Deficiencies in Case Management and Access to Care for HUD-VASH Veterans at the VA Greater Los Angeles Healthcare System in California

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess confidential complaints alleging a veteran was going to be discharged from the Housing and Urban Development VA Supportive Housing (HUD-VASH) program and “should not have been,” and that other veterans were discharged from HUD-VASH “for no reason.” The OIG also evaluated access to primary care for veterans enrolled in HUD-VASH who remain unhoused.

The OIG did not substantiate that the veteran, nor other veterans, were discharged from the HUD-VASH program “for no reason.” However, deficiencies existed with the veteran’s case management, including treatment plan and discharge documentation. The OIG determined similar deficiencies occurred in the case management of other veterans discharged from HUD-VASH. Additionally, the electronic health records of many unhoused HUD-VASH veterans, who did not have scheduled primary care appointments, demonstrated the absence of treatment plans and assignments to primary care teams.

Deficiencies in case management and failures in supervisory oversight resulted in missed opportunities for improved case management for HUD-VASH veterans. The OIG is concerned that the absence of treatment plans, as well as primary care assignments, could affect HUD-VASH case management staff’s ability to coordinate veteran-centered care and may contribute to deficient facilitation of clinical services for this vulnerable population.

The OIG made five recommendations to the Facility Director related to completion and oversight of HUD-VASH documentation, HUD-VASH discharges, and assignment to primary care teams for unhoused HUD-VASH veterans.