Employee Spotlight
July 14, 2023
Stacy Potts MSW, LISW-S
Veterans Justice Outreach Coordinator
VA Central Ohio Healthcare System
Q: How long have you worked for VA?
A: Thirteen years.
Q: Tell us about your role as a Veterans Justice Outreach Coordinator (VJO).
A: I’ve always been really passionate about getting to the root cause of homelessness and better understanding recurring homelessness. I believe you have to walk side-by-side with Veterans to truly understand their experiences.
You also have to have a good understanding of the homeless system. I studied the Veteran By Name List (VBNL) and looked for patterns that I was seeing, trying to find ways to improve our system. Around the time COVID hit, I had been studying the VBNL for a while.
It was a matter of life and death at this point, so I knew that I had to talk with our Veterans Service Organization Workgroup (VSOW) about what I was seeing in our homeless system. We did a really good job with coordinated entry, but we were lacking when Veterans exited the system.
I saw that Veterans were entering and exiting the system fairly quickly, and they were rarely connected with resources. We didn’t know where they went, and there was no one there to follow up with them. Then we had a cohort of Veterans who may have had links to case management programs while in shelter, but when they left, those case management programs stopped and were no longer following them.
We had Veterans cycling in and out of homelessness, but we didn’t have programs in place to ensure that their needs were met after exiting the system. The VSO workgroup that I talked with agreed that this was a problem in our system.
I proposed that we create a program to verify that every Veteran would be contacted after leaving the shelter system, ensuring that their needs were continuing to be met. They would be linked with resources and we would do all that we could to prevent them from coming back through the system.
After I did a national presentation on coordinated exit, I had multiple VA locations that were interested in implementing the program. However, only one VA health system was able to get a full-time employee for it, which was the VA Boston Health Care System. They created the position and I’ve been working with them as a consultant.
Q: How are you and your community partners working to prevent returns to homelessness?
A: In coordinated exit, we follow up with them when they’re exiting the system, and if they meet certain criteria, they’re linked with case management. For those who are not linked with case management, we have follow-ups at 6 months and 1 year.
We found that individuals may be fine right when they leave, but 6 months later when we follow up, they might have 2 months of unpaid rent and could really use help.
We’ve been able to prevent homelessness through those 6-month and 1-year follow ups, as these Veterans may have never gotten in touch with us if we hadn’t reached out.
In the Veterans Justice Outreach Program (VJO), I’ve been working with our team to identify those at risk of recurrent homelessness and doing the same thing. In our program, we’ve always looked at our Homeless Operations Management and Evaluation System, or HOMES, and medical records to see if there’s a history of VA services. But something new that we’re doing is working with VA staff members that have Homeless Management Information System (HMIS) access and trying to identify the bigger picture of a Veteran’s homeless history. HMIS tells us a lot more than what HOMES and medical records do.
We can see if a Veteran is calling shelters, how many times they’ve called, if they’re showing up, and more. It tells us if they are at a higher risk of being unsheltered when they get out of jail. We can also better prepare and create better treatment plans by looking at HMIS because we can see if they’ve worked with Supportive Services for Veteran Families (SSVF) and other programs.
We found some Veterans who are currently enrolled in SSVF, and we never would have known that if we weren’t looking at HMIS. We are able to work with SSVF to see if those Veterans are still eligible for a deposit when they get out of jail, or if they are still eligible for the Housing and Urban Development-VA Supportive Housing (HUD-VASH) Program if they’ve been in HUD-VASH before. It also allows us to develop a treatment plan with HUD-VASH so they can be readmitted into the program.
This helps ensure that we’re not simply giving them the number for a shelter when they get out of jail. We’re creating a better plan that will reduce the amount of time they spend homeless.
Q: What’s next on the horizon for improving your community’s homeless response system?
A: About 3 years ago, I started a research project that was approved by our local Institutional Review Board looking at the variables that may predict recurring homelessness. We‘ve done the analysis and we are currently writing our paper. It‘s my plan to help our community create better vulnerability assessments, and ultimately prioritize them for housing.
For certain housing projects, there are many variables we found that may predict recurrent homelessness that are clinical concerns. I hope to help providers understand that clinical concerns are often not addressed while Veterans are homeless. It’s very unlikely that they’re going to be addressed until they’re stably housed because they’re focused on their housing crisis while homeless.
We’ve found that having a higher number of crisis hospitalizations, residential placements, emergency room and Critical Care Unit visits, and having substance use disorder may all predict recurrent homelessness. If we’re going to get to the root cause of homelessness and truly prevent recurrent homelessness, we can’t stop when they leave the shelter system.
Q: What is your why for this work?
A: When I first started out, it was truly about housing as a basic human right. But as time went on, I saw how the homeless population was being mistreated. I’ve witnessed homeless individuals being ignored and forgotten. They’re put behind bars because of homeless crimes or mental health concerns.
Veterans are dying on the streets. I truly think it’s unacceptable, and I want to be a voice for that population to ensure that we improve their quality of life.
