Stakeholder perspectives on sustainment of housing first in a VA permanent supportive housing program

Objective: To evaluate the sustainment of Housing First (HF) implementation in a permanent supportive housing program for homeless-experienced veterans, 5 years after practice implementation. Study setting: From 2016 to 2017, primary data were collected from providers and veterans in the Department of Housing and Urban Development–VA Supportive Housing (HUD-VASH) program at Los Angeles. Study design: Guided by the integrated sustainability framework, we performed a mixed-methods study to evaluate the sustainment of HF, an evidence-based practice implemented to improve housing outcomes. To assess sustainment, we measured fidelity to HF in six of seven HUD-VASH teams. These data were integrated with qualitative interviews with providers and veterans who described perceived sustainment to HF and contextual factors that supported or impeded sustainment. Data collection: Fidelity to HF at 5 years after practice implementation, as a proxy for sustainment, was quantified via surveys with HUD-VASH teams. HUD-VASH providers (n = 51) and 31 veterans participated in semi-structured interviews. Team-based template analyses were used to develop an emergent understanding of stakeholder perspectives on HF sustainment. Principal findings Overall, HUD-VASH teams reported HF sustainment. The lowest fidelity scores were found in the domains of client-to-staff ratios, frequency of client–provider contact, and time to housing. Qualitative findings indicated that outer contextual factors (e.g., housing scarcity) and organizational factors (e.g., staff turnover) impacted HF sustainment. Providers identified changes in leadership and unmet resource needs as impediments to practice sustainment. All stakeholders identified positively with the HF practice and believed that the approach benefited veterans. Conclusions: This snapshot of HF sustainment demonstrates that this practice can be sustained over time. However, strong leadership, organizational resources, and community partnerships are needed. Adaptations to HF in response to outer contextual factors and organizational capacity may result in practice sustainment while allowing for flexibility in service provision.