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Coordinating care: navigating services for homeless veterans

A national program of U.S. Department of Veterans Affairs will fund suicide prevention programs through 2025. Pictured is the VA Medical Center in Wilkes-Barre.
The Wilkes-Barre Veteran Affairs Medical Center (VAMC) connects homeless veterans to housing programs like rapid housing and transitional housing through community partners.

Filing for veteran benefits takes time, usually months to complete. But homeless veterans cannot wait for their benefits to start and neither can the organizations that serve them.

There are a few options for veterans needing immediate support. Crystal Arcarese, chief of social work at the Wilkes-Barre Veteran Affairs Medical Center (VAMC), says homeless veterans can contact their local VA to start a process called ‘coordinated entry’.

“If a veteran that’s not known to the VA enters that system, there’s a partnership. They will refer to the VA to try to engage in any services. They [also] will refer to any community programs, Supportive Services for Veterans and Families. And then we work conjointly to say, 'Which program would they qualify for and which program has an opening,'” says Arcarese.

Local VA’s coordinated entry systems collaborate with the U.S. Department of Housing and Urban Services (HUD) to make sure that homeless veterans do not slip through the cracks in the system, says Arcarese.

During coordinated entry, homeless veterans’ needs are evaluated, according to Wilkes-Barre VA’s Homeless Coordinator and Grant Per Diem Liaison Shannon McLafferty.

“We do a HOMES Assessment, which is a homeless assessment,” says McLafferty. “It’s pretty lengthy, but it basically gives us an idea of what the next step should be. We certainly want to meet the veteran where they’re at, so [we’re] looking at where they want to see themselves, right? Where is their housing goal?”

Veterans are matched to housing programs based on their goals, mental state, and finances. However, Arcarese says that linking veterans to homeless services or providing resources like a pre-paid smartphone is not a problem. Something more concerning is on her mind.

“We can’t find housing. We can’t find landlords that actually have housing that would meet housing quality standards,” says Arcarese. “The rent rates – so, we have developers that come in and build up properties, but they don’t dedicate a number of beds for subsidized housing.”

McLafferty adds that her biggest concern in serving her veterans is finding transportation, especially after the pandemic.

“So, during COVID, we had a rideshare program where we were able to offer Uber and Lyft rides to any homeless veteran. They had to be enrolled in our homeless services, but we could offer them rides to their medical appointments, let’s say they had a court date, to the grocery store,” says McLafferty.

Besides housing and transportation, Jennifer Spitler, NEPA’s Regional Program Outreach Coordinator for the PA Department of Military and Veteran Affairs, says veterans living in rural areas face additional barriers in accessing veteran services.

“In Scranton and Wilkes-Barre, y’know, there’s amazing resources right there,” says Spitler. “But if you are outside of there, if you’re in Bradford, Sullivan, Susquehanna, Wayne, Pike – any one of those counties, getting access to those things, especially for a veteran – that’s even if you’re willing to ask for them – is still going to be challenging.”

Spitler coordinates with Together with Veterans NEPA (TWV,) a suicide prevention program designed for vets living in rural areas. She says veterans, especially those living in rural areas, are less likely to ask for help – it goes against veteran culture.

“You might not think you’re worth it,” says Spitler. “We definitely see a lot of veterans who feel [that] ‘somebody needs it more than me’...very classic veteran mentality of putting others before themselves, because of that culture of service.”

Finding that balance between offering support to veterans and respecting their boundaries is challenging for providers, says McLafferty. However, she prides herself on serving veterans on their own terms.

“We want to have them understand that we’re not here to judge them. We understand…their hardships. We understand [their] I think maybe frustration with the [veteran services] system, because the system can be very overwhelming. So, we try to make [navigating the system] as seamless, but also simplify it as best as we can,” says McLafferty.

Veterans needing assistance with filing for their benefits or for other services can reach out to their local VA for support.

Isabela Weiss is a storyteller turned reporter from Athens, GA. She is WVIA News's Rural Government Reporter and a Report for America corps member. Weiss lives in Wilkes-Barre with her fabulous cats, Boo and Lorelai.

You can email Isabella at isabelaweiss@wvia.org