Created in April 2020, the Veterans Affairs (VA) of Greater Los Angeles’ Care, Treatment, and Rehabilitation Service (CTRS) program was founded in association with Village for Vets, a Los Angeles-based 501(c)(3) nonprofit organization, in response to the increasing number of veterans experiencing homelessness during the COVID-19 pandemic.
The CTRS program is a “low-barrier-to-entry transitional housing initiative”According to the United States Interagency Council on Homelessness, low-barrier-to-entry shelters and housing initiatives, “emphasize welcoming guests in as they are, while having clear and simple behavioral expectations that apply to anyone residing in the shelter. These expectations are narrowly focused on maintaining a safe environment for all.” See: United States Interagency Council on Homelessness, “Key Considerations for Implementing Emergency Shelter Within an Effective Crisis Response System,” usich.gov, August 2017, https://www.usich.gov/resources/uploads/asset_library/emergency-shelter-key-considerations.pdf that provides temporary housing, healthcare, showers, meals, case management and peer support.US Department of Veterans Affairs, “Greater Los Angeles VA Offers Services for Veterans Experiencing Homelessness,” va.gov, October 14, 2021, https://www.va.gov/greater-los-angeles-health-care/news-releases/greater-los-angeles-va-offers-services-for-veterans-experiencing-homelessness/ Initially consisting of a “safe camping area” in a parking lot at the VA’s medical center campus in West LA, the program expanded in November 2021 to include Pallet Shelters, known as tiny homes, that contain a bed, climate control, windows, electrical power outlets and a locking door.Pallet, “Veterans Move Into Pallet Shelters,” palletshelters.com, November 11, 2021, https://palletshelter.com/blog/veterans-move-into-pallet-shelters/Village for Vets, “Arnold Schwarzenegger Donates $250K to Village for Vets for Tiny Shelter Program” villageforvets.org, accessed September 13, 2023, https://www.villageforvets.org/news/arnold-schwarzenegger
Funding for these shelters was originally provided by Village for Vets, with funding for 25 of the first 28 shelters being donated to the organization by former California Governor Arnold Schwazenegger.Pallet, “Pallet Shelter Village Serving Veterans Grows,” palletshelter.com, March 4, 2022, https://palletshelter.com/blog/pallet-shelter-village-serving-veterans-grows/Pallet, “Veterans Move Into Pallet Shelters,” palletshelters.com, November 11, 2021, https://palletshelter.com/blog/veterans-move-into-pallet-shelters/Village for Vets, “Arnold Schwarzenegger Donates $250K to Village for Vets for Tiny Shelter Program” villageforvets.org, accessed September 13, 2023, https://www.villageforvets.org/news/arnold-schwarzenegger By March 2022, through the work of Village for Vets, AyZar Outreach, Brentwood School, UCLA, Lennar and HomeAid, there were 110 shelters in place plus an additional two 800-square-foot dining halls.Pallet, “Pallet Shelter Village Serving Veterans Grows,” palletshelter.com, March 4, 2022, https://palletshelter.com/blog/pallet-shelter-village-serving-veterans-grows/
According to the VA, “the program’s goal is to improve unsheltered Veterans’ healthcare outcomes in a harm reduction environment, while moving participants toward permanent housing solutions.”US Department of Veterans Affairs, “The VA Greater Los Angeles Healthcare System to Institute New Safety Protocols for CTRS Residents,” va.gov, October 27, 2022, https://www.va.gov/greater-los-angeles-health-care/news-releases/the-va-greater-los-angeles-healthcare-system-to-institute-new-safety-protocols-for-ctrs-residents/
A-Mark Foundation funded research by Pepperdine University graduate students to determine the program’s cost-effectiveness, effectiveness at addressing the underlying issue of homelessness among veterans, and the impact of its service delivery model. The study also hoped to make recommendations for the program’s scalability and applicability.
Four masters students, Arif Husein, Maddie Leonardi, Clare McKenzie and Aemon Viens, conducted the research under the supervision of their advisor, Professor Marlon Graf, PhD. Additional data was provided directly to A-Mark Foundation from Village for Vets.
Five stakeholders in the program were surveyed, including program administrators, funders and local community members. Through these interviews, the students found that the low-barrier to entry housing CTRS program is essential in helping get some veterans off the streets. Their research showed that CTRS is preferable to other housing options because veterans get their own secured space and it is located close to healthcare amenities at the VA campus, which improves veteran access to care.
Despite these positives, there are challenges and room for improvement. A lack of staff capacity at the program means that a number of housing units are left empty while some veterans are turned away if arriving outside of certain hours. Other problems include a lack of help for veterans facing eviction from the program, especially in terms of finding new accommodation or challenging their eviction, demonstrating the need for more onsite programs such as legal clinics.
The students were unable, despite repeated requests, to obtain comprehensive funding and budgetary information or utilization data from the VA and therefore could not conduct an accurate cost-analysis or provide recommendations for the program’s scalability and applicability.
According to Village for Vets, there has been a 6.1% decrease in veteran homelessness in Los Angeles between 2020 and 2022 thanks to the collaborative efforts of the VA and partner nonprofits like Village for Vets.Village for Vets, “2022 Annual Report,” villageforvets.org, 2022, https://www.villageforvets.org/annual-report-2021Kristine Lazar and Tom Wait, “Homeless Count Reveals Nearly 42,000 People Are Living on the Streets of LA,” cbsnews.com, September 8, 2022, https://www.cbsnews.com/losangeles/news/homeless-count-reveals-nearly-42000-people-are-living-on-the-streets-of-la/
The Pepperdine student’s presentation of their results and policy analysis is titled, “Evaluation of the Care, Treatment and Rehabilitative Services (CTRS) Program.”
The students used a mixed-method approach to their research, combining qualitative semi-structured interviews with CTRS stakeholders and an in-depth cost analysis.
The students interviewed five stakeholders from partner organizations involved in the integration of the CTRS program, current CTRS program administrators and funders, and community members in the vicinity of the Veterans Affairs West Los Angeles campus. The interviews provided insight into the current program, its effectiveness, and some of the challenges associated with running the program.
The interviews were conducted virtually, lasting between 30 minutes and one hour, and followed a semi-structured protocol that differed between the three different types of interviewees. The interviews included questions that focused on program knowledge, descriptions of their involvement with CTRS, and individual definitions of success and failure.
Prior to commencing the study, the research project was approved by the Institutional Review Board (IRB) at Pepperdine University.
Qualitative Research Surveys
Throughout the five interviews undertaken by the students, the interviewees expressed a mixed view of the success of the CTRS program. While all were grateful to the program and noted key successes, barriers and challenges were identified, including empty units and lack of staff.
One interviewee summed up the program by saying: “The program has been successful in managing a low-barrier-to-entry program and serving different populations, but faces challenges in balancing future planning with creating infrastructure.” Another said, “I’m thankful that the program is there to get people off the street because it’s what’s needed. … [but] from a perspective of looking at it from a big picture, they need to be filling those units and keeping it staffed,… Just keep a constant flow going if the goal really is to end veteran homelessness.”
Key Perceived Successes of the CTRS Program
I. Low-Barrier-to-Entry Housing Is Needed
Many of the interviewees noted the need for low-barrier housing programs like the accommodation provided by the CTRS program. The CTRS program at the VA campus in West LA is the only program of its type supported by the VA in southern California.
One interviewee noted the veteran’s preference for the program due to its low-barrier access and lack of rules. Spouses and service animals are also welcome.
Another interviewee noted its importance being amplified by the fact that many of the veteran beneficiaries of the program suffer from mental health issues that result in repeated discharges from other housing programs.This anecdotal interview note is supported by research from UCLA that states that 92% of CTRS residents had a mental health diagnosis within the last five years, with 65% having a diagnosis of a serious mental illness such as schizophrenia or bipolar disorder. See: UCLA, “UCLA/VA Center of Excellence for Training and Research in Veteran Resilience and Recovery – Care Treatment and Rehabilitation Service (CTRS),” ucla.edu, accessed September 13, 2023, https://hss.semel.ucla.edu/coe-project-ctrs/
The program also helped to provide safe transitional housing for unhoused veterans living in an encampment along San Vicente Blvd outside of the VA campus in West LA, benefitting not only the veterans but the local residents and businesses.
II. Tiny Homes Provide Unique Benefits When Compared to Other Programs
It was noted by some interviewees that many other programs use barrack-style accommodations for their temporary housing programs that can be retraumatizing for veterans. Tiny homes are preferred by the veterans themselves and it was noted that tiny homes, rather than congregate living arrangements, better prepare veterans for the privacy of their own space when they move into permanent houses or apartments.
III. Services Provided On-Site and Close to the VA Buildings Positively Impact Veteran Experience with the VA
A couple of interviewees noted the importance of having on-site services at the CTRS shelter program for the veterans as well as the benefits of being in such close proximity to the in-building services at the VA campus. Specifically nurse practitioners working in a “street medicine” program on-site are particularly welcome.
Challenges and Recommendations for Improving the CTRS Program
I. Ensure Tiny Homes Are Filled to Capacity and the CTRS Program Is Sufficiently Staffed
A number of interviewees noted that there are 30 to 40 empty tiny homes every night, but the VA says that they don’t have enough staff to fill or manage them. Interviewees recommended an increase in hiring for more on-site staff to manage intake and exit paperwork.
II. Reduce the Number of Veterans Turned Away from the Program
Some of the interviewees told the researchers that at times, veterans have been turned away from the CTRS program leading to a loss in trust between the veterans and the VA. The researchers discovered that in order to register with the program a veteran had to arrive within a certain time frame and if they arrived after that time, they would be turned away and told to come back the next day, especially if the six drop-in units were full. The interviewees recommended an extension of the hours of operation for registration and an increase in drop-in units.
III. Ensure Discharged Veterans Have Help Finding Replacement Shelter
A number of interviewees commented about the importance of a coordinated exit process for veterans facing eviction and noted that, at times, the help to find new accommodation is not always forthcoming. It was also noted that there is not a formal appeals process for veterans who dispute charges against them.
Recommendations for improvement include, ensuring the exit process is implemented thoroughly and completely; creating more low-barrier housing opportunities for chronically unhoused veterans and those struggling with their mental health; and investigating all discharges due to bad behavior and try to minimize the amount of veterans evicted for internal policy violations.
IV. Increase On-Site Services for Veterans and Incentives for Staff to Work There
As mentioned above, services provided to veterans on-site and in close proximity to in-building services markedly improve veteran experience with the VA and help keep them in the program. Recommendations for improvement included increasing the types of services provided on-site as well as improving the incentive for VA staff to work on-site with the veterans, which has been noted as being challenging at times.
Quantitative Data Analysis
The researchers urged the VA and other stakeholders to provide data on the utilization of the CTRS program, including how many occupants CTRS has, how many exits CTRS has (broken down by reason/destination), the average length of stay, the average occupancy rate, and what services are provided to residents as well as who provides those services. They were also hoping to gain cost metrics including fixed costs (construction, gas, water, electricity, internet, insurance, etc.) and variable costs (food, services, ongoing operational costs such as operations and management, etc.) to assess the cost-effectiveness of the program, but the VA did not share this information.
Since the completion of the student project, some data has been provided to A-Mark, but not enough to perform a complete analysis.
In an email to the A-Mark Foundation in August 2023, Village for Vets provided the following information:
- There were 1,087 veteran admissions to the program alongside 39 spouse admissions between April 2020 and August 2023.
- 758 of these admissions were for a first-time veteran participant, alongside 32 first-time spouses.
- Gender breakdown: 680 males, 73 females, 5 unspecified.
- The average length of stay is 171 days.
- 108 (14%) of the veterans have moved to Veterans Affairs Supportive Housing (VASH) apartments; 53 (7%) have been reunited with families.
- CTRS works on finding appropriate housing so they do not have a direct “discharged back to homelessness” number.
- All Veterans at CTRS receive VA healthcare.Email to A-Mark Foundation dated August 25, 2023, from Rebecca Ricci, LMFT Executive Program Director at Village for Vets.
A study published in July 2023 by researchers at the VA’s HSR&D Center for the Study of Healthcare Innovation in Los Angeles in collaboration with researchers from UCLA found that the CTRS program was staffed by two full-time social workers, two full-time peer support workers, a part-time preventive medicine physician and a part-time occupational therapist. Biweekly primary care and triages were also held. Services included substance use groups, a healthy teaching kitchen, a storytelling group, a music therapy group, acupuncture, and veteran town halls. Weekly COVID testing was undertaken during the pandemic as were intermittent vaccination clinics.Ippolytos Kalofonos, et al., “A Sanctioned Encampment as a Strategy for Increasing Homeless Veterans’ Access to Housing and Healthcare During the COVID-19 Pandemic,” Journal of General Internal Medicine, 38, July 2023, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10356730/
The VA-UCLA study found that between 4/1/2020 and 10/1/2021 there were 491 veterans admitted to the CTRS program, 110 of which had been admitted before. The average length of stay was 35 days however the range of time spent in the program was one day to over a year.Ippolytos Kalofonos, et al., “A Sanctioned Encampment as a Strategy for Increasing Homeless Veterans’ Access to Housing and Healthcare During the COVID-19 Pandemic,” Journal of General Internal Medicine, 38, July 2023, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10356730/
While the students did use a previous A-Mark Foundation report to produce an estimated annual operating cost for the CTRS program ($4,025 ,950 a year or $11,030 per night), without the ability to compare these costs with positive outcomes for veterans, especially regarding access to healthcare and exit to permanent housing, an actual cost-effectiveness analysis cannot be made.
The purpose of this project was to understand the effectiveness of the VA’s CTRS tiny homes for veterans program. While the lack of available quantitative data made it impossible to undertake a cost-effectiveness survey, interviews with stakeholders involved with the project provided insight into the benefits and challenges of the program. It was not clear whether the VA did not have the data to provide for analysis or if the information exists but was not shared.
Regarding quantitative findings, future research is needed to obtain more specific quantitative data to determine the effectiveness of CTRS.
While the students were unable to provide recommendations for the program’s scalability, they did conclude that, "expanding Los Angeles’ current tiny homes model may come with many advantages," noting that, in theory, tiny homes can meet the increasing need for more affordable housing in towns and cities nationwide while providing people with homes with less costly maintenance and a safe space to store belongings.