returning servicemembers, and success will ultimately depend on sustained attention, systematic oversight by DOD and VA, and sufficient resources.

You are invited to download and read the entire report here:  GAO Report (pdf – 32 pages)

Oldtimer

REFORM NEEDED: Brain-injured vets getting lost in the VA

REFORM NEEDED:

Brain-injured vets getting lost in the VA

I found this in the Opinion Section of the Atlanta Journal Constitution.  It dovetails with an article I was already writing and  nicelly illustrates the enormous problem of finding enough doctors and specialists to adequately care for our heroes that need treatment NOW.  I’ve decided to post it now and follow up with just released GAO testimony relating to the problem which will appear in my next post.  “Stay tuned.”  

Oldtimer

By Kevin Ferris
Philadelphia Inquirer

Published on: 11/12/07

Allen McQuarrie is looking for a few good doctors.  He wants them to volunteer their time and talents to their local Veterans Administration hospital.  Nothing against the quality of the folks already working there. The problem is. there simply aren’t enough doctors and specialists to go around for diagnosis and treatment — or to guide vets through the bureaucratic maze.

Worse, one of the current conflict’s signature wounds — brain injuries — makes it difficult for some vets to juggle the appointments, record-keeping and other demands the VA puts on them.

“We’re doing a wonderful job of getting the wounded off the battlefield and into a hospital in Germany and then back here,” McQuarrie says. “But continuing care once they’re out of the military is what needs systemic change.”

McQuarrie learned of the system’s shortcomings because of his son Doug, a 21-year veteran of the Navy SEALs who has back and brain injuries sustained in combat and training.

Doug McQuarrie has shuttled from the VA to civilian doctors, while trying to hold down a job and support his family in Virginia. The civilians say he needs immediate care, but the VA can’t see him for months — although he can call daily, hoping for a cancellation.

Allen McQuarrie has tried to help from his home in Doylestown, Pa., calling the VA but also seeking assistance from senators and representatives. In the process, he’s learned that Doug’s case isn’t unique — and that the VA desperately needs help.

Despairing and angry, he wrote to Sen. Bob Casey (D-Pa.): “It may be better for our men and women to come home dead than to suffer such painful and ultimately mortal deterioration.”

In the same letter, he asked for emergency legislation to encourage civilian doctors to “adopt” vets and provide the immediate neurological care many need. He suggested tax incentives and improved military insurance to help offset the volunteers’ costs.

McQuarrie’s hopes for a more responsive, faster-acting VA are shared by others including Congress’ Veterans Disability Benefits Commission.

One commission member, retired Marine Corps Maj. Gen. James E. Livingston, a Medal of Honor recipient, emphasizes three required changes.

Have a single review for disabilities. Now there are two.

Streamline the record-keeping process as vets move from care by the Defense Department to the VA.

Adopt the technology that will improve efficiency and speed up treatment.

And don’t worry about the costs.

(there is more to this story in the AJC – click on the link above and read the rest)

Now you have a flavor of the problem:  Not enough doctors to go around, too much paperwork, not enough technology – as viewed from the patient/family side of the problem.   Stay tuned for the recent GAO Testimony on the problem, coming up in my next post.

Oldtimer

Veteran Disability Determination Changes Recommended

Task Force on Returning Global War on Terror Heroes

Recommendation P-1:

 Develop a Joint Process for Disability Determinations

Agencies Responsible for Action: Defense and Veterans Affairs

Lead Agency: Defense
Recommendation: VA and DoD develop a joint process for disability determinations

Background: The Disability Evaluation System (DES) is the mechanism for implementing retirement or separation due to physical disability. There are four elements of DES: physical evaluation, medical evaluation, counseling, and final disposition. The DES physical evaluation has two major components: the Medical Evaluation Board (MEB) and the Physical Evaluation Board (PEB).

VA’s Schedule for Rating Disabilities (VASRD) is codified in statute and serves as a guide for the evaluation of disabilities resulting from diseases or injuries incident to military service. There are evaluation criteria for each condition listed, with disability levels ranging between zero and 100 percent, generally at 10 percent increments, as appropriate to the severity of the condition. The disability rating level is linked to a monetary amount determined by Congress.

In a December 1988 report, the then General Accounting Office said there had been no comprehensive review of the VA rating schedule since 1945, that the rating schedule contained outdated terminology and ambiguous classifications, and had not incorporated recent medical advances. The report recommended that VA thoroughly review the schedule and establish a process for an ongoing evaluation and update. VA agreed to do so and has been conducting a comprehensive revision of the schedule ever since. VA published an advance notice of proposed rulemaking for each of the 15 rating schedule body systems and contracted with an outside consultant, who gathered panels of medical experts for each system, to recommend changes in the rating schedule. Eleven of the 15 body systems contained in the schedule have been revised to date.

While both DoD and VA use the VASRD, not all the general policy provisions set forth in the VASRD apply to the military. Consequently, disability ratings may vary between the two. DoD rates conditions determined to be physically unfitting, compensating for a military career cut short. VA rates all service-connected impairments, combinations of impairments, or service-aggravated conditions, thus compensating for loss of earnings capacity resulting from injuries that could impact civilian employability. Another difference is the term of the rating. DoD’s ratings are permanent upon final disposition. VA’s ratings may change over time, depending upon the progress of the condition(s).

Further, DoD disability compensation is affected by years of service and basic pay; VA compensation is a flat amount based upon the percentage disability rating with possible variance related to number of dependents. Appendix C contains charts depicting the DoD and VA disability processes.  (NOTE from Oldtimer: I’ve already published these charts in earlier posts)

Gap Analysis: For DoD, the terms “permanent and stable” are used extensively in Title 10 but are not clearly defined. These words are the basis for important decisions to retire, separate, and temporarily retire servicemembers. The terms require uniform definition to facilitate consistency and fairness. Many medical and disability authorities have questioned the use of a disability retirement threshold. Historically, the disability retirement threshold stems from “A Report and Recommendation for the Secretary of Defense by the Advisory Commission on Service Pay” (December 1948). The historical record discussion associated with Recommendation 27 (Disability Retirement: Officers, Warrant Officers, and Enlisted Personnel), states:

“Therefore, the standards of disability as used by the Veterans Administration [later became Department of Veterans Affairs], which are civilian standards, are recommended for classification of disability cases into those which may be considered real disability warranting continuing monetary benefits and minor disability not warranting such benefits”.

Congress ultimately incorporated the recommendation in the Career Compensation Act of 1949. Logically, the disability retirement threshold creates an adversarial situation within the DES, when the DES is primarily charged with deciding fit/unfit status.

Servicemembers obviously endeavor to reach the threshold because it results in lifelong benefits such as health care, commissary/exchange privileges, etc., as well as annuity payments. This contributes to tension in the process, adds to servicemember discontent in a system that places the burden of proof on the servicemember who, in many cases, does not have the experience or knowledge, despite assistance, to build a proper case. Additionally, a major challenge is navigating the confusing, inconsistent, and patchwork laws associated with DES. This has resulted in the service branches being inconsistent at times with each other in determining fitness/unfitness and the level of disability.

For VA, examinations performed by DoD for purposes of determining fitness for continued service are generally not adequate for application of the VASRD in determining, for VA disability compensation purposes, the average impairment in earning capacity resulting from all disabilities or diseases incurred in, or aggravated by, service. Unless participating in the Benefits Delivery at Discharge (BDD) program, VA must wait until a servicemember is discharged and files a claim before obtaining service medical records, including any MEB/PEB proceedings, prior to determining if additional examinations are needed. This contributes to the lengthy claims process faced by veterans.

How the Recommendation Addresses the Gap: The development of a joint process whereby VA and DoD cooperate in the assignment of a disability evaluation that would be used in determining fitness for retention, level of disability for military retirement, and VA disability compensation would result in less discontent among servicemembers who believe they are assigned lower disability evaluations by DoD than by VA. This would also help VA provide better service to newly separated veterans by completing their claims in a timelier manner. There are, potentially, a number of provisions that could be undertaken to effect this recommendation, including providing Benefits Delivery at Discharge type service to those servicemembers undergoing the MEB/PEB process.

The impact of implementing this recommendation will be significant. In the near term, having DoD and VA work together to improve the VA disability claims process and the DoD MEB/PEB disability process should provide improvement across the services in consistency of decisions. In the longer term, having full cooperation in the disability claims process should provide improved service to servicemembers and veterans at a lower cost to the Government through increased efficiencies.

Implementation Action and Target Date:
Develop an in-depth plan for VA/DoD collaboration in the MEB/PEB process: Using the present interagency process provided by the Benefits and Joint Executive Committees (BEC and JEC), DoD and VA will develop options presented to leadership in both VA and DoD for review.

Target Date: Begun April 3, 2007;

VA to participate in Advisory Council meeting on May 3, 2007.

Note:  All highlights and bold type are Oldtimer’s – I hope it is not distracting from the report.  This is one recommendation in the Report to the President.  There are a total of 15 recommendations concering veterans.  You can find them all here