Its difficult to say whether Delmar Dreaming Bear struggles more asleep or awake.

Some nights he dreams that the ground is about to swallow him. Other nightmares feature killers in pursuit. If he wakes, say, around midnight and doesnt want to go back to sleep, his adult son may sit up with him until sunrise. But daylight brings its own challenges: Dreaming Bears bandages need changing and his colostomy bag, which dangles down where his legs used to be, requires emptying.

This cycle has repeated itself for months in a Point Loma motel where Dreaming Bear, a 73-year-old Vietnam veteran, lives with several members of his family, including grandchildren who are only a few years old.

He believes stable housing would help him heal, and there is ample rental assistance available for homeless veterans. Yet records show that the VA San Diego Healthcare System has at least temporarily denied him a housing voucher on the grounds that hes too ill to live independently.

Dakotah Dreaming Bear, 28, and her brother, Phillip, are caretakers for their father, Delmar, who lives in a Point Loma motel. Dakotah sleeps in the room next door with her six children. (Nelvin C. Cepeda / The San Diego Union-Tribune)

That decision leaves him feeling like hes in a catch-22. How can he get better in a room so small that his wheelchair barely makes it into the bathroom?

The aid Dreaming Bear applied for, the Veterans Affairs Supportive Housing program, or VASH, is unquestionably a success story. The vouchers have been credited with cutting veteran homelessness in half nationwide, and the federal government announced in October that the tens of thousands who were housed last fiscal year amounted to the programs highest total since before the pandemic.

These efforts are built on the evidence-based Housing First approach, the U.S. Department of Veterans Affairs wrote in a news release, which prioritizes getting a Veteran into housing, then providing or connecting them with the wraparound services and supports they need to stay housed, including health care.

San Diego County has sometimes struggled to use all of its available vouchers, and local leaders have partially blamed the regions brutal housing market. But the local VA, under pressure from members of Congress, has recently increased how many veterans are screened for the program.

Dreaming Bear was born in Pine Ridge, South Dakota, within one of the countrys largest Indian reservations. Military records show he enlisted in the U.S. Army as a teenager in 1969 and was trained as a rifle sharpshooter and ammunition specialist. The decorations he earned in the following months included the Vietnam Service Medal, reserved for those deployed to Southeast Asia during the war.

He was honorably discharged in 1971 and returned to the reservation. His years there felt unstable, he said in an interview. Pine Ridge has a long history of violence — a 1973 confrontation at Wounded Knee between activists and federal officials left several people dead — as well as high levels of poverty. Dreaming Bear said one trailer he lived in lacked running water.

Over the years, his health deteriorated.

Dreaming Bear has struggled with diabetes, arthritis and sepsis, according to medical records he agreed to share with The San Diego Union-Tribune. He has post-traumatic stress disorder. The VA believes his exposure to herbicides during the Vietnam War likely contributed to his coronary artery disease, and all that comes on top of two knee replacements that devolved into a double leg amputation. This is by no means a comprehensive list.

Delmar Dreaming Bear, 73, lives in a motel with his 31-year-old son, Phillip Dreaming Bear. The two slept on the streets of Ocean Beach before they were connected with the nonprofit Housing 4 the Homeless. (Nelvin C. Cepeda / The San Diego Union-Tribune)

Near the start of the year, Dreaming Bear decided he wanted a change. Decades ago hed lived in El Cajon. Why not again try San Diego County?

Dreaming Bear headed south with two adult children and six grandchildren. When the family arrived in February, Dreaming Bear and his son, Phillip, began sleeping outside in Ocean Beach. His daughter, Dakotah, and her children squeezed into their Chrysler Town & Country.

An outreach worker found them all and helped connect the family to several services, including the nonprofit Housing 4 the Homeless, which currently provides them with two motel rooms in Point Loma. One holds Dreaming Bear and his son while the other is for his daughter and grandchildren, whose ages range from 1 to 12. Theres no fixed end date to that aid, although Joanne Standlee, the nonprofits executive director, said funding is always tight.

The local VA has helped as well. The agency gave Dreaming Bear a hospital bed, an electric wheelchair and pays his daughter $17 an hour for 13 hours of caretaking work a week.

But officials have balked at extending a housing voucher. In a July 10 letter, the agency told Dreaming Bear he was not eligible for rental assistance as a result of his medical instability and recommendations for a higher level of skilled care that cannot be provided by the HUD-VASH program.

The issue was revisited in early October during a conference call between a social worker, members of the VAs Homeless Patient Aligned Care Teams and representatives of the VASH program. A sustained period of stabilization, likely 90 days, is necessary before moving forward with his transition to VASH housing, the group wrote in notes reviewed by The San Diego Union-Tribune.

Dreaming Bear was hospitalized in August. In September, officials decided he must be able to stay out of the hospital for around three months before a voucher could be re-considered, records show. The VA plans to meet again about his case in December.

Phillip Dreaming Bear, 31, cares for his father, Delmar Dreaming Bear, 73, in a Point Loma motel. (Nelvin C. Cepeda / The San Diego Union-Tribune)

The team has also stressed the importance of increased involvement from Dreamingbears children, the notes said. Looking ahead, the team will closely monitor Dreamingbears stabilization progress with the goal of moving him to VASH housing once the necessary criteria are met.

Its not entirely clear what those criteria are.

Dreaming Bear signed a document allowing the VA to comment on his case and a reporter delivered it last month to the agencys La Jolla facility. But a VA official quickly rejected the form on the grounds that it needed to be handed over in person by the veteran.

Instead, the Union-Tribune sent the VA several general questions about the voucher approval process. For example, how does the agency define medical instability?

Typically, Veterans enrolled in HUD-VASH are able to independently attend to their activities of daily living, such as cooking meals or going to the bathroom, a spokesperson wrote in an emailed statement. The VA does not exclude Veterans with medical issues that impact their ability to live independently from HUD-VASH, provided resources are available to safely support them.

The agency does have a Geriatrics and Extended Care Program for people with more extensive health needs, although Dreaming Bears VASH rejection letter and the conference call meeting notes do not list that as an option.

The agency said it does sometimes refer veterans to outside organizations for extra care. Some of these resources may be paid for by the VA, depending on the Veteran’s eligibility, the statement added.

Officials do not track how many veterans are annually denied vouchers as a result of medical instability.