«DiscoVeriNg HomelessNess Volume 13, Number 1 • 2011 U.S. Department of Housing and Urban Development | Office of Policy Development and Research ...»
Literature Review When street life becomes the norm, chronically homeless street dwellers are preoccupied with immediate survival needs (food and a safe place to sleep) and not with long-term service or housing needs. Street-based relationships provide social support but fail to provide the resources needed to move off the streets. Accepting housing or shelter often means a departure from known structures and street friendships (Snow and Andersen, 1993). Co-occurring health, substance-abuse, and mental-health problems, which are often untreated, pose additional challenges for these individuals. Thus, access to housing is rare and the risk of dying while living on the streets is high.
The dominant approach to homeless services, the continuum-of-care (CoC) model, has not been successful in moving street dwellers into housing. This model specifies the need for local and regional planning and the implementation of a coordinated homeless-services system to move
homeless-services consumers out of homelessness. This service integration approach is based on the theory that the coordination of public services increases efficiency, effectiveness, and quality of service delivery, thereby leading to better consumer outcomes (Rowe, Hoge, and Fisk, 1998).
Theoretically, a CoC comprehensive system of care for homelessness entails a network of housing and service programs for homeless people, including street outreach, intake and assessment, shelter and services, transitional housing and services, and permanent supported or unsupported housing, depending on individual needs. The homeless-shelter system provides the link to transitional housing but has had little success in housing chronically homeless individuals (Burt et al., 2004), who, for the most part, avoid the shelter system due to shelter rules, overcrowding, and lack of personal safety. In addition, these individuals are often required to go through lengthy treatment programs as a prerequisite to attain housing, which many of them are not able to handle due to the rules and restrictions of these programs.
Outreach to homeless people, the first step in the CoC model, attempts to contact, assess, and engage individuals (mostly street dwellers) in services for homeless individuals, especially those who are underserved or unserved or those who are unable, unwilling, or reluctant to seek services.
Outreach workers look for homeless people in the streets and parks, under bridges, in abandoned buildings or lots, and in other places where they may settle down for the day or night. The shortterm goal of this work is to connect with homeless people and provide care for their immediate needs. Long-term goals of the effort are to connect street dwellers to available services and housing options and to link them to the safety-net programs for which they are eligible. “Outreach is foremost a process of relation-building” (Erickson and Page, 1999: 6-2), aimed at developing a trusting relationship between the outreach worker and the homeless individual. Because this is potentially a lengthy process, success depends on the homeless individual’s ability to establish trust with a service provider and overcome past negative service system experiences. The study described in this article focused on medical outreach to homeless individuals, which has been integrated into providing medical services to individuals living in the streets and follows the same principles discussed previously.
Outreach to homeless street dwellers, whether general or medical, reaches individuals who are more severely impaired (Lam and Rosenheck, 1999). Street dwellers agreeing to enroll in the federally funded ACCESS (Access to Community Care and Effective Services) demonstration project for mentally ill homeless individuals had more severe medical problems, had a higher degree of substance abuse and psychotic challenges, exhibited greater health and social services needs, and received fewer services before enrolling in ACCESS than their sheltered counterparts. Street dwellers who enrolled in the ACCESS program showed equivalent outcomes after 3 months in the program, when compared with sheltered homeless individuals (Lam and Rosenheck, 1999). Further, positive housing outcomes have been linked to successful outreach services (Erickson and Page, 1999).
A positive association between the number of service contacts and housing outcomes has been consistently demonstrated (Morse et al., 1994; Pollio et al., 1997). In addition, the timing of an intervention and improved personal relationships between providers and consumers have contributed to better housing outcomes for mentally ill homeless individuals (Jones et al., 2003; Pollio et al., 2000). Further, coordination of service needs and service system integration is important (Goldman et al., 2002; Pollio, 1990; Rosenheck et al., 1998).
Another promising approach for housing chronically homeless individuals is the Housing First model, which attempts to move the most disabled homeless people directly to housing before treatment, using housing as the transforming element to support participation in treatment. This approach does not require sobriety or participation in long-term treatment programs unlike the traditional CoC approach. Promising results have been demonstrated in a number of projects using the Housing First model (Tsemberis and Eisenberg, 2000). In sum, housing for chronically homeless street dwellers who, for the most part, also have substance abuse and psychiatric disability problems can be successful when affordable housing programs match their service needs (Clark and Rich, 2003; Lipton et al., 2000).
Although the mechanisms for positive housing outcomes for street dwellers have been widely researched, the link that medical services to homeless individuals can provide to connect chronically homeless street dwellers to the CoC and housing has received less attention. Medical outreach to homeless people in Boston uses this same street outreach approach. Respite care is put in place to help homeless individuals recuperate from medical illness. Residential substance-abuse services are designed to help with addressing substance abuse problems. Referral services for both service types aim to connect the homeless street dwellers at risk of death to the CoC to foster movement to more permanent housing. For many, however, it may take numerous cycles between moving off the streets into respite or substance abuse treatment and returning to the streets before they are ready to contemplate housing options (Meschede, 2010). To what extent, then, can medical outreach, medical respite care, and substance abuse treatment services connect homeless street dwellers at risk of death to the homeless CoC? Is the theory of change proposed in the CoC model salient to homeless street dwellers and those providing them with medical and substance abuse services?
Because the goal of this study was to assess the contribution of medical and substance abuse services to connecting chronically homeless street dwellers to the CoC and housing, perspectives of current and former homeless street dwellers are a critical part of the analysis. Before this research, however, few studies have attempted to assess the needs of homeless individuals from their own perspectives. An early study of mentally ill homeless individuals found that consumers of services for the homeless point to the lack of access to basic resources, rather than the lack of access to social services, as the major cause of their homelessness experience, rather than the lack of access to social services (Ball and Havassy, 1984, cited in Culhane, Metreaux, and Hadley, 1999). In a more recent homeless consumer needs assessment, conducted as part of the national ACCESS program, long-term housing was the most frequently cited need (91 percent). Access to psychiatric, dental, and medical services and to public assistance ranked high as well, ranging from 78 percent for psychiatric disability treatment to 70 percent for public assistance. More than one-half of the participants also indicated they needed employment assistance (56 percent). Access to substance abuse treatment ranked the lowest (28 percent) (Rosenheck and Lam, 1997). Access to housing and living wage jobs were also underscored as the most important service needs by homeless shelter users in San Francisco (Martin et al., 2000).
Consumers of homeless programs and their case managers often do not agree on the medical service needs of homeless individuals. The greatest differences between consumer and provider regarding perceived levels of need were for dental care (73 percent of consumers and 44 percent of providers), medical services (72 percent of consumers and 55 percent of providers), substance
abuse services (28 percent of consumers and 44 percent of providers), and psychiatric disability services (78 percent of consumers and 93 percent of providers) (Rosenheck and Lam, 1997).
Providers saw a greater need for psychiatric disability and substance abuse services, but consumers valued dental and medical services more highly.
Consumers of homeless programs stated that barriers to needed services include the lack of knowledge regarding where to go for services and the inability to pay for services (Rosenheck and Lam, 1997). They also cited previous negative service experiences, such as long waits, confusion during service delivery, feelings of being hassled during services, and denial of services. In sum, the lack of clarity about where to obtain services, how to pay for services, and previous negative experiences when receiving services were factors that prevented homeless individuals from seeking care.
In a survey of 400 homeless people in San Francisco (Martin et al., 2000), many expressed their dislike of homeless shelters. Complaints included dirty and insufficient facilities, high noise levels, and disrespectful shelter staff. In addition, they said that shelters did not provide a comprehensive service system centered on helping individuals with exiting homelessness as they had hoped for.
As such, homeless individuals stressed the need for comprehensive case management that focuses on access to housing and employment.
In Boston, the site of this study, outreach to the homeless street population began in 1986, when the city’s largest homeless shelter began operating a night outreach van. Since that time, this van has been searching the streets of Boston for homeless people settling down for the night, checking in with each of them, and providing food, clothing, and blankets. In the early 1990s, several day outreach teams operated by three different homeless services agencies complemented this night outreach team. This study’s partner, the Boston Health Care for the Homeless Program (BHCHP), has been a visible force on the streets, serving chronically homeless individuals. BHCHP began providing services to the homeless population in Boston in 1985 by integrating the delivery of healthcare services into mainstream services for the homeless at places such as homeless shelters and soup kitchens. In 1986, to reach those homeless people not using any of these services, members of the BHCHP medical team started to accompany the night outreach team. When other day outreach teams started to operate in different parts of the city, either a nurse or a nurse practitioner from BHCHP began to accompany each of those teams. In 1985, BHCHP employed a team of eight medical professionals. Today, it has expanded to more than 230 employees, including 12 doctors, 3 dentists, 24 nurse practitioners and physician assistants, and more than 40 nurses.
The BHCHP respite care program “… is a major component of Boston’s service delivery model and offers an opportunity to divert emergency room visits, avoid acute care hospital admissions, and minimize hospital lengths of stay. In calendar year 2000, BHCHP’s medical respite program cared for 969 individuals over 1,600 admissions, with an average length of stay of between two and three weeks” (BHCHP, 2001).
The BHCHP’s street team provides intensified primary medical care to a group of street dwellers identified as being at high risk of death. Their multidisciplinary team of nurses, nurse practitioners, and medical doctors has become a consistent and dependable presence over the years to these individuals living on the streets of Boston (BHCHP, 2001). BHCHP street outreach services encompass three goals: improved primary care; increased access to shelters, detoxification units, hospitals, and other programs; and decreased mortality on the streets (BHCHP, 2001).
In January 2000, the BHCHP street outreach team began providing intensive medical services to a cohort of 120 to 140 street dwellers identified as being at high risk of death based on factors identified in previous research (Hwang, 2000; Hwang et al., 1998). Street dwellers sleeping regularly on the streets for 6 months or more are assigned to the high-risk street cohort when one or more of
the following symptoms are present:
• A triple diagnosis of a medical illness, substance abuse, and a major mental illness.
• A major medical illness requiring acute-care hospital admissions, multiple emergency room visits, or admission to respite care during the previous year.
• Three or more visits to the emergency room during the previous 3 months.
• A diagnosis of cirrhosis, heart failure, or renal failure.
• A history of frostbite, hypothermia, or immersion foot.
Individuals identified as being at high risk of dying in the streets are enrolled on an ongoing basis in an intensive care management program and are followed closely by the BHCHP street outreach team. Constituting about 15 to 20 percent of the total street population, most high-risk individuals are enrolled based on carrying a triple diagnosis of chronic medical illness, severe mental illness, and substance abuse. The use of medical services and substance abuse treatment is very high among high-risk street dwellers, with most cycling between respite or detoxification and the streets numerous times; however, use of these services does not predict better housing outcomes (Meschede, 2010).