Abstract
BACKGROUND: The COVID-19 pandemic intersected with a housing crisis for unsheltered Veterans experiencing homelessness (VEHs); congregate settings became high risk for viral spread. The VA Greater Los Angeles responded by creating the Care, Treatment, and Rehabilitation Service (CTRS), an outdoor, low-barrier-to-entry transitional housing program on VA grounds. This novel emergency initiative offered a protected outdoor environment ("sanctioned encampment") where VEHs lived in tents and had access to three meals a day, hygiene resources, and health and social services. OBJECTIVE: To identify contextual factors that supported and impeded CTRS participants' access to healthcare and housing services. DESIGN: Multi-method, ethnographic data collection. PARTICIPANTS: VEHs residing at CTRS, CTRS staff. APPROACH: Over 150 hours of participant observation were conducted at CTRS and at eight town hall meetings; semi-structured interviews were conducted with 21 VEHs and 11 staff. Rapid turn-around qualitative analysis was used to synthesize data, engaging stakeholders in iterative participant validation. Content analysis techniques were used to identify key factors that impacted access to housing and health services among VEHs residing in CTRS. KEY RESULTS: Staff varied in their interpretation of CTRS' mission. Some conceptualized access to health services as a central tenet, while others viewed CTRS as an emergency shelter only. Regardless, staff burnout was prevalent, which lead to low morale, high turnover, and worsened access to and quality of care. VEHs endorsed trusting, long-term relationships with CTRS staff as paramount for facilitating access to services. Though CTRS addressed basic priorities (food, shelter, etc.) that traditionally compete with access to healthcare, some VEHs needed on-site healthcare services, at their tents, to access care. CONCLUSIONS: CTRS provided VEHs access to basic needs and health and housing services. To improve access to healthcare services within encampments, our data suggest the value of longitudinal trusting relationships, adequate staff support, and on-site health services.