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Su KY, Feldman BJ, Feldman CT, Saluja S, Coulourides Kogan AM, Cousineau MR. Behavioral Health Care Delivery Through Street Medicine Programs in California. Community Ment Health J 2024; 60:283-291. [PMID: 37526807 PMCID: PMC10822007 DOI: 10.1007/s10597-023-01169-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/08/2023] [Indexed: 08/02/2023]
Abstract
Mental health and substance use disorders are prevalent among people experiencing homelessness. Street Medicine can reach unhoused people who face barriers to accessing healthcare in more traditional medical settings including shelter-based clinics. However, there is little guidance on best practices for mental health and substance use treatment through Street Medicine. The aim of the study was to describe behavioral health care through Street Medicine by analyzing data from the California Street Medicine Landscape survey and follow-up qualitative interviews. Most street medicine programs utilize non-psychiatrists to diagnose and treat mental health and substance use disorders, though the capacity to provide the level of care needed varies. There is a lack of street-based psychiatric clinicians and programs have difficulty making referrals to mental health and addiction services. This report shows that Street Medicine could serve as a strategy to expand access to behavioral health care for the unhoused.
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Affiliation(s)
- Kimberly Y Su
- Keck School of Medicine of USC, Los Angeles, CA, USA.
| | | | | | - Sonali Saluja
- Keck School of Medicine of USC, Los Angeles, CA, USA
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Anastas TM, Stewart JC, Rand KL, Hirsh AT. Pain in People Experiencing Homelessness: A Scoping Review. Ann Behav Med 2023; 57:288-300. [PMID: 36745022 PMCID: PMC10094969 DOI: 10.1093/abm/kaac060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Prior work suggests that people experiencing homelessness (PEH) are at heightened risk for developing pain and have a uniquely burdensome pain experience. PURPOSE The aim of this scoping review was to map the current peer-reviewed, published literature on the pain experience of PEH. METHODS In accordance with the US Annual Homeless Assessment Report, we defined homelessness as lacking shelter or a fixed address within the last year. We conceptualized the pain experience via a modified version of the Social Communication Model of Pain, which considers patient, provider, and contextual factors. Published articles were identified with CINHAL, Embase, PubMed, PsycINFO, and Web of Science databases. RESULTS Sixty-nine studies met inclusion criteria. Studies revealed that PEH have high rates of pain and experience high levels of pain intensity and interference. Substantially fewer studies examined other factors relevant to the pain experience, such as self-management, treatment-seeking behaviors, and pain management within healthcare settings. Nonetheless, initial evidence suggests that pain is undermanaged in PEH. CONCLUSIONS Future research directions to understand pain and homelessness are discussed, including factors contributing to the under-management of pain. This scoping review may inform future work to develop interventions to address the specific pain care needs of PEH.
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Affiliation(s)
- Tracy M Anastas
- Department of Psychology, Indiana University – Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA
| | - Jesse C Stewart
- Department of Psychology, Indiana University – Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA
| | - Kevin L Rand
- Department of Psychology, Indiana University – Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA
| | - Adam T Hirsh
- Department of Psychology, Indiana University – Purdue University Indianapolis (IUPUI), Indianapolis, IN, USA
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Kopanitsa V, McWilliams S, Leung R, Schischa B, Sarela S, Perelmuter S, Sheeran E, d'Algue LM, Tan GC, Rosenthal DM. A systematic scoping review of primary health care service outreach for homeless populations. Fam Pract 2023; 40:138-151. [PMID: 35809035 DOI: 10.1093/fampra/cmac075] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Homeless populations (HPs) have difficulties obtaining necessary medical care, and primary health care service outreach (PHSO) might be useful to bridge this gap. OBJECTIVE Using the Centre for Evidence-Based Management Critically Appraised Topics framework, to provide systematic evidence of the usefulness of PHSO interventions for HPs. METHODS A systematic search was conducted in 4 electronic databases: PubMed, Web of Science, CINAHL, and Cochrane (publication dates between January 1980 and November 2020). In total, 2,872 articles were identified. Primary research about PHSO for HPs in high-income countries were included. Data were extracted from eligible studies, summarized, and collated into a narrative account. RESULTS Twenty-four studies that described and evaluated PHSO interventions for adults experiencing homelessness were selected in the final synthesis. Most studies had a nonrandomized design. PHSO was found to successfully address some barriers to health care access for HPs through flexible appointments in convenient locations, fostering an understanding relationship between doctor and patients, and provision of additional basic necessities and referrals. Outreach was provided for a range of health care concerns, and several solutions to engage more HPs in primary care, improve continuity of care and to decrease the running costs were identified. Outreach also helped to implement preventative measures and reduced emergency service admissions. CONCLUSION Our review adds to the evidence that PHSO likely improves health care access for HPs. Further studies over longer time periods, involving collaborations with experts with lived experience of homelessness, and utilizing randomized study designs are needed to test outreach efficacy.
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Affiliation(s)
- Valeriya Kopanitsa
- Faculty of Medical Sciences, University College London Medical School, London, UK
| | - Stephen McWilliams
- Faculty of Medical Sciences, University College London Medical School, London, UK
| | - Richard Leung
- Faculty of Medical Sciences, University College London Medical School, London, UK
| | | | - Shazia Sarela
- Faculty of Medical Sciences, University College London Medical School, London, UK
| | - Sara Perelmuter
- Faculty of Life Sciences, University College London, London, UK
| | - Emma Sheeran
- Health Humanities Centre, University College London, London, UK
| | | | - Guan Chwen Tan
- Arts and Sciences Department, University College London, London, UK
| | - Diana Margot Rosenthal
- Population, Policy and Practice Research and Teaching Department, University College London Great Ormond Street Institute of Child Health, London, UK.,UCL Collaborative Centre for Inclusion Health, University College London, London, UK
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Lo E, Tsai J, Stefanovics EA, Rosenheck R. Does Street Outreach Engage Its Intended Target Population? Clinical Experience in the Veteran's Health Administration Homeless Service Programs. Psychiatr Q 2022; 93:1003-1016. [PMID: 36331755 DOI: 10.1007/s11126-022-10004-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Clinical street outreach programs serve people experiencing unsheltered homelessness, who have been shown to have greater medical and psychiatric comorbidities, and increased social and financial challenges. However, outreach programs may struggle in practice to engage the most vulnerable of these individuals. METHODS Data from the Veterans Health Administration's (VHA's) Homeless Operations Management System (HOMES) from 2018 to 2019 (N = 101,998) were used to compare sociodemographic, clinical, and financial characteristics of literally homeless veterans contacted through street outreach to those who were self-referred or clinic-referred. RESULTS Veterans engaged through street outreach reported substantially more days of unsheltered homelessness in the past month (mean (M) = 11.18 days, s.d.=13.8) than the clinic-referred group (M = 6.75 days, s.d.=11.1), and were more likely to have spent the past 30 days unsheltered (RR = 2.23). There were notably few other differences between the groups. CONCLUSION Despite epidemiologic evidence in the literature showing higher medical, psychiatric, and social and financial vulnerabilities among unsheltered homeless individuals, our street outreach group was not found to be any worse off on such variables than the clinic-referred or self-referred groups, other than increased time unsheltered. Outreach workers seem to engage more unsheltered individuals, but do not necessarily engage those with such severe vulnerabilities. Dedicated outreach program funding, training, and support are needed to support street outreach to those with the most severe problems.
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Affiliation(s)
- Emma Lo
- Yale Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
- Connecticut Mental Health Center, Department of Mental Health and Addiction Services, New Haven, CT, USA.
| | - Jack Tsai
- Yale Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- US Department of Veterans Affairs, VA National Center on Homelessness Among Veterans, Tampa, FL, US
- School of Public Health, University of Texas at Houston, San Antonio, TX, US
| | - Elina A Stefanovics
- Yale Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- US Department of Veterans Affairs, VA National Center on Homelessness Among Veterans, Tampa, FL, US
- VA New England Mental Illness, Research and Clinical Center, West Haven, CT, USA
| | - Robert Rosenheck
- Yale Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- US Department of Veterans Affairs, VA National Center on Homelessness Among Veterans, Tampa, FL, US
- VA New England Mental Illness, Research and Clinical Center, West Haven, CT, USA
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5
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Exploring the conceptualization, operationalization, implementation, and measurement of outreach in community settings with hard-to-reach and hidden populations: A scoping review. Soc Sci Med 2022; 309:115232. [DOI: 10.1016/j.socscimed.2022.115232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/23/2022] [Accepted: 07/16/2022] [Indexed: 11/20/2022]
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Lo E, Lifland B, Buelt EC, Balasuriya L, Steiner JL. Implementing the Street Psychiatry Model in New Haven, CT: Community-Based Care for People Experiencing Unsheltered Homelessness. Community Ment Health J 2021; 57:1427-1434. [PMID: 34059983 DOI: 10.1007/s10597-021-00846-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/22/2021] [Indexed: 10/21/2022]
Abstract
"Street psychiatry" is an innovative model that serves people experiencing unsheltered homelessness, a vulnerable population with increased rates of mental illness and substance use disorders. Through community-based delivery of mental health and addiction treatment, street psychiatry helps the street-dwelling population overcome barriers to accessing care through traditional routes. Throughout the United States, street psychiatry programs have arisen in multiple cities, often in partnership with street medicine programs. We discuss the philosophy of street psychiatry, document operational highlights involved in the development of a street psychiatry program in New Haven, CT, suggest key ingredients to implementing a street psychiatry program, and explore challenges and future frontiers. Street psychiatry is an effective person-centered model of service delivery with the potential to be applied in a variety of urban settings to serve people experiencing street homelessness.
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Affiliation(s)
- Emma Lo
- Department of Psychiatry, Yale University School of Medicine, Connecticut Mental Health Center, 34 Park St, New Haven, CT, 06519, USA.
| | - Brooke Lifland
- Department of Psychiatry, Yale University School of Medicine, 300 George St, New Haven, CT, 06511, USA
| | - Eliza C Buelt
- Massachusetts Mental Health Center, 20 Vining St, Boston, MA, 02115, USA
| | - Lilanthi Balasuriya
- Yale National Clinician Scholars Program, Yale University School of Medicine, 333 Cedar St, New Haven, CT, 06510, USA
| | - Jeanne L Steiner
- Department of Psychiatry, Yale University School of Medicine, Connecticut Mental Health Center, 34 Park St, New Haven, CT, 06519, USA
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7
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Comparing Unsheltered and Sheltered Homeless: Demographics, Health Services Use and Predictors of Health Services Use. Community Ment Health J 2020; 56:271-279. [PMID: 31552539 DOI: 10.1007/s10597-019-00470-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 09/18/2019] [Indexed: 10/26/2022]
Abstract
Secondary data obtained through the 2015 point-in-time homelessness count and an administrative health care utilization database was used to identify differences in demographic characteristics, health service use, and predictors of health service use among people experiencing unsheltered and sheltered homelessness. Compared to sheltered participants, unsheltered participants had higher proportions of males and Caucasians, were younger, were more likely to use any type of health service and ED services, and used significantly more of any health service and ED and outpatient services. Results also confirm that health services utilization is a complex phenomenon predicted by a variety of predisposing, enabling, and need-related factors, including mental health problems. Together, these findings demonstrate important differences between people living unsheltered and those residing in shelters and they inform local health policy and program initiatives tailored towards these homeless populations.
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8
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Wusinich C, Bond L, Nathanson A, Padgett DK. "If you're gonna help me, help me": Barriers to housing among unsheltered homeless adults. EVALUATION AND PROGRAM PLANNING 2019; 76:101673. [PMID: 31228636 DOI: 10.1016/j.evalprogplan.2019.101673] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/25/2019] [Accepted: 06/12/2019] [Indexed: 06/09/2023]
Abstract
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.
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Affiliation(s)
- Christina Wusinich
- New York University Silver School of Social Work, 1 Washington Square North, New York, NY, 10003, United States.
| | - Lynden Bond
- New York University Silver School of Social Work, 1 Washington Square North, New York, NY, 10003, United States.
| | - Anna Nathanson
- New York University Silver School of Social Work, 1 Washington Square North, New York, NY, 10003, United States.
| | - Deborah K Padgett
- New York University Silver School of Social Work, 1 Washington Square North, New York, NY, 10003, United States.
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9
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Rosen MI, Becker WC, Black AC, Martino S, Edens EL, Kerns RD. Brief Counseling for Veterans with Musculoskeletal Disorder, Risky Substance Use, and Service Connection Claims. PAIN MEDICINE (MALDEN, MASS.) 2019; 20:528-542. [PMID: 29800338 PMCID: PMC6387983 DOI: 10.1093/pm/pny071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE High proportions of post-9/11 veterans have musculoskeletal disorders (MSDs), but engaging them in care early in their course of illness has been challenging. The service connection application is an ideal point of contact for referring veterans to early interventions for their conditions. DESIGN Among MSD claimants who reported risky substance use, we pilot-tested a counseling intervention targeting pain and risky substance use called Screening Brief Intervention and Referral to Treatment-Pain Module (SBIRT-PM). Veterans were randomly assigned in a 2:1:1 ratio to SBIRT-PM, Pain Module counseling only, or treatment as usual (TAU). METHODS Participants assigned to either counseling arm were offered a single meeting with a study therapist with two follow-up telephone calls as needed. Participants completed outcome assessments at four and 12 weeks after randomization. RESULTS Of 257 veterans evaluated, 101 reported risky substance use and were randomized. Counseling was attended by 75% of veterans offered it and was well received. VA pain-related services were used by 51% of participants in either of the pain-focused conditions but only by 27% in TAU (P < 0.04). Starting with average pain severity ratings of 5.1/10 at baseline, only minimal changes in mean pain severity were noted regardless of condition. Self-reported risky substance use was significantly lower over time in the SBIRT-PM condition relative to the two other conditions (P < 0.02). At week 12, proportions of veterans reporting risky substance use were 0.39, 0.69, and 0.71 for the SBIRT-PM, Pain Module counseling, and TAU conditions, respectively. CONCLUSIONS SBIRT-PM shows promise as a way to engage veterans in pain treatment and reduce substance use.
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Affiliation(s)
- Marc I Rosen
- Department of Psychiatry, Yale University, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - William C Becker
- VA Connecticut Healthcare System, West Haven, Connecticut
- Section of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Anne C Black
- Department of Psychiatry, Yale University, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Steve Martino
- Department of Psychiatry, Yale University, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Ellen L Edens
- Department of Psychiatry, Yale University, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
| | - Robert D Kerns
- Department of Psychiatry, Yale University, New Haven, Connecticut
- VA Connecticut Healthcare System, West Haven, Connecticut
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10
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Llerena K, Gabrielian S, Green MF. Clinical and cognitive correlates of unsheltered status in homeless persons with psychotic disorders. Schizophr Res 2018; 197:421-427. [PMID: 29486957 DOI: 10.1016/j.schres.2018.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 12/22/2017] [Accepted: 02/16/2018] [Indexed: 12/18/2022]
Abstract
Homeless persons with psychosis are particularly susceptible to unsheltered homelessness, which includes living on the streets, in cars, and other places not meant for human habitation. Homeless persons with psychosis have distinct barriers to accessing care and comprise a high-need and hard-to-serve homeless subpopulation. Therefore, this study sought to understand unsheltered homelessness in persons with psychosis and its relationship to cognitive impairment, clinical symptoms, and community functioning, examined both categorically and dimensionally. This study included 76 homeless participants with a history of a psychotic diagnosis who were enrolled in a supported housing program but had not yet received housing. This study used two different housing stability thresholds (literally homeless at any point vs. literally homeless >20% of days) for comparing homeless Veterans with psychosis living in sheltered versus unsheltered situations on cognition, clinical symptoms, and community integration. Dimensional analyses also examined the relationship between percentage of days spent in unsheltered locations and cognition, clinical symptoms, and community integration. Sheltered and unsheltered Veterans with psychosis did not differ on clinical symptoms or community integration, but there was an inconsistent group difference on cognition depending on the threshold used for determining housing stability. In the unsheltered group, cognitive deficits in overall cognition, visual learning, and social cognition were related to more days spent in unsheltered locations. Rehabilitation efforts targeting specific cognitive deficits may be useful to facilitate greater access to care and successful interventions in this population.
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Affiliation(s)
- Katiah Llerena
- Department of Veterans Affairs VISN 22 Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, United States; UCLA Semel Institute for Neuroscience & Human Behavior, David Geffen School of Medicine, United States; Department of Veterans Affairs VISN 21 Mental Illness Research, Education, and Clinical Center, San Francisco, CA, United States.
| | - Sonya Gabrielian
- Department of Veterans Affairs VISN 22 Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, United States; UCLA Semel Institute for Neuroscience & Human Behavior, David Geffen School of Medicine, United States
| | - Michael F Green
- Department of Veterans Affairs VISN 22 Mental Illness Research, Education, and Clinical Center, Los Angeles, CA, United States; UCLA Semel Institute for Neuroscience & Human Behavior, David Geffen School of Medicine, United States
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11
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Morse GA, York MM, Dell N, Blanco J, Birchmier C. Improving outcomes for homeless people with alcohol disorders: a multi-program community-based approach. J Ment Health 2017; 29:684-691. [PMID: 28686473 DOI: 10.1080/09638237.2017.1340617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background: Relatively few community-based programs have been found to be helpful for homeless people with alcohol disorders, even though this group represents a high-risk, vulnerable population prone to poor outcomes.Aims: This study sought to implement and evaluate intensive community-based programs for homeless people with alcohol disorders.Method: The project worked closely with a homeless outreach team for referrals, and then provided two different, intensive substance abuse treatment approaches matched to the needs of two subgroups: homeless individuals with alcohol disorders without severe mental illness received community reinforcement approach (CRA) and case management services, while those with alcohol and severe mental illness were assigned to assertive community treatment and integrated dual disorders (ACT/IDDT) services. The study enrolled 322 homeless people with alcohol disorders and outcomes were assessed at six months and program discharge.Results: Participants improved significantly over the first six months in a number of outcome areas, including substance abuse, mental health, housing, employment and health; progress generally remained stable between six months and discharge.Conclusions: Community-based programs that coordinate with mobile outreach teams and then provide CRA and ACT/IDDT appear to be promising approaches for helping individuals with alcohol disorders out of homelessness and into recovery.
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Affiliation(s)
- Gary A Morse
- Places for People: Community Alternatives for Hope, Health, and Recovery, St. Louis, MO, USA
| | - Mary M York
- Places for People: Community Alternatives for Hope, Health, and Recovery, St. Louis, MO, USA.,Department of Psychology, Southern Illinois University Carbondale, Carbondale, IL, USA, and
| | - Nathaniel Dell
- Places for People: Community Alternatives for Hope, Health, and Recovery, St. Louis, MO, USA
| | - Julie Blanco
- Places for People: Community Alternatives for Hope, Health, and Recovery, St. Louis, MO, USA
| | - Chelsea Birchmier
- Places for People: Community Alternatives for Hope, Health, and Recovery, St. Louis, MO, USA.,Department of Psychology, Washington University, St. Louis, MO, USA
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12
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Carmona J, Slesnick N, Guo X, Murnan A, Brakenhoff B. Predictors of Outreach Meetings Among Substance Using Homeless Youth. Community Ment Health J 2017; 53:62-71. [PMID: 26293750 DOI: 10.1007/s10597-015-9919-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 08/10/2015] [Indexed: 11/26/2022]
Abstract
Homeless youth have high rates of substance use and often lack connection to social services. Outreach is critical for connecting youth to services, but factors influencing their outreach engagement are unknown. This study examined predictors of meetings with outreach workers among 79 non-service connected, substance using homeless youth between 14 and 24 years of age. Results provide direction to service providers in that older age, higher levels of depressive symptoms, fewer drug-related problems, and no use of hard drugs within the prior 30 days predicted higher meeting attendance. Future research is needed testing strategies that overcome barriers to outreach engagement.
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Affiliation(s)
- Jasmin Carmona
- Department of Human Sciences, The Ohio State University, 135 Campbell Hall, 1787 Neil Avenue, Columbus, OH, 43210, USA.
| | - Natasha Slesnick
- Department of Human Sciences, The Ohio State University, 135 Campbell Hall, 1787 Neil Avenue, Columbus, OH, 43210, USA
| | - Xiamei Guo
- Institute of Psychology, Xiamen University, No. 422, Siming South Road, Xiamen, 361005, Fujian, China
| | - Aaron Murnan
- Department of Human Sciences, The Ohio State University, 135 Campbell Hall, 1787 Neil Avenue, Columbus, OH, 43210, USA
| | - Brittany Brakenhoff
- Department of Human Sciences, The Ohio State University, 135 Campbell Hall, 1787 Neil Avenue, Columbus, OH, 43210, USA
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13
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Services Receipt Following Veteran Outpatients' Positive Screen for Homelessness. Am J Prev Med 2016; 50:336-343. [PMID: 26564329 DOI: 10.1016/j.amepre.2015.06.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 06/23/2015] [Accepted: 06/23/2015] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The Veterans Health Administration seeks to reduce homelessness among Veterans by identifying, and providing prevention and supportive services to, patients with housing concerns. The objectives of this study were to assess the proportion of Veterans Health Administration patients who received homeless or social work services within 6 months of a positive screen for homelessness or risk in the Veterans Health Administration and the demographic and clinical characteristics that predicted services utilization. METHODS Data were from a cohort of 27,403 Veteran outpatients who screened positive for homelessness or risk between November 1, 2012 and January 31, 2013. During 2013, AORs were calculated using a mixed-effects logistic regression to estimate the likelihood of patients' receipt of VHA homeless or social work services based on demographic and clinical characteristics. RESULTS The majority of patients received services within 6 months post-screening; predictors of services utilization varied by gender. Among women, diagnosis of drug abuse and psychosis predicted receipt of services, being unmarried increased the odds of using services among those screening positive for homelessness, and a diagnosis of post-traumatic stress disorder increased the odds of receiving services for at-risk women. Among men, being younger, unmarried, not service-connected/Medicaid-eligible, and having a medical or behavioral health condition predicted receipt of services. CONCLUSIONS Receipt of housing support services among Veterans post-homelessness screening differs by patient demographic and clinical characteristics. Future research should investigate the role that primary and secondary prevention interventions play in Veterans' resolution of risk for homelessness and experience of homelessness.
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14
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Byrne T, Montgomery AE, Fargo JD. Unsheltered Homelessness Among Veterans: Correlates and Profiles. Community Ment Health J 2016; 52:148-57. [PMID: 26289119 DOI: 10.1007/s10597-015-9922-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/10/2015] [Indexed: 10/23/2022]
Abstract
We identified correlates of unsheltered status among Veterans experiencing homelessness and described distinct subgroups within the unsheltered homeless Veteran population using data from a screening instrument for homelessness that is administered to all Veterans accessing outpatient care at a Veterans Health Administration (VHA) facility. Correlates of unsheltered homelessness included male gender, white race, older age, lower levels of VHA eligibility, substance use disorders, frequent use of VHA inpatient and infrequent use of VHA outpatient services, and residing in the West. We identified six distinct subgroups of unsheltered Veterans; the tri-morbid frequent users represented the highest need group, but the largest group was comprised of Veterans who made highly infrequent use of VHA healthcare services. Differences between sheltered and unsheltered Veterans and heterogeneity within the unsheltered Veteran population should be considered in targeting housing and other interventions.
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Affiliation(s)
- Thomas Byrne
- Boston University School of Social Work, 264 Bay State Rd., Boston, MA, 02215, USA. .,U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, 4100 Chester Ave, Suite 201, Philadelphia, PA, 19104, USA.
| | - Ann Elizabeth Montgomery
- U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, 4100 Chester Ave, Suite 201, Philadelphia, PA, 19104, USA.
| | - Jamison D Fargo
- U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, 4100 Chester Ave, Suite 201, Philadelphia, PA, 19104, USA. .,Department of Psychology, Utah State University, 2810 Old Main Hill, Logan, UT, 84322, USA.
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15
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Rowe M, Styron T, David DH. Mental Health Outreach to Persons Who are Homeless: Implications for Practice from a Statewide Study. Community Ment Health J 2016; 52:56-65. [PMID: 26711095 DOI: 10.1007/s10597-015-9963-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 11/08/2015] [Indexed: 11/25/2022]
Abstract
In order to help states establish best practice standards for mental health outreach and engagement teams for persons who are homeless, this study aimed to identify key functional elements needed to effectively address the multiple needs of these persons. A statewide survey across six representative outreach programs was initiated in Connecticut. Focus groups with staff and clients, interviews with program administrators, shadowing of outreach workers on their rounds, and review of relevant written materials were conducted. Four main functional themes regarding optimal outreach work-constructive outreach team characteristics; availability of a wide range of services and resources for clients; navigation of multiple service systems; and favorable work demands and training opportunities-were identified through thematic analysis. The article concludes with recommendations for incorporating these four essential functional elements into mental health outreach and engagement practice to effectively meet the varied needs of the target group.
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Affiliation(s)
- Michael Rowe
- Yale Program for Recovery and Community Health, Department of Psychiatry, Yale University School of Medicine, 319 Peck Street, Building 1, New Haven, CT, 06513, USA.
| | - Thomas Styron
- Department of Psychiatry, Connecticut Mental Health Center, Yale University School of Medicine, New Haven, CT, USA
| | - Daryn H David
- Yale Program for Recovery and Community Health, Department of Psychiatry, Yale University School of Medicine, 319 Peck Street, Building 1, New Haven, CT, 06513, USA
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Stergiopoulos V, Dewa CS, Tanner G, Chau N, Pett M, Connelly JL. Addressing the Needs of the Street Homeless. INTERNATIONAL JOURNAL OF MENTAL HEALTH 2014. [DOI: 10.2753/imh0020-7411390101] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Vicky Stergiopoulos
- a Centre for Research on Inner City Health, the Keenan Research Center of the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Carolyn S. Dewa
- b Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, University of Toronto, Toronto
| | | | - Nancy Chau
- d Health Systems Research and Consulting Unit, Centre for Addiction and Mental Health, Toronto
| | - Mike Pett
- e Centre for Addiction and Mental Health, Toronto
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Fleisch SB, Kelly AC. Street psychiatry as a community rotation for residents: the UNC Homeless Support Program. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2014; 38:246-247. [PMID: 24619914 DOI: 10.1007/s40596-014-0071-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 02/24/2014] [Indexed: 06/03/2023]
Affiliation(s)
- Sheryl B Fleisch
- Department of Psychiatry, Vanderbilt University, Nashville, TN, USA,
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Zlotnick C, Zerger S, Wolfe PB. Health care for the homeless: what we have learned in the past 30 years and what's next. Am J Public Health 2013; 103 Suppl 2:S199-205. [PMID: 24148056 DOI: 10.2105/ajph.2013.301586] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
In the 1980s, the combined effects of deinstitutionalization from state mental hospitals and the economic recession increased the number and transformed the demographic profile of people experiencing homelessness in the United States. Specialized health care for the homeless (HCH) services were developed when it became clear that the mainstream health care system could not sufficiently address their health needs. The HCH program has grown consistently during that period; currently, 208 HCH sites are operating, and the program has become embedded in the federal health care system. We reflect on lessons learned from the HCH model and its applicability to the changing landscape of US health care.
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Affiliation(s)
- Cheryl Zlotnick
- Cheryl Zlotnick is with the Children's Hospital Oakland Research Institute, Oakland, CA, and the Department of Nursing, Faculty of Social Welfare and Health Sciences, University of Haifa, Mount Carmel, Israel. Suzanne Zerger is with the Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario. Phyllis B. Wolfe is with P. B. Wolfe & Associates, Washington, DC
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Abstract
The impact of mental illness, comorbid substance abuse, and medication nonadherence, coupled with disjointed psychiatric and social services, conspires to a disproportionately high rate of psychiatric disorders among people who are homeless in the United States. This article reviews the prevalence of homeless among the mentally ill as well as the prevalence of mental illness among the homeless and details barriers in access to care and the solutions that have been attempted. The need and solutions to introduce a new generation of physicians and allied health care workers to the unique health care needs of the homeless population are highlighted.
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Affiliation(s)
- Adriana Foster
- Department of Psychiatry and Health Behavior, Medical College of Georgia, Georgia Health Sciences University, 997 Saint Sebastian Way, Augusta, GA 30912, USA.
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20
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Canavan R, Barry MM, Matanov A, Barros H, Gabor E, Greacen T, Holcnerová P, Kluge U, Nicaise P, Moskalewicz J, Díaz-Olalla JM, Strassmayr C, Schene AH, Soares JJF, Gaddini A, Priebe S. Service provision and barriers to care for homeless people with mental health problems across 14 European capital cities. BMC Health Serv Res 2012; 12:222. [PMID: 22838503 PMCID: PMC3441802 DOI: 10.1186/1472-6963-12-222] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 07/13/2012] [Indexed: 11/15/2022] Open
Abstract
Background Mental health problems are disproportionately higher amongst homeless people. Many barriers exist for homeless people with mental health problems in accessing treatment yet little research has been done on service provision and quality of care for this group. The aim of this paper is to assess current service provision and identify barriers to care for homeless people with mental health problems in 14 European capital cities. Method Two methods of data collection were employed; (i) In two highly deprived areas in each of the 14 European capital cities, homeless-specific services providing mental health, social care or general health services were assessed. Data were obtained on service characteristics, staff and programmes provided. (ii) Semi-structured interviews were conducted in each area with experts in mental health care provision for homeless people in order to determine the barriers to care and ways to overcome them. Results Across the 14 capital cities, 111 homeless-specific services were assessed. Input from professionally qualified mental health staff was reported as low, as were levels of active outreach and case finding. Out-of-hours service provision appears inadequate and high levels of service exclusion criteria were evident. Prejudice in the services towards homeless people, a lack of co-ordination amongst services, and the difficulties homeless people face in obtaining health insurance were identified as major barriers to service provision. Conclusions While there is variability in service provision across European capital cities, the reported barriers to service accessibility are common. Homeless-specific services are more responsive to the initial needs of homeless people with mental health problems, while generic services tend to be more conducive to long term care. Further research is needed to determine the effectiveness of different service delivery models, including the most effective coordination of homeless specific and generic services.
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Affiliation(s)
- Réamonn Canavan
- Health Promotion Research Centre, National University of Ireland Galway, Galway, Ireland.
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Levitt AJ, Jost JJ, Mergl KA, Hannigan A, Degenova J, Chung SY. Impact of chronically street homeless tenants in congregate supportive housing. THE AMERICAN JOURNAL OF ORTHOPSYCHIATRY 2012; 82:413-20. [PMID: 22880979 DOI: 10.1111/j.1939-0025.2012.01164.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
New initiatives to house chronically street homeless (CSH) adults have led to increasing proportions of this population living in congregate supportive housing, but little is known about the impact of this shift on supportive housing programs. The present multisite, mixed-methods study examined service utilization and lease compliance among 52 chronically street homeless and 46 long-term shelter stayer (LTSS) adults during their first 12 months in congregate supportive housing. Quantitative analysis of administrative data revealed that CSH tenants used significantly more service resources than LTSS tenants, including more advocacy, escorting, and psychiatric treatment and more assistance with financial, housing, and mental and physical health issues. The 2 groups did not differ significantly on measures of lease compliance. Qualitative focus groups with CSH tenants, service provider staff, and property management staff all indicated that existing supportive housing services are suitable for this population, although some adjustments, additional resources, or both, may be indicated.
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Affiliation(s)
- A J Levitt
- Center for Urban Community Services, 198 E. 121st St., 5th floor, New York, NY 10035, USA.
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Abstract
This article describes a homeless intermediate care pilot project that took place at a 120-bedded homeless hostel in South London in 2009. During the year, 34 hostel clients directly benefited from intermediate care. At the end of the year, the number of hospital admissions to the hostel had dropped 77% relative to 2008, and the number of accident and emergency (A&E) attendances had dropped 52%. Hospital 'did not attends' (DNAs) were 22% lower. An economic evaluation found that the pilot project was cost neutral overall, and there is some evidence that health outcomes improved. The project now has mainstream funding and has recently received a national community nursing award. Its success has been recognized nationally as an example of innovative practice in work with vulnerable groups (Department of Health (DH), 2010).
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Tuchman E, Sarasohn MK. Implementation of an evidence-based modified therapeutic community: staff and resident perspectives. EVALUATION AND PROGRAM PLANNING 2011; 34:105-112. [PMID: 20800284 DOI: 10.1016/j.evalprogplan.2010.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Revised: 07/14/2010] [Accepted: 08/03/2010] [Indexed: 05/29/2023]
Abstract
The widespread successful implementation of evidence-based practices (EBPs) into community substance abuse settings require a thorough understanding of practitioner and client attitudes toward these approaches. This paper presents the first that we know of a qualitative study that explores staff and resident experience of the change process of a therapeutic community to an evidence-based modified therapeutic community for homeless individuals with co-occurring substance abuse and mental illness disorders. The sample consists of 20 participants; 10 staff and 10 residents. Interviews were conducted at the agency, recorded and transcribed verbatim. Transcripts were organized and coded from a grounded theory perspective. Themes and patterns of staff and resident experience were identified. The change in program structure from TC to MTC were perceived by staff as efforts to accommodate the particular needs of the homeless individuals with mental and substance abuse disorders and feeling they were inadequately prepared with inadequate resources to facilitate a successful transition. Participant descriptions were described in terms of loss of structure, loss of peers and being helped. Findings have potential to shape implementation of evidence-based practices in community substance abuse treatment.
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Affiliation(s)
- Ellen Tuchman
- Silver School of Social Work, New York University, 1 Washington Square North, New York, NY 10003, USA.
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Bamberg JH, Chiswell M, Toumbourou JW. Use of the program explication method to explore the benefits of a service for homeless and marginalized young people. Public Health Nurs 2011; 28:140-9. [PMID: 21732968 DOI: 10.1111/j.1525-1446.2010.00909.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Maintaining the alignment between the dynamic development of health and social services and the rapidly advancing scientific evaluation literature is a central challenge facing service administrators. We describe "program explication," a consulting method designed to assist services to identify and review implicit program logic assumptions against the evaluation literature. Program explication initially facilitates agency staff to identify and document service components and activities considered critical for improving client outcomes. Program assumptions regarding the relationship between service activities and client outcomes are then examined against available scientific evidence. We demonstrate the application of this method using an example of its use in reviewing a service for homeless young people operating in Melbourne, Australia, known as the Young People's Health Service (YPHS). The YPHS involved 21 activities organized within 4 components. The intended benefits of each of the activities were coherently articulated and logically consistent. Our literature search revealed moderate to strong evidence for around 1 quarter of the activities. The program explication method proved feasible for describing and appraising the YPHS service assumptions, thereby enhancing service evaluability.
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Affiliation(s)
- John H Bamberg
- Western Region Health Centre, 81 Paisley St., Footscray, Melbourne, Australia 3011.
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25
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Davidson L, White W, Sells D, Schmutte T, O'Connell M, Bellamy C, Rowe M. Enabling or Engaging? The Role of Recovery Support Services in Addiction Recovery. ALCOHOLISM TREATMENT QUARTERLY 2010; 28:391-416. [PMID: 30880870 PMCID: PMC6419765 DOI: 10.1080/07347324.2010.511057] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Recovery capital-the quantity and quality of internal and external resources to initiate and maintain recovery-is explored with suggestions for how recovery support services (RSS) (nontraditional, and often nonprofessional support) can be utilized within a context of comprehensive addiction services. This article includes a brief history of RSS, conceptual and operational definitions of RSS, a framework for evaluating RSS, along with a review of recent empirical evidence that suggests that rather than enabling continued addiction, recovery supports are effective at engaging people into care, especially those who have little recovery capital, and/or who otherwise would likely have little to no "access to recovery."
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Affiliation(s)
- Larry Davidson
- Program for Recovery and Community Health, Department of Psychiatry, Yale University, New Haven, Connecticut USA
| | | | - Dave Sells
- Program for Recovery and Community Health, Department of Psychiatry, Yale University, New Haven, Connecticut USA
| | - Timothy Schmutte
- Program for Recovery and Community Health, Department of Psychiatry, Yale University, New Haven, Connecticut USA
| | - Maria O'Connell
- Program for Recovery and Community Health, Department of Psychiatry, Yale University, New Haven, Connecticut USA
| | - Chyrell Bellamy
- Program for Recovery and Community Health, Department of Psychiatry, Yale University, New Haven, Connecticut USA
| | - Michael Rowe
- Program for Recovery and Community Health, Department of Psychiatry, Yale University, New Haven, Connecticut USA
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26
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Lloyd C, Bassett H. The role of an Australian homeless health outreach team. Part 1: background. INTERNATIONAL JOURNAL OF THERAPY AND REHABILITATION 2010. [DOI: 10.12968/ijtr.2010.17.7.48895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Chris Lloyd
- Homeless Health Outreach Team, Ashmore Clinic, Ashmore City, Queensland, Australia
| | - Hazel Bassett
- Homeless Health Outreach Team, Ashmore Clinic, Ashmore City, Queensland, Australia
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Kelly VG, Merrill GS, Shumway M, Alvidrez J, Boccellari A. Outreach, engagement, and practical assistance: essential aspects of PTSD care for urban victims of violent crime. TRAUMA, VIOLENCE & ABUSE 2010; 11:144-156. [PMID: 20554505 DOI: 10.1177/1524838010374481] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The purpose of this article is to examine the literature on the increased risk factors of disadvantaged inner-city residents for becoming victims of violence and for developing posttraumatic stress disorder (PTSD) and barriers to accessing comprehensive mental health services. Second, the article discusses the limitations of evidence-based treatments for early intervention with urban victims of violence and provides a new model of care emphasizing outreach, engagement, and practical assistance. Finally, the article concludes with recommendations for comprehensive hospital-based urban programs in terms of practice, policy, and research.
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28
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Rosen CS, Matthieu MM, Norris FH. Factors Predicting Crisis Counselor Referrals to Other Crisis Counseling, Disaster Relief, and Psychological Services: A Cross-Site Analysis of Post-Katrina Programs. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2009; 36:186-94. [DOI: 10.1007/s10488-009-0216-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Accepted: 12/04/2008] [Indexed: 11/29/2022]
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Mistrust of outreach workers and lack of confidence in available services among individuals who are chronically street homeless. Community Ment Health J 2009; 45:144-50. [PMID: 18807181 DOI: 10.1007/s10597-008-9163-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Accepted: 09/04/2008] [Indexed: 10/21/2022]
Abstract
This qualitative study explored how individuals who are homeless perceive outreach practices and available services. Interviews were conducted with 24 people who had been homeless for >/=1 year and who consistently resided on the streets of west midtown, Manhattan, New York. Reasons why these individuals refuse services include a pervasive mistrust of outreach workers and the agencies that employ them, as well as a prominent lack of confidence in available services. The findings suggest a need for an approach to outreach that incorporates giving individualized attention from outreach workers, using an empathetic listening approach, minimizing stereotyping, providing greater choices, and employing formerly homeless people as outreach workers.
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30
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Rickards LD, McGraw SA, Araki L, Casey RJ, High CW, Hombs ME, Raysor RS. Collaborative initiative to help end chronic homelessness: introduction. J Behav Health Serv Res 2009; 37:149-66. [PMID: 19337841 DOI: 10.1007/s11414-009-9175-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 02/08/2009] [Indexed: 11/30/2022]
Abstract
The Collaborative Initiative to Help End Chronic Homelessness was a coordinated effort by the US Departments of Health and Human Services (HHS), Housing and Urban Development (HUD), and Veterans Affairs (VA), and the US Interagency Council on Homelessness to house and provide comprehensive supportive services to individuals with serious psychiatric, substance use, health, and related disabilities who were experiencing long-term chronic homelessness. Eleven communities received 3-year grants from HHS and VA (2003-2006) and up to 5-year grants from HUD (2003-2008) to implement the initiative. This article provides background on chronic homelessness, describes the federal collaboration to comprehensively address chronic homelessness, and introduces the seven articles in this special issue that describe the findings and lessons learned from the participating communities in addressing chronic homelessness. Collectively, these articles offer insight into the challenges and benefits of providing housing and services to individuals experiencing chronic homelessness.
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Affiliation(s)
- Lawrence D Rickards
- Homeless Programs Branch, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, US Department of Health and Human Services, Rockville, MD 20420, USA.
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31
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Ploeg J, Hayward L, Woodward C, Johnston R. A case study of a Canadian homelessness intervention programme for elderly people. HEALTH & SOCIAL CARE IN THE COMMUNITY 2008; 16:593-605. [PMID: 18371167 DOI: 10.1111/j.1365-2524.2008.00783.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
The aims of this study were to describe: (1) how the Homelessness Intervention Programme addressed the needs of elderly people who were homeless or at risk of homelessness; and (2) the factors that influenced the ability of the programme to address client needs. The programme was offered by a multi-service non-profit agency serving low-income families and individuals in an urban neighbourhood in Ontario, Canada. Using a case study approach, we conducted 10 individual interviews and three focus groups with programme clients, programme providers, other service providers and programme funders. Programme providers completed intake forms, monthly follow-up forms and exit/housing change forms for each of the 129 clients served by the programme over a 28-month period. Approximately equal proportions of clients were between 54 years old and 65 years old (47%) and over 65 years (53%). There were equal proportions of women and men. In addition to being homeless or marginally housed, clients lived with multiple and complex issues including chronic illness, mental illness and substance abuse. Through the facilitation of continuity of care, the programme was able to meet the needs of this vulnerable group of elderly people. Three types of continuity of care were facilitated: relational, informational and management continuity. The study confirmed the value of a continuous caring relationship with an identified provider and the delivery of a seamless service through coordination, integration and information sharing between different providers. Study findings also highlighted the broader systemic factors that acted as barriers to the programme and its ability to meet the needs of elderly people. These factors included limited housing options available; limited income supports; and lack of coordinated, accessible community health and support services. The central findings stress the importance of continuity of care as a guiding concept for intervention programmes for homeless and marginally housed elderly people.
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Affiliation(s)
- Jenny Ploeg
- School of Nursing, McMaster University, Hamilton, ON, Canada.
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Tobias C, Cunningham WE, Cunningham CO, Pounds MB. Making the connection: the importance of engagement and retention in HIV medical care. AIDS Patient Care STDS 2007; 21 Suppl 1:S3-8. [PMID: 17563287 DOI: 10.1089/apc.2007.9992] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Despite the availability and proven efficacy of medical treatment, many individuals living with HIV in the United States today are not engaged in regular HIV medical care or receiving antiretroviral medications. This journal supplement highlights results of a national 5-year multisite Outreach Initiative, funded by the Health Resources and Services Administration (HRSA) in 2001 to "engage people in HIV care, turn sporadic users of care into regular users, and promote retention in care." The introductory paper for the supplement provides background information on the characteristics of individuals who are not engaged in regular HIV care, the barriers they face, intervention options, and the public policy implications of this issue. Interventions to engage and retain underserved populations living with HIV in medical care are essential to ensure access to medical care and to reduce disparities in health outcomes.
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Affiliation(s)
- Carol Tobias
- Health and Disability Working Group, Boston University School of Public Health, Boston, Massachusetts 02210, USA.
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Tommasello AC, Gillis LM, Lawler JT, Bujak GJ. Characteristics of homeless HIV-positive outreach responders in urban US and their success in primary care treatment. AIDS Care 2007; 18:911-7. [PMID: 17012080 DOI: 10.1080/09540120500331297] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Homeless HIV+ persons with persistent mental illness and substance use disorders need services, but are hard to reach and enrol into treatment. Connecting them to services is a major challenge of the AIDS epidemic. This report describes characteristics of homeless HIV+ substance abusers who responded to outreach and enrolled in integrated treatment services. The target population was urban, homeless, HIV+ individuals with substance dependence and/or mental illness diagnoses. Health and physical functioning were measured using a refinement of the Medical Outcomes Study Health Survey. Questions based on the PRIME-MD measured subjects' mental health status. Outreach occurred at shelters, soup kitchens, and on the streets. The outreach team consisted of a nurse, substance abuse counsellor, and a formerly homeless person. Outreach contacted 3,059 individuals; 1,446 entered the clinic, 110 of 206 eligible candidates enrolled in the study, and 82.7% of study participants completed 12-month follow-up interviews. Enrollees exhibited 5th percentile composite health scores. They reported heavy street drug use and unmet service needs particularly for housing and financial assistance. Outreach successfully recruited targeted individuals into treatment. They stayed in treatment and demonstrated improvements on measures of physical and mental health 12-months later.
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Affiliation(s)
- A C Tommasello
- Office of Substance Abuse Studies, University of Maryland School of Pharmacy, Baltimore, MD 21201-1602, USA.
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Rosen MI, McMahon TJ, Lin H, Rosenheck RA. Effect of Social Security payments on substance abuse in a homeless mentally ill cohort. Health Serv Res 2006; 41:173-91. [PMID: 16430606 PMCID: PMC1681526 DOI: 10.1111/j.1475-6773.2005.00481.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To determine whether receipt of social supplemental security income (SSI) or Social Security disability income (SSDI) disability payments is associated with increased drug and alcohol use. DATA SOURCES/STUDY SETTING Secondary analysis of data from 6,199 participants in the Access to Community Care and Effective Social Supports and Services demonstration for the homeless mentally ill. DESIGN Observational, 12-month, cohort study completed over 4 years. Substance abuse and other outcomes were compared between the participants who did not receive SSI or SSDI during the 12-month study, those newly awarded benefits, and those without benefits throughout the 12 months. DATA COLLECTION METHODS Social Security administrative records were used to corroborate Social Security benefit status. Drug and alcohol use were measured by self-report and clinician ratings. PRINCIPAL FINDINGS Participants who did not receive benefits significantly reduced their substance use over time. In generalized estimating equations models that adjusted for potentially confounding covariates, participants who newly received Social Security benefits showed no greater drug use than those without benefits but had significantly more days housed and fewer days employed. Participants whose benefits antedated the demonstration and continued during the 12 months had more clinician-rated drug use over time than those without benefits. CONCLUSIONS In this vulnerable population, participants with newly awarded benefits did not have any different drug use changes than those without benefits, and had relatively more days housed. The hypothesis that Social Security benefits facilitate drug use was not supported by longitudinal data in this high-risk population.
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Affiliation(s)
- Marc I Rosen
- Yale University School of Medicine, Department of Psychiatry, VA Connecticut Health Care System, West Have, CT 06516, USA
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35
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Farrell SJ, Huff J, MacDonald SA, Middlebro A, Walsh S. Taking it to the street: a psychiatric outreach service in Canada. Community Ment Health J 2005; 41:737-46. [PMID: 16328586 DOI: 10.1007/s10597-005-6430-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This paper describes a model of flexible psychiatric outreach service in Canada designed to meet the needs of persons who are homeless or marginally housed and have mental illness. The activities of the Psychiatric Outreach Team of the Royal Ottawa Hospital for individual clients and the community agencies who serve them are profiled, followed by a demographic and mental and physical health profile of the clients seen in the past year. The differences from other models of service and the benefits and limitations of this unique multidisciplinary team are discussed, with implications for future service development for this vulnerable population.
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Affiliation(s)
- Susan J Farrell
- Royal Ottawa Hospital, 1145 Carling Avenue, Ottawa, Ontario, K1Z 7K4, Canada
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Reyes JC, Robles RR, Colón HM, Matos TD, Finlinson HA, Marrero CA, Shepard EW. Homelessness and HIV risk behaviors among drug injectors in Puerto Rico. J Urban Health 2005; 82:446-55. [PMID: 15917501 PMCID: PMC3456053 DOI: 10.1093/jurban/jti073] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This report examines associations between homelessness and HIV risk behaviors among injection drug users (IDUs) in Puerto Rico. The study sample consisted of 557 IDUs who were not in treatment, recruited in inner-city neighborhoods of the North Metro Health Care Region. Subjects were categorized into three groups by residential status (last 30 days): housed, transitionally housed (living with friends, family, or others but considering themselves homeless), and on-the-street homeless (living on the street or in a shelter). Multiple logistic regression models were fitted to assess effects of residential status on each HIV risk behavior after adjusting for sociodemographic and drug-use related covariates. Transitionally housed and on-the-street homeless subjects made up 16% of the total sample. On-the-street homeless IDUs were more likely to test positive for HIV than were transitionally housed and housed IDUs. In the adjusted analysis, on-the-street homeless subjects were significantly more likely to share needles, share rinse water, and practice back loading than the other two groups. Sexual risk behaviors (last 30 days) were not significantly associated with residential status after adjustment. Findings from this study present an added challenge to drug treatment and HIV prevention and treatment programs, to provide services that can address the additional needs of drug users suffering the stressors of homelessness.
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Affiliation(s)
- Juan C Reyes
- Center for Addiction Studies, School of Medicine, Universidad Central del Caribe, 60327, Bayamón, PR 00960-6032, USA.
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Abstract
Carrying hundreds of patient files in a suitcase makes medical street outreach to the homeless clumsy and difficult. Healthcare for the Homeless--Houston (HHH) began a case study under the assumption that tracking patient information with a personal digital assistant (PDA) would greatly simplify the process. Equipping clinicians with custom-designed software loaded onto Palm V Handheld Computers (palmOne, Inc, Milpitas, CA), Healthcare for the Homeless--Houston assessed how this type of technology augmented medical care during street outreach to the homeless in a major metropolitan area. Preliminary evidence suggests that personal digital assistants free clinicians to focus on building relationships instead of recreating documentation during patient encounters. However, the limits of the PDA for storing and retrieving data made it impractical long-term. This outcome precipitated a new study to test the feasibility of tablet personal computers loaded with a custom-designed software application specific to the needs of homeless street patients.
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Affiliation(s)
- David S Buck
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX 77098, USA.
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Skinner DC. A modified therapeutic community for homeless persons with co-occurring disorders of substance abuse and mental illness in a shelter: an outcome study. Subst Use Misuse 2005; 40:483-97. [PMID: 15830731 DOI: 10.1081/ja-200052429] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This article reports on a study conducted to determine the effectiveness of a modified therapeutic community (MTC) shelter on client outcomes. The seven-study hypotheses focused on whether greater effectiveness in the MTC would be demonstrated in longer periods of sobriety, fewer days of psychiatric hospitalization, shorter lengths of stay in a shelter, positive discharge from the shelter, medication compliance, housing placement within the first year, and appropriate housing placement according to level of functioning. The study utilized a quasi-experimental design with two groups: 1) an experimental group (E) homeless persons with co-occurring disorders (COD) of substance abuse/dependence and mental illness who reside in a modified therapeutic community (N = 70); and 2) a comparison group (C) of veterans with CODs living in a general shelter (N = 70). The data collection procedures involved a retrospective review of closed case records for subjects in the facilities from September 1, 1998-June 1, 2000 for the MTC shelter, and from June 1, 1999-June 1, 2000 for the general shelter. Baseline differences between the E and C groups were found in age, length of homelessness, years of education, years of work experience, veteran status, marital status, and psychiatric diagnosis; all except for veteran status were unrelated to outcomes and were controlled in subsequent analyses. Significant difference was found on medication compliance when controlled for both groups. Overall, this study showed some promise for the MTC approach. The study also raised a question as to the contribution of veteran status to the differences between groups and to treatment of CODs.
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Affiliation(s)
- Darren C Skinner
- Co-Occurring Programs, Gaudenzia Inc., 1306 Spring Garden Street, 5th Floor, Philadelphia, PA, USA.
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Abstract
BACKGROUND Outcomes research involves the secondary analysis of data collected routinely by clinical services, in order to judge the effectiveness of interventions and policy initiatives. It permits the study of large databases of patients who are representative of 'real world' practice. However, there are potential problems with this observational design. AIMS To establish the strengths and limitations of outcomes research when applied in mental health. METHOD A systematic review was made of the application of outcomes research in mental health services research. RESULTS Nine examples of outcomes research in mental health services were found. Those that used insurance claims data have information on large numbers of patients but use surrogate outcomes that are of questionable value to clinicians and patients. Problems arise when attempting to adjust for important confounding variables using routinely collected claims data, making results difficult to interpret. CONCLUSIONS Outcomes research is unlikely to be a quick or cheap means of establishing evidence for the effectiveness of mental health practice and policy.
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Affiliation(s)
- Simon M Gilbody
- Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds. Department of Health Studies, University of York, UK.
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Gilbody S, Whitty P. Improving the delivery and organisation of mental health services: beyond the conventional randomised controlled trial. Br J Psychiatry 2002; 180:13-8. [PMID: 11772845 DOI: 10.1192/bjp.180.1.13] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is an ethical imperative to evaluate service and policy initiatives, such as those highlighted in the recent National Service Framework, just as there is to evaluate individual treatments. AIMS To outline the best methods available for evaluating the delivery and organisation of mental health services. METHOD We present a narrative methodological overview, using salient examples from mental health services research. RESULTS Cluster randomised studies involve the random allocation of groups of clinicians, clinical teams or hospitals rather than individual patients, and produce the least biased evaluation of mental health policy, organisation or service delivery. Where randomisation is impossible or impractical (often when services or policies are already implemented), then quasi-experimental designs can be used. Such designs have both strengths and many potential flaws. CONCLUSIONS The gold standard remains the randomised trial, but with due consideration to the unit of randomisation. Use of quasi-experimental designs can be justified in certain circumstances but should be attempted and interpreted with caution.
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Affiliation(s)
- Simon Gilbody
- Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, Leeds LS2 9LT, UK.
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Rowe M, Frey J, Bailey M, Fisk D, Davidson L. Clinical responsibility and client autonomy: dilemmas in mental health work at the margins. THE AMERICAN JOURNAL OF ORTHOPSYCHIATRY 2001; 71:400-407. [PMID: 11822212 DOI: 10.1037/0002-9432.71.4.400] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Mental health outreach to homeless persons requires practice standards for cases in which clinical assessment and client autonomy conflict. After reviewing the principles of mental health outreach and presenting case examples, conditions and boundaries within which outreach workers negotiate the clinical responsibility/client autonomy dilemma are discussed. Guidelines to support sound clinical practice while respecting client autonomy are also discussed.
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Affiliation(s)
- M Rowe
- Department of Psychiatry, School of Medicine, Yale University, New Haven, Conn., USA.
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