Ethics and the I- CARE Values in HUD-VASH INTEGRITY-COMMITMENT-ADVOCACY-RESPECT-EXCELLENCE

1. Ethics and the I- CARE Values in HUD-VASH INTEGRITY-COMMITMENT-ADVOCACY-RESPECT-EXCELLENCE Ann Shahan, BSN Teresa Pittman, LCSW

2. Why Ethics and I CARE? • We are ambassadors of the VA – everything we do as individuals reflects on VA as a health care provider and organization • Show how much we care about Veterans • Become Veterans’ preferred provider of choice • Change the negative perception of the VA • Core Values provide a structure for our culture and how we relate to our stakeholders • Relevant, meaningful and actionable • Something we can live by each day

3. Who ARE You? • What are your personal ethics and how are those demonstrated in your work? • What are your professional ethics and how do you personally connect with those? • Boundaries • Trust • What is the culture of the VA where you work? • Honesty • What is the culture of the team you are on? • Veteran-centric care • Documentation of your work/ HOMES/Work Load

4. Ethical Domains • Stewardship • Resources • Time • Services delivered to Veterans – are we meeting their needs? • Responsiveness • How nimble are we to respond to a homeless Veteran’s needs? • How quickly are we able to help a Veteran to obtain safe/decent shelter/housing • How quickly can we help a Veteran to exit from homelessness? • Are we responsive to the needs of the Veteran or to our own needs? • Quality • Are we providing cutting edge services and care? Using Best/Innovative Practices? • Are we looking at the effectiveness of our program to meet the needs of Veterans? • Are we providing good data so we have a accurate picture of how we are doing? • Do program improvements address those areas where we are missing the mark?

5. VA’s Core Values VA has a set of values that are provided to set the ethical culture of the VA • Integrity • Commitment • Advocacy • Respect • Excellence

6. Integrity • Definition: Adherence to moral and ethical principles; soundness of moral character; honesty. Virtue. • Examples of Integrity in HUD-VASH: • Following the ethics of your professional organization • Maintaining appropriate boundaries • Being honest with the Veteran, in documentation, on HOMES forms • Being genuine with the Veteran • Real concern for the Veteran’s well-being

7. Example of Poor Integrity • Manipulating HOMES entries so that Performance Measures are improved (time in HUD-VASH) • Showing up at community planning meetings, but not engaging with what VA can bring to the process/resolution • Engaging in a dual relationship with a Veteran client • Check: • Honesty – of the process, data, promises • Are your actions demonstrating you are trustworthy? • Do you consider what is in the best interest of the Veteran?

8. Great Field Example of INTEGRITY • In New York State, they have been grappling with their HOMES data accuracy, which is more difficult because of the way the VISN is all under one facility code. They have worked very hard to straighten out their data and to ensure that it is accurate. Recently, they noted that the issues were related to the returned vouchers held by Veterans who were no longer receiving case management. Because they didn’t have a way to exit them from the system, this kept the numbers looking inflated rather than the “real” number of housed Veterans, which they saw as a problem. However, with the new Housing and Employment Tracker, they can now exit those Veterans in HOMES and ensure that their data reflects their true number of housed Veterans.

9. Commitment • Definition: A pledge or promise; an accepted obligation. Engagement; involvement. • Examples of Commitment in HUD-VASH • Keeping appointments • Being on time • Meeting promises • Actions of support for the Veteran • Actions to meet the mission • Timely and accurate documentation • Program improvement actions

10. Examples of Poor Commitment • Making a referral, but not ensuring the Veteran is able to follow-up with the referral - No warm hand-off • Seeing a Veteran once a month, not based on acuity but because the Handbook says a minimum of once a month • Not documenting in HOMES • Lack of program improvement activities • Check: • Commitment to ending each Veteran’s homelessness • Belief in achieving the mission • Willingness to “go the extra mile”

11. Great Field Example of COMMITMENT • A 58 year old male veteran, living in permanent housing and enrolled in HUD-VASH had open wound on leg that was infected.  The primary care physician (PCP) informed nurse (RN) that this veteran would likely lose his let to amputation in the next month if Veteran did not stay off his leg. The nurse and occupational therapist (OT) consulted with PCP.  The RN and OT went to the Veteran’s home to provide education and identify any barriers that he may have to staying off his leg and how they could assist. The RN, OT and Veteran set a goal of staying off his leg for five days and would only walk on his leg when he went to the bathroom and to prepare meals. The OT assessed the Veteran’s interests and we went to a local store and she purchased puzzles, models and puzzle books for the Veteran to work on for the five days. The interdisciplinary team visited the Veteran each day to provide support and assist with addressing barriers. The RN visited daily to assess medical needs. • The team was able to get a meals on wheels program to deliver his meals for a few weeks-so he did not have to cook. The Veteran met his goal of staying off of his leg for five days  and when he attended his PCP appointment, the doctor was pleased with his progress.   This was several months ago and the veteran continues to heal and is managing his chronic illnesses.

12. Advocacy • Definition: The act of pleading for, supporting, or recommending; active support, especially of a cause • Examples in HUD-VASH: • Assist the Veteran to stabilize and sustain their housing • Appeal process with the PHA • Assist the Veteran to gain the resources they need –security/utility deposits, furniture, etc. • Helping to lower child support payments to a manageable amount • Obtain access to resources such as SSI/SSDI, NSC, SC, food stamps, etc. • Obtain access to needed medical and mental health treatment as requested

13. Examples of a Lack of Advocacy • Giving the Veteran the address for a service– no warm handoff, no assistance to get there or connect • Holding on to information about the Veteran that could help the Veteran to receive better care • Not intervening with the landlord to try to work out a solution, like a payment plan for overdue rent • Check: • Your follow up/follow through • Look for options/needs • The Veteran’s ability to advocate for him/herself

14. Great Field Example Of ADVOCACY A Veteran in Minnesota is enrolled in the HUD-VASH program. He is a disabled Veteran. Once he was housed, he got a job so he could earn money to help other homeless Veterans. The PHA would not allow the Veteran to utilize the Earned Income Disregard because he did not check the “disabled” box on the voucher application. The Veteran was over income. He had to pay his full rent and no longer has the voucher subsidy. The case manager felt this was wrong and helped the Veteran to appeal this with the PHA. The hearing officer agreed and ordered the PHA to return the Veteran to his voucher, pay back the difference on the rent subsidy, and essentially make things right for the Veteran. The PHA said the hearing officer overstepped his authority and refused. The case manager is seeking higher level assistance – first with HUD, now is looking for other help with this. He continues to advocate for this Veteran to make things right for him.

15. Respect • Definition: • Esteem for or a sense of the worth or excellence of a person, a personal quality or ability; • Deference to a right, privilege, privileged position, or someone or something considered to have certain rights or privileges; • Proper acceptance or courtesy; acknowledgment such as respect for the elderly.; • The condition of being esteemed or honored; • A formal expression or gesture of greeting, esteem, or friendship

16. Respect Examples of Respect in HUD-VASH: • Greeting the Veteran and making him/her feel welcome • Promoting Veteran independence and decision-making • Being on time • Listening • “Walking in the Veteran’s shoes” • Allow the Veteran to control his/her life, making informed choices and decisions, respecting them enough to let them succeed or fail but always learn • Veterans earned their benefits with their service; It is a privilege to be able to provide services to them

17. Examples of Disrespect • Calling a Veteran by his or her first name without being invited to do so • “Surprise” visits to the Veteran’s home • Telling the Veteran what he or she has to do rather than informing the Veteran of the options or steps to achieve a goal – denying choice • Speaking disrespectfully about a Veteran with another person • Check your: • Tone • Attitude • Body Language • Words

18. Great Field Example of RESPECT In Houston, the HUD-VASH team was working with a chronically mentally ill homeless woman who would work very hard to obtain housing, but then would invite her family. Each time this, resulting in eventual loss of her home either due to the behaviors of family members, or relapse. The team began to work with her in a different way, after an episode where she was evicted. They spent more time helping her to work through her feelings about her family, and providing options for her to provide support without jeopardizing her housing. They shared information about resources, and was able to help her work through her feelings of guilt and shame over past behaviors. Over time, the Veteran began to trust them enough to share her feelings, and this led to her willingness to make positive change. This team worked with the principle of meeting the Veteran where she was and this display of respect changed the Veteran’s entire outlook on the program. They respected his process and took things at the Veteran’s speed.

19. Excellence • Definition: Being exceptionally good; extreme merit; superiority; An action, characteristic, feature, etc. in which a person exceeds. • Examples in HUD-VASH: • Rapidly housing Veterans • Reducing the time from first contact to housed • Helping the Veteran to develop useful new skills • Performance Improvement • Helping the Veteran to stay housed

20. Barriers to Excellence • Doing things “the way we have always done it” • Being closed to new ideas/processes/models • More worried about fallout/blame than the Veteran’s needs • Following the letter of the law instead of the spirit of the law • Check: • How are others doing this work? What is the “cutting edge?” • Am I open to trying new things/models? • What is the “big picture” and how am I working to achieve that?

21. Great Field Example of EXCELLENCE A Veteran living in Canada became homeless when his marriage ended. He wanted to return to his home community in Missouri, but he didn’t have the resources. Working together, the VA HUD-VASH staff in Missouri and in New York State helped the Veteran to return to the United States and get to Missouri. The story is much richer than this. The Western New York team was in contact with the Canadian Consulate, who helped the Veteran to make it to Buffalo. Once there, the Veteran was provided with a hotel room and food from McDonalds because he couldn’t travel further due to an approaching winter weather system. He wanted something to remember Buffalo by, so they went to their clothing room and found a Buffalo Bills winter hat and lanyard. They helped him to catch the bus to Missouri, after making sure he had breakfast and money for the trip from the General Post funds. The Veteran decided to return to Buffalo, where he was quickly housed in the HUD-VASH program. He continues to be successfully housed there and in the great care of the Buffalo team, who demonstrated to the Veteran early on how much they cared about him through their personalized, efficient and comprehensive actions.

22. Ethics in I CARE • Notice ethics in I CARE is not specifically one of the I CARE elements • It is found interwoven in the different parts of I CARE • Integrity – Following a code of ethics/morality/virtue. You are your word with actions that support what you say • Commitment – Ethic of making the commitment to make things different for another person or persons; being your word; making the change needed in the world • Advocacy – Ethic of ensuring that the commitment is met with direct action and ethical purpose; promoting the rights of the Veteran, noting the impact of the program on the Veteran’s life; supporting housing choice • Respect – Ethic of the Golden Rule; recognizing the Veteran as a valued member of our society with special honors; actions of respect • Excellence – Ethic of hard work, honestly achieving measurable outcomes, developing program changes to improve the outcomes for Veterans

23. Stakeholders • Ethics and the I CARE values apply to ALL Internal and External Stakeholders • Competent, professional actions • Courtesy toward all; show recognition for the dignity and worth of all human beings • Provide reliable assistance and services • Embrace diversity of people, ideas, perspectives and processes • Develop partnerships • Sustain appropriate boundaries/prevent dual relationships • Accurately present yourself, your organization, your profession, and stakeholders viewpoints/feedback • Be strengths based with a positive focus

24. Summary • VA’s I CARE values and ethical interactions with stakeholders are closely tied together • Working together to implement a cultural change in our VAMCs takes consistent messaging, action, and review, with changes to meet the I CARE culture • What you do as an individual shapes the larger group and brings about the cultural changes needed in VA • How are you demonstrating I CARE and ethics? • Celebrate when the team demonstrates I CARE and ethics! • Strive for consistently keeping the Veteran’s needs in the forefront of all we accomplish

25. Resources • https://vaww.portal2.va.gov/sites/icare/icare/SitePages/WhatIsICARE.aspx • http://www.ethics.va.gov/ • http://vaww.va.gov/VHASERVICECENTER/Workforce_Development.asp • http://vaww.cbi.va.gov/ceweek.asp • http://www.ethics.va.gov/docs/necrpts/NEC_Report_20030701_Ethical_Boundaries_Pt-Clinician_Relationship.pdf

26. Questions? • Ann.Shahan@va.gov • Teresa.Pittman@va.gov