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«DiscoVeriNg HomelessNess Volume 13, Number 1 • 2011 U.S. Department of Housing and Urban Development | Office of Policy Development and Research ...»

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This group of long-term homeless and hard-to-serve individuals was intentionally picked for this study, which aimed to demonstrate failures and achievements of those services that attempt to reach those individuals who are most likely to be left out of the traditional CoC model.

Focusing on the interview data of this mixed-method case study of Boston’s high-risk street cohort,

this article seeks to answer the following research questions in four broad areas:

1. What are homeless service providers’ theories of homelessness and assumptions about how their services may improve the housing, health, psychiatric disability, and employment of the street homeless? How do homeless street dwellers assess these services?

2. What factors enable homeless street dwellers to attain and maintain housing according to service providers and former street dwellers’ experiences?

3. What are the barriers in connecting homeless street dwellers with services so that they can attain and maintain housing based on service providers and current and former street dwellers’ assessments?

4. What changes in the service delivery approach for homeless street dwellers who are at risk of street death would improve housing and other outcomes for these individuals?

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Methodology Researchers in this study collected qualitative data through 36 semistructured interviews with key informants to document views on service delivery and service goals, as well as successes and barriers in connecting homeless street dwellers to the CoC and housing. This purposive sample, by program type for providers, by housing status, gender, and race for consumers, included six BHCHP street outreach workers, eight BHCHP respite care providers, four detoxification staff of programs collaborating with BHCHP, and nine current and nine former high-risk homeless individuals (see exhibit 1).

Clinicians from the BHCHP street outreach team approached current and former members of the high-risk cohort and informed them about the study. After individuals agreed to participate in the study, a team member introduced them to the interviewer. Most interviews took place at a walk-in clinic for the homeless; some took place at the homes of former high-risk street dwellers.

Consumer participants were reimbursed for their time by providing them with supermarket gift cards. After the participants granted consent, the interviewer taped all consumer interviews and transcribed them. Among the consumer interviewees were five women (28 percent); most were White (72 percent) and closely resembled the overall high-risk street cohort (see exhibit 2).

Analysis of the 36 interview transcripts first used an open-coding approach (Strauss and Corbin, 1998). The initial coding list was expanded during this process, yielding close to 200 free codes.

The next step of the qualitative analyses combined these free codes into major themes for each interview transcript, including properties and dimensions (Miles and Huberman, 1994). After creating these tree codes, researchers grouped and compared themes relevant to the research questions across interview groups. This step also included quantifying the extent of themes on theory

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of homelessness, service needs, and program logic, as well as successful practices and barriers to housing across interview groups. Finally, based on the interview themes, recommendations for ending chronic homelessness are presented.

Results This section returns to the four research questions on the effects of homelessness theories on service delivery, bridges and barriers to housing, and recommended changes to the service delivery system. Major themes from the interview information are portrayed across interview groups, thereby contrasting important group differences.

Service Providers’ Theories of Change and Role of Their Programs The complexities of reasons for homelessness, as well as the interaction of causal factors that range from economic factors to substance abuse, were well documented by both providers and consumers. Although service providers alluded to the complexity and variety of causes of homelessness, they mainly attributed their clients’ homelessness to problems with mental health, substance abuse, and medical issues rather than lack of affordable housing and insufficient incomes.

I think the top two reasons are substance abuse and mental illness. There are a few people who would otherwise choose to live on the streets but substance abuse certainly leads people to very drastically change their lives. They abandon their families, jobs, losing jobs and homes, and mental illness also causes that decline. The patients I work with who have been on the street for a long time are usually more severely mentally ill and/or more serious substance abusers. (service provider) This viewpoint is not surprising, given the high rates of health problems and substance abuse in the high-risk street cohort.

Consumers did not discuss the role of mental health as a causal factor for their homelessness but supported in their testimonies the prominent role of substance abuse in contributing to losing their home. Consumers, however, also tended to talk about the lack of sufficient income to afford housing more than providers, thus pointing to structural causes such as high rents and loss of jobs as the main contributors to their becoming homeless. Both providers and consumers also alluded to family breakup as another factor that contributed to the homelessness of high-risk street dwellers.

I think people become homeless because they become estranged from support systems that they have and they sort of lose their way. … There are many things that can get in the way of somebody. It could be that they have been in an abusive relationship, they have sort of maneuvered away from all these support systems that they have. There is no one reason, but I think the bottom line is that people become separated from support and they get separated from connections with other people who can help them to stay in the path. (service provider) Overall, there were no major disagreements between providers’ theories of homelessness and the reasons consumers attributed to their homelessness (see exhibit 3).

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Receiving continuity of care from BHCHP outreach team.

b Service providers and consumers strongly disagreed regarding their assessments of major service needs of high-risk street cohort members. Providers stressed the need for mental health and substance abuse services, but consumers focused more on housing and medical concerns. It was evident that providers thought of substance abuse as a major barrier to achieving housing, whereas consumers, although they acknowledged the need to address substance abuse problems, were much more focused on their lack of housing as a major service need. For some, substance abuse was directly linked to the hopelessness of street life and the lack of resources to enable individuals to leave the streets.

I was more in the streets, doing a lot of drugs; I was drinking. I didn’t care; I had nothing to live for. Life wasn’t worth living. ‘Poor me.’ I was feeling like why was I handed this hand of cards. I had nothing but losses in my life. My parents passed

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away, my grandfather died, it was why me? What did I do to deserve all this? And thinking, if I deserve all this, I might as well keep going with it. (former street dweller) Although service providers thought that clinical issues needed to be addressed first, it became evident in the interviews that it is necessary to address both housing and clinical needs in conjunction with one another to support high-risk street dwellers’ move off the streets.

Service providers listed several domains of their program theory and underlying assumptions about how their services facilitate housing (see exhibit 3). These assumptions included developing trusting relationships with consumers, providing access to medical and other services, providing continuity of care, decreasing mortality on the streets, and working toward breaking the cycle of homelessness. For the most part, service providers viewed providing access to medical services and forming trusting relationships with the high-risk homeless street population as their primary role. Addressing housing needs was viewed as secondary. As such, service delivery by the street outreach team and respite care providers was dominated by addressing short-term medical needs, rather then long-term residential concerns.

Street outreach workers, who often make the first service contact with street dwellers, described developing trust and providing primary care medical services as their foremost goal. Establishing trusting relationships with high-risk street cohort individuals was seen as the foundation for addressing both short- and long-term needs.

But it is really, really important we establish that trust relationship. So that means we never promise anything that we can’t deliver. We are really consistent and if we say we are gonna be at some place, then we are there. Whether or not the person comes…. Because I think that a lot of our people have been in relationships that have been very conditional, and our goal is not to make that judgment, that’s not what we are about. Our goal is provide support and care and to really not do that with a judgment, and realizing that we cannot change somebody. But we can support them. (service provider) Because the high-risk cohort was identified out of the need to decrease mortality on the streets, it was not surprising that street outreach workers also named the reduction of mortality as a goal of their services. When prompted about linking street dwellers to housing programs, street outreach workers did not view this need as the focus of their work, referring to other programs with that mission. However, connecting street dwellers with respite care or linking them with services from other state departments, such as the Department of Mental Health (DMH) or the Department of Mental Retardation (DMR), was regarded as an important first step in helping individuals move off the streets.

Respite care providers also stressed the importance of establishing trusting relationships with their clients and providing access to medical care. Although discharge planning is integral to the respite program, very few talked about connecting clients to residential programs or housing. In reality, more than 50 percent of clients return to the streets from respite care (Meschede, 2010). As such, respite care staff members seem to accept this pattern of high-risk street dwellers’ numerous cycles between the streets and respite care.

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We try to get them into a shelter, or just getting them to a point where they are safe upon discharge from here. More than half of the people end up back on the streets.

(service provider) Detoxification staff focused on the narrower task of providing medical detoxification and then referring residents to other programs within the substance abuse CoC, and linking them with medical and mental health care. They reported working closely with clients while they are in detoxification but not maintaining contact afterwards.

Consumers described the services they received from the street team and at respite care primarily as medical; however, many also underscored the caring and respectful relationships with the street outreach team, which were extended to providing support during and after moving into housing.

Some of those who had moved into housing viewed the services they received from respite care as helpful in attaining housing. They were often allowed to exceed program length limitations to enable them to move from respite care directly into housing. Respite care can be a valuable bridge to housing for high-risk street dwellers by keeping individuals in the program until a placement has been secured.

To tell you the truth, most of that [individuals in housing] has to do with us making exceptions, like us keeping somebody here for ten months to get them into an ideal placement. (respite care provider) Service providers who identified housing as a major service need also mentioned that their work should include providing linkages to permanent housing. Conversely, those who were more concerned with substance abuse and mental health needs tended to focus more on treatment-related services and were less optimistic about high-risk individuals succeeding in housing without such prior treatments. As one provider explained, “I have never seen anyone go from the streets into housing and survive [remain in housing].” Services on the streets, at respite care, and at the detoxification programs were guided by a consumerfocused approach to providing care to high-risk individuals. The predominant philosophy centered on letting the consumer be in charge of addressing housing needs, including waiting until they introduce the topic. The steps necessary to facilitate movement from the streets were addressed only at that point. Some respite care providers shared their frustration with this approach. It is hard “watching people make poor decisions,” one service provider said. Providers’ theories of change, however, were also guided by a belief that housing can be achieved only in a certain way, most often through placement in long-term treatment programs. Those who are involved in referral decisions, such as the case managers at respite care, supported this theory of change.

Successful Practices Accessing Housing and Barriers to Housing The extent of program capacities and resources and of referrals and interagency collaboration were among the most important issues facilitating and hindering high-risk street dweller’s movement off the streets (see exhibit 4). In theory, successful referrals from respite care or detoxification were expected to link individuals with long-term service programs that would help them achieve secure and permanent housing. Most current and former high-risk street dwellers, however, frequently cycled between the streets and respite care and between the streets and detoxification.

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At the service system level, these numerous cycles between short-term residential treatments (respite and detoxification programs) and the streets can be explained, to some extent, by the lack of program capacities at these programs and the lack of follow-up at longer term treatment centers.

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