Aging and the Homeless Community Follow Up Presentation ...

Aging and the Homeless Community Follow Up Presentation ...

Aging and the Homeless Community Follow Up Presentation: Implications for the Field Thursday, January 27, 2016 1:00 p.m.2:30 p.m. EST VHAs National Center on Homelessness among Veterans Roger Casey, PhD Brenda Johnson, LCSW, CCM, VHA-CM Call Overview

Conference call process Mute computer speakers if dialing into VANTS TMS link Call Archive Downloads HERS Proceeding Document, December 2015 HERS Follow Up Implications PowerPoint Slides Structure of the call 2 The National Center on Homelessness among Veterans To promote the development of policy and practice that targets ending and preventing Veteran homelessness through

supporting the implementation of relevant research findings into clinical practice, providing education and training for VA and community partners, disseminating evidence-based and emerging best practices, and developing new empirical knowledge. 3 Presentation-Overview HERS Summary Implications

Medical and Psychiatric Considerations Building a Community Consortium Cognitive Decline The Importance of Working with Entitlements SOAR Building Relationships and Providing Support in the Community Decisional Capacity and Barriers 4 Aging and the Homeless Community Homeless Evidence and Research Synthesis (HERS) Round Table November 19, 2015 Brought together researchers on homelessness and

aging to discuss Population predictions Special needs Impact of aging on service delivery. 5 Implications for the Field Opportunity to Explore these populations shifts and the effects these changing demographics may have on Implementing services Developing alternatives organizational management

6 Todays Presenters Introductions Goodlett McDaniel Medical and Psychiatric Considerations Araceli Orona Building a Community Consortium John Schinka Cognitive Decline in Aging Homeless Veterans Marilyn Warlick Building Relationships and Providing Support in the Community

Ana Shahan The Importance of Working with Entitlements SOARS Lisa Moody Decisional Capacity and Barriers 7 HERS Summary Population expectations Population characteristics Program considerations 8 HERS Presentation Summary

Projecting changes in the scope and health services utilization of older Veterans who experience homelessness Thomas Byrne, PhD Investigator The Center 2010 - largest age group among male homeless 49-51 y/o 11.3% Veterans; only 5.9% non-Veteran Veterans ages 62-74 expect to increase by 50 250% (by 2020) Those Veterans 60 and older projected increase from 16,921 (2015) to 21,350 (2020) Health care cost increases Between $10,000 and $15,000 under 25-51 y/o Over $15,000 over 55 y/o Summary: geriatric conditions and end of life issues in homeless programing Staff training

Facility changes Systematic efforts to target population needs 9 HERS Presentation Summary Mortality risk and factors influencing death in older homeless Veterans John Schinka, PhD Investigator The Center 35% entering homeless programs 55 y/o, or older Mortality in 55 y/o and older group Homeless group - higher proportions of death associated with Mental health, infections, accidents, self harm Suicide rare but odds greater in homeless; 0.4% as opposed to those

housed 0.2% Predictors of death sample of homeless Veterans Those variables moderately associated with increase risk of death included: serious medical problems, hospitalization for alcohol, alcohol dependence, unemployment three years and age 60 years old. Summary Homelessness increases mortality rates in older veterans Possible risk index could be constructed as predictor and identity those most vulnerable. 10 HERS Presentation Summary Planning palliative care for homeless Veterans at the end of life Evelyn Hutt, MD Internist/palliative care physician VA Colo Health Care System

Study informing palliative care HSR&D (2013) Approaches to care Barriers Framework for meeting needs and program design Challenges found Symptom management, addiction, unstable housing, and behavioral health care Housing Too limited, programs require functional independence and sober facilities Continuity of care within VA systems Need for collaboration with homeless staff Summary Education for providers on housing; VA resources and linkages, housing criteria flexibly; priority housing for end of life needs; hospital to home

11 HERS Presentation Summary The aging of the homeless populations: emerging clinical issues Margot Kushel, MD Professor of Medicine U of California, San Francisco Median age 50 y/o; health age 70-80 y/o Key health concerns Chronic diseases: substance use, geriatric conditions (chronic functional and visual impairment, falls, and incontinence. Leading causes of mortality - all homeless 45 y/o plus Heart disease and cancer Managing chronic disease Medications, compliance, diets, activities,

Older homeless; 39% difficulty with ADLs 38% global cognitive impairment 40% executive function impairment (managing complex tasks) 34% reported fall in past 6 months 48% screened positive for incontinence 45% visual impairments 36% hearing impaired

Summary Acute and chronic health issues by the aging homeless population 12 Implications Research Implications Changing demographics Homelessness increases mortality risk and rates in older Veterans

Geriatric conditions and end-of-life issues Unmet needs of veterans who are unhoused Requirements for care - flexible Staff awareness of and linkages with available VA and community resources Strategies for: Chronic diseases, substance use, and cognitive, functional and visual impairment, falls, and incontinence 13 What are Implications for.. Direct Care Assessment in prevention and outreach Relationship / coordination with medical providers, community, other agencies and resources Health and mental health care needs

Sustainability and support Program Design Future programing shifting demographics Facilities Community collaboration Agency linkages 14 Aging and the Homeless Community

Medical/Psychiatric Considerations J. Goodlett McDaniel, EdD, PMHNP-BC, MBA First thoughts Average life expectancy for a US male in early 2000s was 78 years. For a chronically homeless male, average life expectancy between 42 and 52 years (OConnell/NHCHC, 2005). 64 for single males and 69 for single females in 2015 HERS Collaborative care more than doubled the effectiveness of depression treatment for older adults in primary care settings. At 12 months, 50% of patients had a 50% reduction in depressive symptoms, compared to only 19% of others (OConnell/NHCHC, 2005)

Multi-disciplinary Teams function best when increasing access to onsite care, facilitating testing and specialty referrals, maximizing community and outreach services, improving housing retention rates, and finding and serving American heroes living without basic shelter ARNP Provides direct service and coordinates with care Team as appropriate in order to assist Veteran to remain in permanent supportive housing I would like you to meet. Mr. Y.

ARNP climbed through a mobile home window, Vet on floor, blue.. Mr. H. Vet slept in boat after hours lived in a bubble Mr. H. and Mr. Y.

69 y.o., Air Force, Pilot 16 active problems (Depression, ETOH abuse, Wandering, Dementia, GAD, Pain, Insomnia, Vision problems) Pre-screen for care giver report + for cog def, Good health generally Living in HUD VASH apartment Strengths: Caregiver via Craiglist, family in area, bicycle for transport, able to make medical f/u Good health, active, wants help Stressors:

Loss of former wife and girlfriend at Holidays Decrease in executive functioning (memory, money, meds?) Immediate Treatment Goals: Team approach (Neuropsych consult, MD reports, caregivers sudden exit, family questions arise, PsyD charting, Psychiatrist asked to help, Flag posted) Diagnostic clarification- Appt scheduled for meeting with PsyD SAFETY 62 y.o., Viet Nam Veteran

7 hospitalizations in one year 36 active problems (Depression, Polysubstance, Suicidal, Explosive, Dementia, GAD, Pain, Pneumonia, Neuropathy, Dehydration, Weight loss, Incontinence, Multiple fractures) 5 active medications, >300 discontinued/expired 5 psych, 5 medical, 3 psychosocial diagnoses 16 procedures/diagnostic tests, 16 consults Last discharge to Nursing Home (day-to-day) Strengths:

Physically resilient Manages $ Stressors: Poor health, fractures, falls, dementia Decrease in executive functioning (memory, money, meds?) Immediate Treatment Goals: Frequent contact with nursing home Social Worker Monitoring health gains SAFETY Similar problems require unique solutions: ^BP, Lipids, Glucose; Poverty; Substance use (ETOH*); ED use; Weapons; Frequent hospitalizations; Multiple providers (Multiple f/u referrals with 19% no show rate: - Prosthetics, Psychiatry, Kinesiotherapy, Smoking Cessation, Psychology, Neurology, Medicine, Occupational Therapy, Physical Therapy, GI, Pain, Speech, Neuropsychology, Ophthalmology, Dental?)

Building a Community Consortium Araceli Orona, LCSW Aging Veteran Project Brief Overview of Project (Hx., Purpose, Goal) Eligibility, Criteria & Referral Process Services Rendered Clinical Significance of Project 20

Aging Veterans Project Almost half of homeless veterans in the United States are over the age of 51 and are comprised primarily of veterans representing the Baby Boomers and are veterans of the Vietnam War years. The issue of homeless veterans is not just a matter of finding homes for those who currently lack housing, but also establishing proactive programs aimed at preventing homelessness for those most at risk. Khadduri J, Culhane D. 2010 Annual Homeless Assessment Report to Congress. Darby, Pa, USA: Diane Publishing; 2011. 21 Aging Veteran Project Goal

Brief Overview of Project (Hx., Purpose, Goal) o o o Eligibility, Criteria & Referral Process o o o History: Initiated in 2011 as a result of VA and Community Research regarding homelessness among the

aging veteran population Purpose: To assist veterans in maintaining and sustaining independent housing. Goal: To purchase Homemaker/Home Health Aide services for veterans active in the homeless program and for veterans who are at risk of becoming homeless. VA healthcare eligible Needing assistance with ADLs and/or IADLs to sustain independent or supportive housing as a result of compounding medical, cognitive, and/or severe mental illness A consult must be submitted by veterans Primary Care Provider (physician, nurse practitioner, or psychiatrist). Services Rendered o o Homemaker Services: Light housekeeping, laundry services/ironing, bed linen changing, grocery

shopping, meal preparations/cooking, and navigating public transportation Home Health Aide Services: Transferring/mobility, Bathing, Dressing, Toileting, Feeding & HMKR services 22 Aging Veteran Project Clinical Significance Vignette Decrease in ER visits, Nursing Home Placements, and Assisted Living Facilities Increase in emotional & physical well-being Increase in housing stability Decrease isolation and loneliness More cost-effective than long-term care 23

Cognitive Decline in Aging Homeless Veterans John Schinka, PhD Cognitive Decline in Aging Homeless Veterans NCHAV Presentation January 2016 John A. Schinka, PhD School of Aging Studies, University of South Florida, Tampa FL 1/Definitions and Basic Facts

I will be discussing dementia, which is a major issue for the veteran population. Dementia is not a specific disease. Dementia is a general term that describes a condition primarily characterized by a decline in cognitive ability, particularly memory, sufficient to affect the ability to perform daily activities. 2/Definitions and Basic Facts

Most cases of dementia are progressive and irreversible. The most common of these is Alzheimer's disease (AD), which accounts for 70+ percent of cases. The second most common dementia is vascular dementia. The very large majority of cases of dementia have late onset and occur at age 65+. Early onset AD is very uncommon (1% of cases of AD). 3/Definitions and Basic Facts

Late onset AD and other dementias do have a complex genetic component. These dementias are not inherited in classic "dominant/recessive" pathways but rather as an interactive combination of multiple genes. The veteran population is aging and approximately 45% of veterans are now age 65+--they have entered the age of risk for dementia and particularly AD.

4/Definitions and Basic Facts The veteran homeless population also has a significant number of age 65+ veterans. In FY15, 8.3% (1 in 12) of veterans receiving housing services from VA were age 65+. 5/Assessing Cognitive Change Significant memory loss is not a characteristic of normal aging.

However, some degree of cognitive decline does occur, beginning as early as age 50 in some individuals. Normal cognitive decline is usually characterized by common complaints that do not interfere with functional capacity. 6/Assessing Cognitive Change

"I came into this room to get something and I forget what it is." "I can't find my car keys (glasses, wallet). "I know I put that screwdriver (spatula, hairbrush) on that counter and now it is gone." "I ran into a person at Home Depot who is a church member but I couldn't remember her name." 7/Assessing Cognitive Change

What are signs of possible early dementia in someone who is age 65 or older? 1. Memory loss that disrupts daily life: forgetting recently learned information, important dates or events, asking for the same information over and over; relying on others to take over or complete tasks. 8/Assessing Cognitive Change

2. Problems in planning and execution: difficulty in following a plan or working with numbers, confusion in following a familiar recipe or keeping track of monthly bills, taking much longer to do routine task, confusion in following the rules of a familiar game. 3. Repeatedly losing track of dates, seasons, and the passage of time. 9/Assessing Cognitive Change

4. Problems following/joining a conversation: stopping in the middle of a conversation, repeating the same information, problems finding the right word or calling things by the wrong name (e.g., calling a wrench a "turn tool"). 10/Assessing Cognitive Change 5. Losing or misplacing things: putting things in unusual places (e.g., wallet in bathroom cabinet), losing something and not be able to

retrace steps to find the object, accusing others of stealing. 6. Poor judgment: giving large amounts of money to telemarketers, paying less attention to grooming or hygiene. 10/Assessing Cognitive Change 7. Withdrawal: decreased participation in social activities or sports, trouble keeping up with a favorite sports team, stopping a hobby or

interest without a good reason. 8. Changes in mood/personality: episodes of confusion, suspiciousness, depression, fearfulness; easily upset at home, work, with friends or in places when out of comfort zone. 11/Some Considerations Sudden onset of confusion, disorientation, or behavioral change is not a feature of dementia or normal aging at any age and should

trigger a medical evaluation. 12/Some Considerations There are few factors that produce an earlier age of onset. The most important of these is significant head trauma producing solid evidence of substantial brain injury or repeated minor incidents of head trauma (e.g., as is seen in professional boxers and football players. 13/Some Considerations

A history of common head injury is reported by most older adults and the large majority of alcoholics. There is no evidence that these injuries are related to earlier onset of dementia. Alcohol abuse over long periods of time has a small effect on increase in risk for AD. 14/Some Considerations

A family history of dementia should not be considered a diagnostic criterion in assessing cognitive decline. Reliable assessment of cognition in alcoholic veterans should be done after at least 30 days of sobriety. 15/How to Assess and Refer If there are indications that a veteran age 65+ is showing signs of

cognitive problems, a quick screening may help to focus a consult request. Currently, the most reliable and efficient of the screening instruments for dementia is the Montreal Cognitive Assessment (MOCA). 16/How to Assess and Refer

The MOCA has been widely studied and used in the US and is frequently used in VA settings. It is relatively easy to learn to administer and can be completed and scored in about 15 minutes. There is no fee/charge. The MOCA form and instructions for administration/interpretation for the English version can be obtained at 17/How to Assess and Refer MOCA consists of 13 mini-tests:

Trail-Making, Copying, Clock Drawing Animal Naming List Learning (Immediate Recall) Digit Span, Letter ID, Serial 7s Sentence Repetition, Letter Fluency Abstractions List Recall (Delayed Recall) Orientation 18/How to Assess and Refer

If your MOCA screen is positive, you want to refer the veteran for a full dementia workup. Check with your local VA hospital/clinic Neurology and/or Psychology Services to see which clinics handle these referrals. Your referral should briefly state the clinical reason for concern and the result of the MOCA evaluation. 19/Sample Consult Request This is a 68 y/o homeless veteran with HS educ, previously employed as a store sales manager. He is sober X 2 mos, medically

stable, has no acute health problems. In our program, he has difficulty organizing his day, becomes confused following even simple instructions, forgets appts, repeats same questions about appointment, tasks, etc. over and over. A MOCA administered yesterday revealed a score of 21. Please evaluate for cognitive decline/dementia. Building Relationships and Providing Support in the Community Marilyn Warlick, LCSW, LCAS, C-CATODSW Building Relationships and Providing Support in the Community Effects of losses in aging are increased through experiences of

being: A Veteran A Homeless Person Two individual Veterans and Case Management -- benefits offered in connecting. 48 Advocate.. to manage change and connecting to community 70+ year old Veteran kicked out of his house after he and his wife separated. The Veteran received $780 a month in SSD income not eligible for a NSC Pension. He had severe COPD and was living in his car for about 4 months. The Veteran presented to the PACT team social worker who advised the HUD VASH team in but there were no vouchers. The Veteran was hospitalized frequently in local community hospitals generally 4-5 times a month for a few days at a time where they would recommend o2 for him but were unable to

provide it as he lived in a car. He would spend his days at the outpatient clinic canteen area so he didnt have to sit in the car, and nights after the clinic closed at a local Walmart until he went to his local car to sleep. His case worker worked with him to try to find alternatives until he was willing to move then contacted HUD VASH to see if there were vouchers available in that county. Housing was found quickly for him in a 55+ apartment complex. He was hospitalized about 8 times between the intake and his move in as it was summer and very very hot, but he didnt want to go to a shelter. Hes been in housing now over a year and a half. Has home 02, is active with the local elderly services department who helps him with food and transportation, and has started to reconnect to his family who he was estranged from for several years. 49 Isolation: health care and housing accommodations for aging: I can talk with you

60 y/o Successfully managed HUD VASH independent living 4 years with 4+ yrs sobriety, meetings close communications with two children and former wife Past 6 months saw, 3 Admissions due to dehydration, wt loss, depression. Increasing difficulty with digestion, lack of interest to prepare meals care for his home. Refused Social Security application living off 30%SC. Through Discuss of losses, feelings of loneliness and value of relationships with his children could motivate for application to Social Security. Family discussion of care in place, discussions with members in acute care Medicine and Psychiatric Units as well as Primary Care Provider Team Members for in home supports, extended in hospital stay or move to other extended stay options. 50 Foundations for Clinicians in Building Relationships and

Providing Support in the Community Build skills of meeting the Veteran where they are In Their Home. Role of mentors and resources over the years Presence to the suffering in this moment Connecting Best Practices in Research to the present moment, the present relationship Effective use of self and team - resilience 51 The Importance of Working with Entitlements SOAR Ann Shahan, BSN, M.Ed Mainstream Income Benefits

Ann Shahan VACO-HUD-VASH Regional Coordinator 206-437-9125 [email protected] SSI & SSDI: The Basics SSA: Social Security Administration SSI: Supplemental Security Income; needs based; federal benefit rate is $733 per month in 2016; provides Medicaid in most states SSDI: Social Security Disability Insurance; amount depends on earnings put into SSA system; Medicare generally provided after 2 years of eligibility The disability determination process for both programs is the same

VETERANS HEALTH ADMINISTRATION Definition of Disability The definition of disability and application process is different for VA and SSA benefits Discharge status is not a factor in SSI/SSDI determination Disabling condition does not need to be related to military service Those denied for VA benefits may still be eligible for SSI/SSDI Veterans can access SSA benefits while they are waiting for VA benefits There is no partial disability with Social Security VETERANS HEALTH ADMINISTRATION SOAR Technical Assistance Initiative SOAR SSI/SSDI Outreach, Access & Recovery

Focuses on people who are experiencing or at risk of homelessness A model for assisting individuals to apply for Social Security disability benefits Sponsored by the Substance Abuse & Mental Health Services Administration (SAMHSA) in collaboration with SSA since 2005 SOAR is active in all 50 states; no direct funding is provided to states SOAR TA Center helps states and communities by providing technical assistance and training VETERANS HEALTH ADMINISTRATION Importance of SSI/SSDI for Veterans SSA disability benefits can provide access to: Income Veterans can receive SSI/SSDI in conjunction with, or as an alternative to, VA disability benefits

Health insurance Veterans can use the Medicaid and Medicare health benefits that comes with SSI/SSDI to supplement VA health services For Veterans with disabilities, SSI/SSDI can increase income and housing stability, and reduce their future risk of homelessness Opportunity for staff serving Veterans to help with both SSA and VA disability benefits VETERANS HEALTH ADMINISTRATION VA Caseworkers Guide VETERANS HEALTH ADMINISTRATION SOAR Online Course Free, web-based course to train case managers in completing SSI/SSDI applications using SOAR Standardized, self-paced training Includes completion of a practice SSI/SSDI application Individualized feedback from the SOAR TA Center 16 CEUs from NASW Class 1 of the course provides a SOAR 101 VETERANS HEALTH ADMINISTRATION Get Involved with SOAR Find your SOAR TA Center Liaison Find your SOAR State Team Lead


Ability to express choice Ability to understand relevant information Ability to appreciate information as it impacts self case Ability to reason using relevant information in ones 62

What Rights are Examined? MEDICAL FINANCIAL LEGAL RESIDENTIAL 63 BRAINSTORMING FOR THE FUTURE Partnerships with other agencies. Expansion of medical foster homes. Developing small, group homes. Expanding the use of vouchers in medical foster homes, community living centers, assisted living facilities, etc.

Committees/Boards 64 The alleged incapacitated person has the capacity to: make informed decisions regarding his/her right to marry. make informed decisions regarding his/her right to personally apply for government benefits. make informed decisions regarding his/her right to have a drivers license or operate a motor vehicle. make informed decisions regarding his/her right to travel. make informed decisions regarding his/her right to seek or retain employment. make informed decisions regarding his/her right to contract. 65 (continued)

The alleged incapacitated person has the capacity to: make informed decisions regarding his/her right to sue, or assist in the defense of suits of any nature against him or her. make informed decisions regarding his/her right to manage property or to make any gift or disposition of property make informed decisions determining his/her residence.

make informed decisions regarding his/her right to consent to medical and mental health treatment. make informed decisions affecting the social environment or other social aspects of his/her life. 66 Please indicate those areas in which the person LACKS THE CAPACITY to make informed decisions regarding his/her rights and for which a less restrictive method of protective services is not adequate to protect the person from a substantial risk of harm to his/her personal welfare or financial affairs. Decisions concerning travel or where to live.

Consent to or refusal of medical or other professional care, counseling, treatment or service. Permitting access to, refusal of access to or consent to release of confidential records and papers. Control or management of real or personal property or income from any source. Acting as a member of a partnership. 67 Continued. Management of a business. Making contracts. Payment or collection of debts. Making gifts. Initiation, defense, or settlement of lawsuits. Execution of a will or waiving the provisions of an existing will.

Decisions concerning education. 68 Aging and the Homeless Community Follow Up Presentation: Implications for the Field Research to Practice Medical and Psychiatric Considerations Building a Community Consortium Cognitive Decline in Aging Homeless Veterans

Building Relationships and Providing Support in the Community The Importance of Working with Entitlements SOARS Decisional Capacity and Barriers 69 Aging and the Homeless Community Follow Up Presentation: Implications for the Field Thanks to presenters TMS registration link

Archive will be available Thanks for attending 70 Presenter Bios James Goodlett McDaniel, EdD, PMHNP-BC, MBA James Goodlett McDaniel is certified as a PMHNP-Family working for the Veterans Health Administration in the Health Care for Homeless Veterans Program in Jacksonville, Florida. Licensed in both Virginia and Florida. Dr. McDaniel has been a nurse practitioner since 1995. He has served as an associate provost at a large public University, created and managed psychiatric and long-term care programs; created new community models for delivery of capitated services with a community mental health center; and, has delivered, managed, and taught in innovative educational programs for undergraduate and graduate nurses. ARACELI ORONA, LCSW Since 2010, Araceli Orona, Licensed Clinical Social Worker, has served in various capacities within the homeless program at Jesse Brown VA Medical Center in Chicago, IL. Araceli Orona has had the privilege in contributing to the VA mission as a HUD VASH SUD Specialist, HPACT Social Worker, Program Coordinator for Community Resource and Referral Center, and currently as the Coordinator for the Aging Veteran Project and a Team Lead for the HUD VASH program.

Throughout her experiences within the VA, Ms Orona continues to demonstrate great passion and conviction in meeting the VAs mission to End Homelessness. John Schinka, PhD After receiving his PhD at the University of Iowa, John A. Schinka joined the staff of the Tampa VA Medical Center and the Department of Psychiatry at the University of South Florida. He established the Memory Disorder Clinic at the Tampa VA and helped to develop the Byrd Alzheimer's Disease Center at the University. After thirty years of clinical work, research in aging and cognition, and supervision of interns and residents, Dr. Schinka joined the National Center on Homelessness among Veterans to work on research on homeless veterans. He recently retired from the VA and is now a Professor of Aging Studies at the University of South Florida. Marilyn Warlick, LCSW, LCAS, C-CATODSW Ms Warlick has worked within the VAMC for over 25 years. During these years she has worked in various settings including Geropsychiatry and Substance Abuse Programs and serving as Clinical Coordinator for the OEF/OIF Program and Coordinator for Hospice and Palliative Care Program. Marilyn is currently working as Case Manager with the HUD/VASH Program serving our homeless Veterans in Tampa, Florida. Ann Shahan, BSN, M.Ed. Ann Shahan, BSN, M.Ed., started her career with the Veterans Health Administration in 1983 as a staff nurse on an inpatient psychiatric unit. Prior to her current positon with VACO as Housing and Urban Development-Veterans Administration Supportive Housing Regional Coordinator, Ann was the Network Homeless Coordinator for VISN 20 and Homeless Coordinator for Puget Sound Health Care System in Seattle, Washington.

Lisa Moody, LCSW Lisa Moody is a Licensed Clinical Social Worker currently working with the HUD VASH team in Tallahassee, Florida. Ms Moody also worked with Home Based Primary Care with the VA before transferring to HUD VASH. Lisa holds a small clinical practice outside the VA and conducts capacity evaluations for the Courts. 71 Contact: VHAs National Center on Homelessness among Veterans Roger Casey, PhD Director, Education and Dissemination [email protected] Brenda Johnson, LCSW, CCM, VHA-CM Education Coordinator [email protected]


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