Short versus longer term effectiveness of an outreach program for the homeless mentally ill

"If you're gonna help me, help me": Barriers to housing among unsheltered homeless adults

Despite a legally-mandated right to shelter and extensive outreach efforts, an estimated 3,675 homeless individuals were living on the streets of New York City in 2018. Through interviews with 43 unsheltered homeless individuals in the borough of Manhattan (age range 21-74 years), this qualitative study examined barriers they face in accessing housing and other services as well as experiences surviving on the street. Through thematic analysis of the interview data, the most common barriers found were obtaining required identification documents, lack of accessibility of shelters amid complex healthcare needs, waiting as part of the process, and exclusion of pets from shelters and housing options. Themes capturing survival on the street included sleeping safe, avoiding shelters, and meeting daily needs. Virtually all barriers street homeless New Yorkers face stem from bureaucratic policies that, however well-intentioned, do not address their diverse needs. Thus, long delays and poor communication, combined with crowded, unsafe shelters, lead to frustration and alienation. While homelessness is ultimately the result of a severe and chronic shortage of affordable housing, creating accessible, safe, pet-friendly shelter and safe haven options and instituting a smoother, more transparent process for moving from the streets could substantially reduce street homelessness.

Determinants of Tenancy Sustainment Following Homelessness: A Systematic Review

BACKGROUND

Tenancy sustainment-maintenance of a tenancy to avoid a premature end of tenure-is fundamental to prevention of homelessness. Understanding what enables a successful tenancy is essential in informing interventions designed to support people in leaving homelessness.

OBJECTIVES

To conduct a systematic review identifying determinants associated with tenancy sustainment following homelessness.

SEARCH METHODS

A detailed search of 12 electronic databases, as well as gray literature sources, was conducted in 2015 and updated in 2016.

SELECTION CRITERIA

We included all study designs with a population of homeless or formerly homeless individuals in which tenancy sustainment was the primary outcome. Two reviewers independently carried out abstract and full-text reviews. QualSyst, a validated quality appraisal tool, was used in assessing the methodological quality of articles.

DATA COLLECTION AND ANALYSIS

A data extraction form was developed for the review and was completed by a pair of reviewers to ensure accuracy. The heterogeneity of the studies included indicated that a narrative overview of the results was most appropriate.

MAIN RESULTS

Forty-three articles reporting 38 studies were included. Determinants were categorized at 4 levels: individual, interpersonal, community, and structural. Participation in specific programs (e.g., Housing First), receipt of social support, and older age were identified as positive determinants of tenancy sustainment.

CONCLUSIONS

This systematic review is the first, to our knowledge, to focus solely on tenancy sustainment as a primary outcome. Although a range of determinants associated with tenancy sustainment were identified, it was difficult to draw strong conclusions owing to the heterogeneity of the studies. Despite being a fundamental concept in homelessness research, tenancy sustainment is poorly defined and conceptualized. A deeper understanding of tenancy sustainment will inform the development and evaluation of interventions that support people in leaving homelessness and maintaining tenancies. Public Health Implications. Housing stability is central to preventing homelessness and addressing the numerous public health concerns that can co-occur with homelessness. Our review highlights that a standardized approach to measuring housing stability and more high-quality intervention studies are essential.

Mortality, mental disorders and addiction: a 5-year follow-up of 82 homeless men in Stockholm

A 5-year follow-up study was performed on 82 homeless men, with mental problems, who had been contacted by an outreach team run by the Social welfare administration of Stockholm 1995/1996. Data have been collected from the Cause of Death Register, death certificates, forensic autopsy reports, hospital medical reports, Hospital Discharge Register, interviews with social workers and with those men who were able to participate. The standardized mortality ratio (SMR) was 4.7 times higher than expected. The highest mortality was found in the group where drug addiction was dominant; 46% had died. In the group of men with severe psychiatric disorders, with diagnosis such as schizophrenia, none had died. Compared with the others, they had spent less time in homelessness. Among the survivors, 75% were still homeless at the follow-up in spite of considerable treatment interventions from the social services and health authorities. Residential institutions or treatment seemed to have some protective effect concerning misuse, diseases and injuries. Among the still homeless, the mental health problems combined with substance use problems had increased with 17%. The life and housing situation for the whole group seemed not to have improved, even if fewer of them were staying in hostels for homeless people.

Health care for the homeless assesses the use of adapted clinical practice guidelines

This article describes a process of evaluating and adapting existing clinical practice guidelines (CPGs) for homeless individuals by different healthcare providers in multiple healthcare settings across the country. Data were collected using a standardized evaluation tool in nine sites across the United States. Clinicians completed an evaluation of the CPG after every use. Most clinicians used the CPG five times. Descriptive statistics were reported on the characteristics of the clinicians, and the utility of the guidelines and written comments. Clinicians had an average of 12 years of clinical experience, 8 years of which were specifically spent working with homeless individuals. Ninety-one percent of the clinicians practiced in urban settings. The majority of clinicians felt the adapted guidelines met evaluation criteria. The major weaknesses reported the delineation of outreach and case management activities. Results did not vary by clinicians' disciplines, years of experience, or any other indicators. Clients and clinicians providing primary care to homeless individuals may benefit from utilizing Health Care for the Homeless Clinicians' Network adapted CPGs to assure quality, evidenced-based care to a vulnerable population.

Long-term effectiveness of the ACCESS program in linking community mental health services to homeless persons with serious mental illness

This study examined the long-term effectiveness of the ACCESS (Access to Community Care and Effective Services and Supports) project on service utilization and continuity of care among homeless persons with serious mental illness. A 3-year longitudinal analysis, using Medicaid claims data, tracked behavioral health service utilization among 146 Medicaid-eligible participants in the Pennsylvania ACCESS program. Utilization patterns of inpatient, outpatient, and emergency department services for psychiatric and substance abuse treatment were examined during the year prior to, during, and one year after the implementation of the ACCESS project. Use of psychiatric ambulatory care significantly increased among intervention participants and remained greater following ACCESS intervention. Better continuity of care following hospitalization was achieved during and after the intervention. The number of days spent hospitalized significantly decreased during the intervention. These results suggest that the ACCESS intervention was effective in linking hard-to-reach homeless persons with serious mental illness to the community mental health service system, and that this effect was maintained after termination of the intervention.

Consumer preference programs for individuals who are homeless and have psychiatric disabilities: a drop-in center and a supported housing program

We illustrate Fairweather's approach to Experimental Social Innovation and Dissemination with two experimental studies of programs to reduce homelessness for 168 and 225 people with mental illness and often substance abuse. Literally homeless participants were randomly assigned to programs that emphasized consumer choice or to the usual continuum of care, in which housing and services are contingent on sobriety and progress in treatment. A drop-in center that eliminated barriers to access to services was more successful than control programs in reducing homelessness, but after 24 months only 38% of participants had moved to community housing. A subsequent apartment program, in which individuals in the experimental condition moved to subsidized apartments directly from the street, with services under their control, had 79% in stable housing (compared to 27% in the control group) at the end of 6 months. Groups in this study did not differ on substance abuse or psychosocial outcomes.

Longitudinal Perspective: Adverse Childhood Events, Substance Use, and Labor Force Participation Among Homeless Adults

OBJECTIVES

We examined the long-term effects of adverse childhood events on adulthood substance use, social service utilization, and subsequent labor force participation.

METHODS

A county-wide probability sample of 397 homeless adults was interviewed three times in a 15-month period. By using a path model, literature-based relationships between adverse childhood events and labor force participation with the mediating effects of adulthood substance use and service use were tested.

RESULTS

Adverse childhood events were precursors to adulthood alcohol and drug use. Consistent substance use was negatively associated with long-term labor force participation and with social service utilization among homeless adults. Adverse events at childhood, however, were positively associated with service use.

CONCLUSIONS

Adverse childhood events may contribute to negative adulthood consequences, including consistent substance use and reduced labor force participation. Agencies that are involved in halting the abuse or neglect also should participate in more preventive interventions. Job-related assistance is particularly important to facilitate employment and labor force participation among homeless adults.

Street outreach for homeless persons with serious mental illness: is it effective?

OBJECTIVES

This study examined data on case management clients who are homeless and have a severe mental illness to determine how those contacted through street outreach differ in their socio-demographic characteristics, service needs, and outcomes from those clients contacted in shelters and other health and social service agencies.

METHODS

As part of the Center for Mental Health Services' Access to Community Care and Effective Services and Supports (ACCESS) program, data were obtained from potential clients over the first 3 years of the program at the time of the first outreach contact (n = 11,857), at the time of enrollment in the case management program (n = 5,431), and 3 months after enrollment (n = 4,587).

RESULTS

Clients contacted at outreach on the street, as opposed to being contacted in shelters and service agencies, were generally worse off. They were more likely to be male, to be older, to spend more nights literally homeless before the contact, to have psychotic disorders, and took longer to engage in case management. They expressed less interest in treatment and were less likely to enroll in the case management phase of the project. Subjects contacted on the street who did enroll were more impaired than their street counterparts who did not enroll. Three month outcome data showed that enrolled clients contacted through street outreach showed improvement that was equivalent to those enrolled clients contacted in shelters and other service agencies on nearly all outcome measures.

CONCLUSION

Street outreach to homeless persons with serious mental illness is justified as these clients are more severely impaired, have more basic service needs, are less motivated to seek treatment, and take longer to engage than those contacted in other settings. Street outreach is further justified as it engages the most severely impaired among the street population. Street outreach also appears to be effective as the clients reached in this way showed improvement equal to that of other clients in most outcome domains when baseline differences were taken into account.

Preventing recurrent homelessness among mentally ill men: a "critical time" intervention after discharge from a shelter

OBJECTIVES

This study examined a strategy to prevent homelessness among individuals with severe mental illness by providing a bridge between institutional and community care.

METHODS

Ninety-six men with severe mental illness who were entering community housing from a shelter institution were randomized to receive 9 months of a "critical time" intervention plus usual services or usual services only. The primary analysis compared the mean number of homeless nights for the two groups during the 18-month follow-up period. To elucidate time trends, survival curves were used.

RESULTS

Over the 18-month follow-up period, the average number of homeless nights was 30 for the critical time intervention group and 91 for the usual services group. Survival curves showed that after the 9-month period of active intervention, the difference between the two groups did not diminish.

CONCLUSIONS

Strategies that focus on a critical time of transition may contribute to the prevention of recurrent homelessness among individuals with mental illness, even after the period of active intervention.