Innovating Outreach to Unconnected Veterans

A veteran sits in a folding chair inside a sunlit room with brick walls, gesturing expressively as he appears to be in conversation. He is wearing a military uniform with an American flag patch on his sleeve. The room has large windows with horizontal blinds, allowing sunlight to stream in.

This year in the United States, 40% of Americans will experience material hardship.  However, less than half will receive help from any source. There are a variety of reasons behind this heartbreaking statistic. Like many people we’ve interviewed, some Americans say they were “taught to be independent” and “can tough it out.” Others feel ashamed of asking for help, especially from government programs with a stigma attached to them. Still, others don’t know what programs are available to them. 

These barriers can lead to differences in program take-up. For example,  44% of qualified women and children in North Carolina are not enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Nationally, the US Department of Agriculture estimates that 22% of eligible people do not participate in the Supplemental Nutrition Assistance Program (SNAP), colloquially known as food stamps. 

These barriers to seeking help are also prevalent among US veterans. According to the most recent data (2017), less than half of veterans use any VA benefit or service in a year. Nearly 20 percent of veterans have no health insurance

The gap between the number of people who qualify for programs and services and those who enroll is often called the take-up gap. Previous research has extensively documented the take-up gap in government programs. However, fewer studies have examined interventions to reach people with social needs unconnected to services. 

This summer, NNSI researchers Qiwen Zhang, Yeha Kim, Tatum Thomas, Yasmin Zaiani, Janice Yoo, and director Michelle Shumate are investigating one innovative outreach program targeting these veterans in North Carolina. Veterans Services of the Carolinas, a Asheville Buncombe Community Christian Ministry (ABCCM) program, has begun a unique outreach program to connect veterans with services. They call it Project Delorean. They are using predictive analytics social needs scores, a product of Unite Us, as the beginning of personalized outreach to veterans

The Project Delorean team begins with a list of veterans the model believes have high social needs but are not connected to services. Reaching out to these veterans via e-mail and phone reduces the learning costs of getting help. They succeed in reaching these clients about 30% of the time.

Once the team reaches the individual, they do a comprehensive intake screening. They use techniques like motivational interviewing to get to know the veteran, build trust, and understand their needs. This allows them to develop a plan for addressing immediate and long-term needs. 

Veterans Services of the Carolinas is one of the coordination centers for NCServes. So, whether the veteran needs a service that ABCCM can provide or needs to make a closed-loop referral to one of the other veteran servicing providers in the network, they can be sure that the veteran will receive the requested service. Project Delorean is reaching people that Veterans Services of the Carolina hadn’t reached before. According to one staff member: 

I think the entire project is working well because it’s hitting a completely different area of people we didn’t know needed help. Because before, if they called us, they needed help, we’d put stuff out there and hope that they’d see it and call us. And now that we have these predictive analytics, we’re helping significantly more people because we are calling them and trying to get them help before they don’t know what else to do.”

The NNSI team has been investigating this potentially innovative model. We began documenting the outreach process last spring and which clients were receiving priority. This summer, we’re taking a deep dive into predictive analytics and the program’s outcomes. We are comparing the services requested by clients who come through Project Delorean to clients who independently come through the no-wrong-door NCServes’ system. 

Early results suggest that project Delorean clients are more likely to request help with Benefits Navigation than their traditional NCServes clients. These early results suggest that the opacity of benefits remains an important barrier to those requesting help. Later this summer, we’ll update this blog with new results and a link to a white paper. 

This research is part of our research agenda on integrated social care. The lab is committed to researching innovative solutions to connect people to needed services. We are always open to hearing from partners about new social care innovations. Please contact our director, Michelle Shumate, at if you have a project to tell us about.