Evaluation of threshold: An independent living program for homeless adolescents

The Threshold Project, a residential treatment program, was designed to work with homeless and alienated young women who were approaching 18 years of age but lacked the skills, values, and attitudes necessary to care for themselves and assume the responsibilities of adulthood. Project services were designed to prepare these young women for independent living and to break the intergenerational cycle of abuse and neglect experienced by this population. Threshold offered a series of progressively more independent living experiences to young homeless women ages 16-18 years, who had been sexually/physically/emotionally abused or neglected, and who had been involved in or at high risk for prostitution. A majority of the clients responded well to the requirements of the program, including the expectation that they maintain employment and participate in educational programs during the semi-independent living phase of the project. A follow-up assessment undertaken after clients left the project found that 42% of the young women met all "success" criteria, that is, they lived independently (or in stable situations), attended school and/or were employed, had not engaged in prostitution or other offense behavior, and did not abuse alcohol or other substances.     

A demonstration program for homeless male alcohol and other drug abusers

The National Institute on Alcohol Abuse and Alcoholism, in consultation with the National Institute on Drug Abuse, awarded nine demonstration grants in 1988 for community-based programs addressing issues of the homeless alcohol and other drug (AOD) abusers. Project Connect in Louisville, Kentucky, was one of the nine demonstration grants. The three-year project was designed to address a multitude of needs of the homeless male AOD abuser, including housing, medical, employment/economic, and social support, in addition to treatment for AOD abuse. The present article details the evolution and implementation of Project Connect and describes characteristics of the target population. In addition, the article presents issues and problems that surfaced during program implementation in order to assist other communities that are considering similar programs for their homeless populations.     

Sober Housing and Motivational Interviewing: The Treatment Access Project

This paper describes an innovative program that provides rental subsidies for sober housing and supportive services to persons in early recovery who are homeless and have substance use disorders. Preliminary data point to the success of this program in enhancing recovery and exiting from homelessness. In supporting sober house placements, the Treatment Access Project creates a bridge that supports these individuals in their transition from clinical treatment services to the community. Integration with natural community supports can help to build self-efficacy, which can enhance the likelihood that this population will obtain and maintain abstinence, gainful employment, and permanent housing.     

Invited commentary: co-occurring health conditions among women living with profound life challenges

People challenged by homelessness are living with several losses including the loss of a home, employment, economic security, health or well-being, and personal security. Assistance programs for people who are homeless consist of housing, emergency shelter, food services, employment assistance, peer support, medical care, and mental health services. An article by Riley et al. (Am J Epidemiol. 2011;175(5):515-522) appearing in this issue of the Journal examines the relation between basic subsistence needs and health outcomes in a cohort of 129 human immunodeficiency virus-infected women who were recruited from a probability sample of low-income hotels, homeless shelters, and free food programs in San Francisco, California. The results of their study underscore the importance of addressing subsistence needs and providing access to medical and psychological treatment for homeless and unstably housed women. In addition to subsistence needs, more attention should be given to comorbid psychiatric and medical conditions that occur among homeless women, including trauma-related disorders.     

Needs of homeless people coping with psychiatric problems: findings from an innovative advocacy project

In this article the authors report on the self-perceived needs of 40 homeless people who are coping with psychiatric problems. These people were among 207 with psychiatric problems participating in an innovative advocacy project based outside the formal mental health system. Compared with domiciled participants, the homeless participants had more accentuated and somewhat different major daily living needs in the areas of income and benefits, housing, legal services, employment, and health care. On the basis of these findings, the authors draw implications for social work practice with homeless people coping with psychiatric problems.     

Housing Stability and Recovery Among Chronically Homeless Persons With Co-Occuring Disorders in Washington,DC

Pathways Housing First provides access to housing, support, and treatment services to clients having the most complex needs—persons who have been homeless for at least 5 years and have both a psychiatric disability and substance dependency. In a 2-year Housing and Urban Development-funded demonstration project in Washington, DC, in 2007 and 2008, we observed promising outcomes in housing retention and reductions in psychiatric symptoms, alcohol use, and demand for intensive support services. The program is designed to be fiscally self-sustaining through extant public disability benefits for housing, treatment, and support services. This approach shows strong support for first providing a permanently supported housing solution for chronically homeless and severely disabled individuals in need of housing and treatment of co-occurring disorders.

KEY FINDINGS

• ▪Housing retention of severely disabled and chronically homeless individuals having extensive service needs, each alcohol dependent and homeless for a minimum of 5 years at intake, was 97% in the first year and 84% in the second year.
• ▪Highly distressed individuals showed significant reduction in psychiatric symptoms within the first year of housing, with client-centered housing support and voluntary psychiatric treatment provided as desired by the client.
• ▪Psychiatrically disabled and alcohol-dependent individuals can make significant mental and behavioral health improvements in recovery within a year of housing without abstinence or treatment compliance demands upon enrollment and with voluntary addiction treatment as desired by the client.
• ▪Demand for intensive ACT services was reduced to much less intensive and costly community support services for 14% of clients within 2 years.

Individuals who remain chronically homeless frequently suffer debilitating effects of serious mental illness and addiction. These frequently co-occurring disorders represent an extremely difficult hurdle for individuals to overcome. Typical housing programs demand sobriety and compliance with psychiatric and behavioral treatment as a condition of admission and continued enrollment. A more realistic, compassionate, and effective approach provides housing without such prerequisites and instead provides immediate access to permanent housing with supports as a foundation for recovery.     

Designing services for homeless women

The complexity of homelessness suggests that the development of policy and service strategies requires careful analysis of the unique features of identifiable groups within the homeless population. To begin this process, the characteristics and needs of homeless women are specified and their routes to homelessness delineated. Responses to homeless women, with the exception of battered women, have focused primarily on the provision of emergency services. Future policy and services must focus on the adequacy and accessibility of these emergency services as well as the need for transitional and long term housing and social services. The multidimensional nature of homelessness and the heterogeneity of homeless women require a wide range of alternatives that can be tailored to each woman's unique needs for service.     

Developing programs for homeless veterans: understanding driving forces in implementation

Between 1992 and 2003, services for homeless veterans at the Veterans Affairs Greater Los Angeles Healthcare System went from inappropriate utilization of hospital medical and psychiatric beds, to a continuum of residential treatment, transitional housing, and employment programs through arrangements with private agencies. The authors use elements of Hasenfeld and Brock's Political Economy Model (1991) to explain this transformation in service delivery that was spearheaded by a VA social work leadership team. It is argued that three driving forces crucial to program implementation were present: technological certainty, economic stability, and concentration of power. Evidence of the implementation's impact includes creation of new homeless program beds, a reduction in use of medical/psychiatric beds, and a large number of formerly homeless veterans with housing and employment at program discharge. Study limitations and implications for future studies are discussed.     

Project Redirection: evaluation of a comprehensive program for disadvantaged teenage mothers

An evaluation of Project Redirection, a two-year demonstration program designed to help pregnant teenagers and teenage mothers, shows that teenagers from a comparison group, who were not enrolled in the demonstration program, were significantly more likely than project participants to experience a repeat pregnancy after one year, but that after two years the difference was small and nonsignificant. Likewise, at 12 months into the program, the project participants proved more likely to be using contraceptives, but by 24 months the comparison group had caught up. After one year of participation, the project teenagers were more likely than the others either to be in school or to have graduated (56 and 49 percent, respectively). However, this differential also disappeared by 24 months. Nonetheless, even at that point, project teenagers who had dropped out prior to joining the program and those who had had a repeat pregnancy were more likely to be in school or to have completed school than were similar comparison teens. Project teenagers also were somewhat more likely to have held a job during the two-year period than were teenagers not enrolled in the program. All in all, the evaluation demonstrated that teenagers who participated in the project and remained in it for more than a year had consistently better outcomes in education, employment and repeat pregnancy than any other group had. Comparison teenagers who had never participated in any special program for pregnant teenagers, on the other hand, demonstrated consistently poorer outcomes than any other group.     

Predictors of homeless veterans' irregular discharge status from a domiciliary care program

This study addresses the relationship of homeless veterans' discharge status from a domiciliary care program to biopsychosocial characteristics presented at admission into the program. Hypotheses were that younger age, less education, and substance abuse or psychiatric disorder would predict an irregular discharge. Research participants were 367 homeless male veterans who had been admitted to a domiciliary care program at the West Los Angeles Veterans Affairs Medical Center for treatment of medical, psychiatric, or substance disorders. Status of veterans' program discharge (regular or irregular) served as the outcome measure. Logistic regression analysis revealed that irregular discharge from the program was more likely among veterans who were black, who had poor employment histories, or who had problems with alcohol. Results are discussed in light of the need to maintain homeless veterans in treatment programs so that they can achieve maximum benefit from available programs.     

Service system integration, access to services, and housing outcomes in a program for homeless persons with severe mental illness.

OBJECTIVES: This study evaluated the hypothesis that greater integration and coordination between agencies within service systems is associated with greater accessibility of services and improved client housing outcomes. METHODS: As part of the Access to Community Care and Effective Services and Supports program, data were obtained on baseline client characteristics, service use, and 3-month and 12-month outcomes from 1832 clients seen at 18 sites during the first year of program operation. Data on interorganizational relationships were obtained from structured interviews with key informants from relevant organizations in each community (n = 32-82 at each site). RESULTS: Complete follow-up data were obtained from 1340 clients (73%). After control for baseline characteristics, service system integration was associated with superior housing outcomes at 12 months, and this relationship was mediated through greater access to housing agencies. CONCLUSIONS: Service system integration is related to improved access to housing services and better housing outcomes among homeless people with mental illness.     

Permanent Housing Placement and Reentry to Services Among Family Recipients of Homelessness Prevention and Rapid Re-Housing Program (HPRP) Assistance

The Homelessness Prevention and Rapid Re-Housing Program (HPRP) provided individuals and families who were either at-risk or currently experiencing homelessness with time-limited financial and housing support services. Evaluations of HPRP showed a high rate of family placement into permanent housing. However, little research has explored immediate and longitudinal outcomes for families enrolled in HPRP. Using Homeless Management Information System data from Indianapolis, Indiana, we examined demographic and program-related predictors of families entering permanent housing and their risk of reentry into homeless services following HPRP participation. The sample included 511 families who enrolled in the program from 2009 to 2012, with an average follow-up period of 4.5 years. We conducted analyses separately for Homelessness Prevention (HP) recipients (n?=?357) and Rapid Re-Housing (RRH) recipients (n?=?154). Results revealed that HP families were more likely to enter permanent housing if they: included adults who were older in age, were enrolled longer in the program, were provided rental arrear services and utility payments, and did not receive legal services. RRH families receiving rental assistance services had significantly greater odds of entering permanent housing. Among permanently housed families, at least one family member in 10.9% of HP recipients and 18.8% of RRH recipients reentered homeless services. HP families with younger children and one veteran family member were at increased risk of reentry to homelessness services. RRH recipients who did not receive moving cost services and had more children were at greater risk of reentry. Study findings suggest a need for future research on HP and RRH interventions that identify unique service needs among families who are experiencing housing instability or homelessness.     

Health status, needs, and health care barriers among the homeless

Perceived health status, health conditions, and access and barriers to care are important predictors of mortality and the use of services among the homeless. This study assesses these issues by structured interview of 128 homeless adults from San Francisco. Of these adults, 21.1 percent were women (mean age 37 compared to 42 for men). In terms of ethnicity, 38 percent were white; 30 percent were African American; 17 percent were Latino; and 15 percent were Asian/Pacific Islander, Native American/Alaskan, or of mixed ethnicity. Of these adults, 49 percent rated health as poor or fair. Men were four times as likely as women to report their health status as excellent or good. Persons of color were more likely to report unmet needs for shelter, regular meals, employment, and job skills/training. These findings add information on those homeless not often included in research and indicate that these marginalized individuals may be in the poorest health.     

Supportive housing for chronically homeless individuals: Challenges and opportunities for providers in Chicago,USA

Chronically homeless individuals often have extensive health, mental health and psychosocial needs that pose barriers to obtaining and maintain supportive housing. This study aims to qualitatively explore supportive housing providers’ experiences and challenges with housing chronically homeless individuals and examine opportunities to improve supportive housing systems of care. In 2014, we conducted qualitative in‐depth interviews with 65 programme administrators and case managers of supportive housing programmes in Chicago, IL. Data were analysed using an inductive thematic content analysis. Analysis revealed four themes that capture the primary challenges faced by housing providers: housing priorities, funding cuts, co‐ordinated entry and permanency of housing. Housing for the chronically homeless has been prioritised, yet service providers are being expected to provide the necessary services to meet the needs of this population without commensurate funding increases or agency capacity. Additionally, case managers and administrators discussed the tension over housing tenure and the permanency of supportive housing. Findings provide qualitative insight into the challenges providers face implementing supportive housing for chronically homeless individuals.     

Moving substance-abusing women from welfare to work

Substance abuse and welfare reform are among the nation's highest priorities, and research that examines linkages between the two is of extreme importance to both government policy and the community. Welfare reform will have serious implications for substance abusers as well as for the various professionals who treat them and work to move their clients into functional recovery and self-sufficiency. Within the context of welfare reform and the special needs of substance-abusing populations, the present study examines current welfare status, work status, and barriers and facilitators to gaining and maintaining employment among 100 low income women who participated in a long-term residential substance-abuse treatment program in Miami, Florida. Participants completed a face-to-face interview to assess a detailed employment history and current sources of income as well as the Addiction Severity Index. Results indicate that completers of the treatment program were more likely to be working post-discharge than non-completers. Similarly, the longer the length of stay in the program, the more likely the client was to be working post-discharge. Multivariate analysis indicates a high-school education, participation in the treatment center's aftercare program, and treatment duration of more than one year were independently related to work status. These data suggest that as welfare reform becomes a reality, continuing support of various types, particularly drug treatment, is needed to assist substance-abusing women in gaining and maintaining employment.     

Occupational Concerns of Women Who Are Homeless and Have Children: An Occupational Justice Critique

SUMMARY

The purpose of this exploratory study was to describe the occupational goals and concerns of women who are homeless with children. Twenty-seven women with children living in homeless shelters completed interviews using the Canadian Occupational Performance Measure (COPM). Occupational issues and concerns were identified for each participant, and then they were pooled. A total of 169 occupational concerns were described and analyzed. The most common occupational issues identified by participants concerned finances, employment, education, transportation, housing, time for self, personal appearance, home management, and parenting. Analysis of identified occupational concerns suggests that the homeless women with children experienced a range of institutional and social barriers to occupational participation: essentially a form of occupational injustice. This study raises questions concerning the most effective roles for occupational therapists to facilitate empowerment so that women who are homeless may fully participate in the communities where they live.     

The homeless alcoholic: who cares?

Two homeless alcoholics, males aged 58 and 40 years, suffered from multiple health problems. Sleeping outdoors, excessive drinking and incompetence refrained them from seeking proper assistance. The patients were assessed on many occasions at primary care services provided in shelters in Amsterdam, at police stations and in the streets. They were also frequently admitted to shelter infirmaries, alcohol clinics and general hospitals. Despite substantial individual health damage, community costs and extreme care consumption, coercive treatment was not applied to prevent the death of the first patient and to stabilise the situation of the second. It is stated that a specific group such as homeless alcoholics can hardly be treated except during moments of crisis. Coercive treatment should be applicable in order to stabilise these patients so as to prevent early mortality among the alcoholic homeless with comparable health problems. Outreach primary care services for the alcoholic homeless should actively cooperate with addiction and mental health services in providing adequate care.     

Mothers experiencing homelessness: mental health, support and social care needs

Little is known about the experiences of mothers who become homeless. The numbers of women with children in this situation are growing, most becoming homeless following domestic or neighbour abuse, or the breakdown of family relationships. This qualitative study aimed to describe mothers' experiences of homelessness in relation to their mental health, support and social care needs. Twenty-eight homeless women with dependent children residing in hostels were interviewed. The experience of homelessness was stressful, but viewed as a respite for many of the participants because they had experienced violence and harassment prior to their stay in the hostels. Many described poor mental health, which they related to the conditions in hostels and traumas that they had experienced before becoming homeless. Their experiences and perceptions of the services available were mixed. Some valued the support offered by staff and other residents, but the majority felt that there was a lack of resources to address their needs. Many women had difficulty coping with homelessness, and several said that support from other homeless women was an important source of help. Services need to work together to meet the multiple health, social, psychological and housing needs of these women.     

The responsibility to care for single homeless people

This paper examines the reasons why in contemporary Britain many single homeless people with severe physical and mental health problems and welfare needs do not receive the treatment, care and financial support that they manifestly need, and in particular considers the interaction between their personal characteristics and the organisation and the obligations of services. Homelessness is a complex concept associated with problems of housing, health, social care and income. The greatest weaknesses of the service system are that no single agency has a statutory responsibility to ensure that vulnerable homeless people are served, and none of the generalist welfare agencies have a duty to seek out those who do not present. As a result, single homeless people fall between the housing, health and social services and amass exceptional unmet needs. The paper appraises the approaches to single homeless people's problems that have recently been introduced by the Rough Sleepers' Unit (RSU), and discusses the ways in which current reforms of the welfare services may impact on the situation of homeless people. With the possibility that the RSU's prime responsibility for commissioning single homeless people's services will transfer to local authorities in 2002, the paper concludes by specifying the implications for voluntary and statutory providers and makes recommendations about the attribution of the responsibility to care for this vulnerable group.