Review of Facility Leaders’ Oversight of Care Coordination Services within Homeless Programs at the VA Portland Health Care System in Oregon

Report Information

Issue Date
Report Number
25-04102-182
VISN
State
Oregon
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Report Topic
Care Coordination
Mental Health
Patient Safety
Major Management Challenges
Healthcare Services
Leadership and Governance
Recommendations
5
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the VA Portland Health Care System (facility) in Oregon to evaluate allegations that a lack of leadership oversight contributed to staff not conducting care coordination services for veterans within select homeless programs. The allegations included the names of veterans enrolled in homeless programs who were reported to have limited case management contacts, including two veterans (Veteran A and Veteran B) who died.

The facility’s homeless programs are aligned under Community Reintegration Services (CRS) and include Health Care for Homeless Veterans (HCHV), Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH), and Grant and Per Diem (GPD) homeless programs.

The OIG substantiated the HCHV program coordinator did not ensure case managers contacted veterans once a month as required or complied with facility policy for discharging veterans. The OIG also substantiated the CRS director did not provide the oversight necessary to ensure GPD liaisons met with veterans as required. Competing workload demands and limited resources contributed to the leaders’ insufficient oversight.

Veteran A, who was enrolled in the HCHV program, died by suicide. The OIG found the HCHV case manager did not contact Veteran A monthly as required but noted Veteran A was engaged in ongoing mental health care. The OIG was unable to determine whether more frequent contact from the HCHV case manager would have altered Veteran A’s outcome.

Veteran B, who was enrolled in the HUD-VASH program, died in police custody. The OIG found the HUD-VASH case manager missed opportunities to address Veteran B’s deteriorating mental health status.

The OIG made five recommendations. In response, the Facility Director shared plans and actions taken to improve compliance with veteran contacts and discharges, evaluate the CRS program reporting structure, and review Veteran A’s and Veteran B’s care.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Portland Health Care System Director ensures the Community Reintegration Services director and Health Care for Homeless Veterans program coordinator establish a process to monitor and verify case managers comply with monthly veteran contacts as required by the facility’s HCHV Case Management Workflow Guide, and takes action as warranted.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Portland Health Care System Director ensures Health Care for Homeless Veterans staff discharge veterans from the Health Care for Homeless Veterans program in accordance with the facility’s HCHV Case Management Workflow Guide.

No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2026

The VA Portland Health Care System Director reviews the quality management evaluations, once completed, for Veteran A’s and Veteran B’s care, and takes action as warranted.

No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 8/6/2026

The VA Portland Health Care System Director evaluates the Community Reintegration Services reporting structure and resources to determine if the current structure allows for effective oversight of essential homeless programs, and makes modifications if needed.

No. 5
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The VA Portland Health Care System Director ensures the Community Reintegration Services director monitors and verifies Grant and Per Diem liaisons’ compliance with Veterans Health Administration Directive 1162.01 requirements related to conducting veteran contacts.