by
Sally Erickson, M.S.W.
Jaimie Page, M.S.W., L.S.W.
Outreach and engagement strategies are critical in helping homeless persons transition from the streets into housing and services. A literature review was conducted and commonalities across populations were found (although the preponderance of literature describes homeless persons with mental illnesses). Definitions, exemplary practice models, values/principles, worker stances, measurable outcomes, and multi-level factors relating to outreach and engagement are presented as well as issues related to research and funding.
Lessons for Practitioners, Policy Makers, and Researchers
The process of outreach and engagement is an art, best described as a dance. Outreach workers take one step toward a potential client, not knowing what their response will be—will the client join in or walk away? Do they like to lead or follow? Every outreach worker has a different style and is better at some steps than others. To dance with grace, when the stakes are high, is the challenge for all of us.
In the U.S., we now have the benefit of more than ten years of McKinney funding which has made possible scores of outreach programs across the country. Rural and urban, small and large, comprehensive or finite, they reach out to people who are homeless and challenged by poverty, violence, marginalization, poor health, mental illness, substance abuse, and other issues.
This paper will provide definitions; exemplary practice models, including worker stances, values/principles, outreach functions and services, outreach across populations; measurable outcomes; and an extensive bibliography for further inquiry. The preponderance of available literature was published in the late 1980s and early 1990s, and focuses on mental health-related outreach programs. The few outreach-related articles published in recent years perhaps reflect the greater use, acceptance, and integration of existing outreach programs as part of a community's effort to provide a "continuum of care" to persons in need. This paper will present both a review of the literature and experiential information relating to best practices.
Priority Home! (1994) describes the federal plan to break the cycle of homelessness by "public and private mental health, medical, and substance abuse service-providers to initiate street outreach efforts, the utilization of safe havens ... and implementation of a continuum of care..." This federal validation of outreach as an accepted and expected part of a community solution to homelessness, which includes access to housing and services, recognizes the unique efforts of outreach workers across the country.
Outreach is the initial and most critical step in connecting, or reconnecting a homeless individual to needed health, mental health, recovery, social welfare, and housing services. Outreach is primarily directed toward finding homeless people who might not use services due to lack of awareness or active avoidance (ICH, 1991; McMurray-Avila, 1997), and who would otherwise be ignored or underserved (Morse, 1987). Outreach is viewed as a process rather than an outcome, with a focus on establishing rapport and a goal of eventually engaging people in the services they need and will accept (ICH, 1991; McMurray-Avila, 1997). Outreach is first and foremost a process of relationship-building (Rosnow, 1988) and that is where the dance begins.
Engagement is a crucial process for successful outreach. It is described as the process by which a trusting relationship between worker and client is established. This provides a context for assessing needs, defining service goals and agreeing on a plan for delivering these services (Barrow, 1988, 1991; ICH, 1991; Winarski, 1994). Some clients require slower and more cautious service approaches (Morse, 1987). The engagement period can be lengthy-and the time from initial contact to engagement can range from a few hours to two years (ICH, 1991) or longer. Effective workers can "establish a personal connection that provides a spark for the journey back to a vital and dignified life" (Winarski, 1998).
Based on a review of the literature and best practices found in the field, the following are important elements to address in a good outreach program: characteristics of the population served, values and principles, worker stances/characteristics, and goals of outreach.
Programs cannot assume is that all communities have the same percentages of "types" of homeless people. There is a range in the population that may differ from one region to the next. Rather than basing interventions on formulaic assumptions such as "1/3 mentally ill, 1/3 veterans, 1/4 families," each community needs to assess the characteristics of it's homeless persons, identify service gaps, and develop effective responses. For example, in one city 80 percent of the homeless were single men, while in another, 65 percent were families with children (U.S. News & World Report, 1988).
Characteristics Of Homeless Persons Needing Outreach
Outreach programs attempt to engage individuals who are unserved or underserved by existing agencies (Axelroad, 1987). This distinction is significant because the outreach model was developed to meet the large service gap found among this unique population. An outreach model is unnecessary and even counter-productive with other populations.
Outreach programs serve persons who may have psychiatric disorders and/or substance abuse issues. They may be highly vulnerable and considered "difficult to serve" (Rog, D.J., 1988). They usually cannot negotiate the requirements of or trust traditional service-providers. These persons may have poor health, lack insurance, and are unable to make or keep medical appointments and follow through with complex medical regimes. Homeless youth may be those who are estranged from family and fearful of adult service-providers. Homeless youth are perhaps the most vulnerable group of youths, and are in need of creative and early interventions, in order to prevent an acclimation to street life which includes prostitution, substance abuse, and crime. Further, homeless teems with children are viewed as perhaps the most vulnerable of homeless families (Bronstein, 1996).
Two factors commonly associated with homelessness among women include pregnancy and the recent birth of a baby. Homeless pregnant women experience a range of problems including poverty, isolation, substance abuse, and histories or past and present victimization. A lack of prenatal care and poor nutrition may also exacerbate health problems (Weinreb, et al., 1995).
Other groups include the elderly, women escaping domestic violence, families, and marginalized persons such as those who are transgendered and those in the sex industry.
Many of the people outreach programs attempt to serve are isolated, have minimal resources, minimal access to social services (Sullivan-Mintz, 1995; ICH, 1991), have had negative experiences with service-providers (McMurray-Avila, 1997), and have been victims of violence (Goodman, et al., 1995; Weinreb, et al., 1995). Workers give priority to those who are most at-risk who are least likely to seek out and successfully access available services, for whatever reason: fear, mental status, lack of insight and motivation, or low self-esteem. Rog (1988) describes the need to reduce barriers to service-utilization and facilitate the engagement process. Workers may also encounter persons who are able to access services and can help by providing one-time information and direction, but the focus is on the former group.
Successful outreach programs must be based on a core set of values and principles which drive interventions. Values and principles also serve to set the stage for developing realistic goals in an arena of limited resources and potentially slow progress.
There are common worker stances/characteristics found among successful outreach workers and programs. These characteristics are critical because successful engagement will largely be determined by the relationship between clients and workers. Effective worker stances/characteristics include:
Outreach programs vary in relation to considering credentials, ethnicity, or gender when hiring outreach workers. People with a variety of backgrounds may function as mental health outreach workers: physicians, social workers, nurses, nurse-practitioners, and para-professionals. Some programs employ formerly homeless persons with mental illnesses (Axelroad, 1987; Morse, 1987). A survey of ACCESS programs reported that 75 percent of programs do not require a bachelor's degree for an outreach worker. More important were characteristics such as a personal commitment to the work, flexibility, and a willingness to adjust schedules to the needs of the clients (Wasmer, 1998).
Some programs state that it is not necessary to have workers of the same ethnicity, cultural background or gender as the clients, nor who have a lot of street experience. They further state that the only essential characteristic is a common language (Axelroad, 1987; Nasper, 1992). However, an outreach team of two males in Milwaukee found that they had served 80-90 percent men and had difficulty establishing trust with homeless women. As a result, they now have mixed gender teams (Rosnow, 1988). Agencies promote an equal opportunity atmosphere, and the staff composition mirrors that of the general population.
Many outreach programs successfully use mental health consumers as outreach workers (Tosh, 1990 and 1993, and Lieberman, et al., 1991) and/or formerly homeless persons (Mullins, 1994). The benefits of such peer models allow for effective outreach, sharing of their personal expertise, fostering of partnerships between consumers and non-consumers, increased self-esteem of the working peers, and the evolution of consumers becoming active in changing services throughout the country. Consumers/peers/formerly homeless persons can contribute significantly in the development of program design, implementation, and evaluation. Their expertise should be actively sought out by outreach programs. To be sure, homeless persons and formerly homeless persons have expertise, skills, and insight that professionals who have never experienced homelessness lack. Programs recognize that peers working in homeless and mental health fields often endure the pressures of maintaining their own housing and overcoming stigma (Tosh, 1993), allow for reasonable accommodations to assist them, and offer training and on-going meetings (Leiberman, et al., 1991).
There are four main goals of outreach found across different areas of outreach client populations. The first is to care for immediate needs (Plescia, 1997), including to ensure safety, provide crisis intervention, refer to immediate medical care, and help clients with immediate clothes, food, and shelter needs. Workers must develop a trusting relationship (Plescia, 1997; Cohen and Marcos, 1992; Sullivan-Mintz, 1995) in order to achieve the additional goals of providing services and resources, whenever and for as long as needed (Winarski, 1998). Lastly, workers aid in connecting clients to mainstream services (Plescia, 1997).
An inherent factor related to these goals is the notion of phasing. Objectives are developed and reached over a period of time with small steps that are directed to a more structured, service-oriented goal. Persons often phase from accepting food from the outreach worker, to developing trust, to discussing a goal that in part can be achieved through services provided in the community and to accepting those services. Case management goals are gradually developed by both the client and worker. Outreach and engagement principles carry over into case management and are viewed as an ongoing process. As trust develops, clients take a more active role in setting and achieving case management goals. Ultimately, the goal is to successfully phase or integrate persons into the community and/or into a social service agency (ies) which would assume the task of promoting community integration. Just as clients are phased into outreach services from the streets, they are phased into the community from outreach.
There are at least three ways of classifying outreach models found in the literature. One set looks at a linkage model versus a continuous relationship model. A second set looks at a mobile versus fixed model. A third set describes models based on a service continuum.
Linkage vs. Continuous Relationship Model
Some outreach programs serve as linkages, referring clients to mainstream mental health or other service-providers. Examples of "find and link" programs are New York's Project HELP, which conducts in-vivo assessments and delivers people to the psychiatric hospital by voluntary and involuntary means, and Chicago's Mobile Assessment Unit (MAU), that visits shelters and streets to identify mentally ill persons and link them to resources (Wasmer, 1998). Other examples may include linking temporarily displaced families with housing.
Linkage-only programs that do not provide follow-up tracking have been determined to be ineffective for some disabled populations. A 1986-87 study of 13 federally funded homeless mental health demonstration programs reported that most outreach programs were running ineffective models. Many spent the majority of their time in screening and identifying individuals and providing verbal referrals, but little follow-up assistance. One project contacted 430 eligible persons, yet only 22 received follow-up mental health treatment. Five found housing and three received entitlements (Hopper, et al., 1990 in Morse, 1996).
Providing linkage-only services to certain homeless populations can lead to barriers and service gaps, resulting in lost clients. Morse (1991, 1996) suggests strategies to increase the effectiveness of this model: incorporate the expectation of an eventual service-provider transition early in the engagement and service-planning with a client; remain involved and actively involve the client in the referral process, including scheduling appointments, arranging transportation, and providing emotional support; work with the linkage site staff, informing them about client needs and characteristics; provide follow-up support as needed to both client and new staff; and provide advocacy on behalf of the client if needed.
In a continuous relationship model, workers perform outreach and continue on as the person's case manager. Outreach has been shown to be a necessary component of ongoing case management for mentally ill clients. Axelroad and Toff (1987), point out the difficulty in distinguishing outreach from case management for homeless mentally ill persons for two reasons. First, the fragility of the population requires trust and continuity of care when helping clients move from an outreach phase to a treatment phase. Second, outreach workers must often provide case management services because of the frequent shortage of appropriate and relevant case management services for which to refer clients.
The drawbacks to the continuous relationship model are small recommended caseloads, 10:1, which may be unrealistic for many agencies, and little capacity to outreach with new clients (Morse, 1991, 1996). However, the approach has been shown to be effective at maintaining contact with clients and housing retention (Morse, 1996). In addition, outreach workers may prefer the excitement, lack of structure, and immediacy of outreach. For this and other reasons related to individual personality traits, some outreach workers may not be as effective as case managers.
At Safe Haven in Honolulu, outreach workers opted for the continuous relationship model out of necessity when they were unable to transition "graduated" residents to case managers at the community mental health centers. Historically, the engagement strategies used in interaction between clients and outreach workers have been substantially different from strategies used at traditional service settings, leaving clients with little incentive to transition to a less user-friendly service-provider. Outreach roles expanded to encompass case management and advocacy, and they remained connected with clients through follow-up. Perhaps as a result, a majority of Safe Haven clients have successfully transitioned into the community. In Safe Haven's first 28 months, 43 residents transitioned from the program—63 percent into permanent independent housing, with 98 percent of these retaining their housing.
Mobile vs. Fixed
Outreach may be mobile or fixed depending on the needs of the target population (Sullivan-Mintz, 1995). Outreach may take place on the streets, as well as in shelters, drop-in centers, emergency rooms, hospitals, and jails (Axelroad, 1987; Morse, 1987). The mobile model requires that the projects be "equipment heavy," including agency vehicles/vans, employee cars, and communication systems such as pagers, cellular phones, and walkie-talkies (Wasmer, 1998).
Fixed-site outreach programs such as drop-in centers or day programs for the mentally ill, within high-density homeless areas, can be more easily accessed by greater numbers of clients, increase staff efficiency, and can provide additional incentive services. Many outreach programs have both a mobile and fixed-site component (Morse, 1987). In a survey of eight ACCESS programs, 77 percent of clients were engaged by mobile methods and the balance at drop-in centers. (Wasmer, 1998)
For certain clients with primary substance abuse issues, mobile outreach is more successful for several reasons. There is less stigma and community opposition when outreach workers meet clients individually on the streets rather than having clients come to a centralized location. Another reason is that clients who are high or intoxicated are often asked to leave fixed service sites.
Wasmer (1998) describes a link/serve continuum, with outreach programs that "find and link" or "find and serve." The latter include case management programs, assertive community treatment and intensive case management programs, drop-in centers, shelter-based programs, and low demand residences/safe havens. Of eight ACCESS outreach programs Wasmer surveyed, all were the "find and serve" type.
Different types of team approaches are described in the literature, depending on the mission of the team. They may focus on emergency psychiatric intervention, case management, health care, HIV education/prevention, harm reduction for sex industry workers, substance users, and others.
With mentally ill persons, using a team approach after engagement has been established assures that a client will learn to develop trusting relationships with several staff people. It also increases the likelihood of being able to attain assistance when necessary. Teams can include or have access to social workers, nurses, nurse-practitioners, substance abuse staff, medical and psychiatric consultants, and other outreach specialists. The team approach can also aid in combating burn-out and expanding caseloads (Axelroad & Toff, 1987) and the inherent sense of isolation individual outreach workers can feel. A study of five New York outreach programs showed that 98 percent of homeless mentally ill clients had a significant relationship with more than one staff member, indicating that involvement with the programs did not consist only of the client's relationship with a single worker (Barrow, 1988).
One survey of eight ACCESS-funded outreach programs reported that all sites used a team approach, with majority of first contacts made by two mental health professionals, one taking the lead and one observing (Wasmer, 1998).
Based on a review of the literature (Winarski, 1994, 1998; ICH 1991; Morse, 1996) and review of best practices in the field, several outreach functions/services are common among exemplary outreach programs.
Outreach programs cannot serve all potential clients. Exemplary programs have clearly defined program goals and objectives. Some programs target a subset of the population, such as persons with mental illnesses, and others limit outreach to a particular geographic or "catchment" area (ICH, 1991).
If geographic limits or catchment areas are a defining factor in determining the target population, then the size of the area allows for repetitive contact. Knowing fewer clients better is the goal. Workers have the flexibility to leave this zone and follow their potential clients elsewhere (McQuistion, 1996). If a client is determined to be out of the mission of the outreach program, provisions can be made for referring non-target clients to the appropriate programs. (ICH, 1991).
Once workers identify the target population, the next task is to locate them. Individuals can be found under bridges and freeway overpasses, alleys, parks, and vacant lots. In rural areas or on the fringes of urban areas, outreach workers may go to the beaches, riverbanks, foothills, wooded areas or desert. They may be in public facilities such as libraries, airports, and bus stations. They may be in places where people live on the edge of homelessness, such as welfare hotels, cheap motels, and SROs. Some teams have special arrangements with jails, detox/treatment programs or other institutions, to enter and make contact with ongoing clients or potential clients regarding available services on their release (McMurray-Avila, 1997).
Sometimes homeless persons will serve as voluntary scouts for outreach workers, alerting them to homeless persons who appear to be in need of intervention. Volunteer homeless persons can also help outreach workers locate clients who have been missing for some time. Outreach coalitions, comprised of outreach workers from different agencies, can meet periodically and help each other locate missing clients, as well as help each other stay on top of recent trends in geographic concentrations of homeless persons.
Outreach conducted by peers, such as youth, substance users, or sex industry workers, can be effective in locating, engaging, and completing assessments of the clients perceived needs. When going out in teams with non-peer professionals, they are able to introduce professionals to participants on the streets. Youth who serve as peers/mentors for other homeless youth, for example, help convey a sense of understanding of the factors that may have led them to becomes homeless such as abuse and share resource information, teach safety, and help make a bridge between street life and the world of "professional" adults whom they generally don’t initially trust. Hiring program participants encourages increased feelings of self-esteem and empowerment on the part of participants and generates empathetic, effective outreach staff (Mullins, nd). An effective outreach program for at-risk HIV youth in the sex industry in New York provides training to peer youth outreach workers, a support group, an active and real voice in program development, and a stipend for their work. These youth outreach workers have been successful in saving lives and reducing risk associated with their lifestyle and that of their peers in a way that adults could not have.
Engagement is a crucial, on-going, long-term process necessary for successful outreach (Morse, 1991, 1997). In a study of five New York outreach programs, homeless mentally ill clients first contacted by outreach workers were engaged an average of 3.9 months before intensive services began (Barrow, 1988).
Engagement reduces fear, builds trust, and sets the stage for "the real work" to begin (Cohen, 1987). Morse (1991) classifies engagement in terms of four "stages": 1) setting the stage, 2) initial engagement tactics, 3) ongoing engagement tactics, and 4) proceeding with the outreach/maintaining the relationship.
Setting the stage: Workers become a familiar face and begin to establish credibility in places where homeless persons frequent (Morse, 1991). They use a non-threatening stance/approach (Cohen and Marcos, 1992), and get some kind of permission from the client, either verbal or non-verbal, before approaching. In these early stages, workers gently cease interactions that appear too overwhelming to clients and try again later.
Initial engagement tactics: Workers attempt to engage the potential client in conversation, beginning with non-threatening small talk (Morse, 1991). This allows workers to assess for signs of problems and also the impact of the interaction. Is the client feeling intruded upon (Morse, 1991)? Workers provide incentive items (Cohen, 1989; Cohen and Marcos, 1992) such as food, drinks, condoms, cigarettes, vitamins, toiletries, etc., with real and perceived benefits that promote trust.
Ongoing engagement tactics: Workers begin to "hang out" and "share space" with clients (Morse, 1987). As clients become more comfortable, workers begin to provide or help the client to meet some important needs that can be easily solved or obtained. This might include providing transportation to get clothes, linking the client with medical care, and providing incentive services that are based on clients' perceived needs (Cohen, 1989). Engagement strategies used in the initial phase continue.
Proceeding with outreach/maintaining the relationship: As trust is established, workers help clients define service goals and activities, which may include the pursuit of housing, income, and medication (Morse, 1991). Staff accompany clients to appointments, help them prepare for upcoming tasks, and assist in the negotiation of service settings.
At Honolulu's Health Care for the Homeless Project, staff use six simple engagement strategies in their interactions with diverse groups.
Workers need to conduct an assessment of an individual's comprehensive, holistic needs before providing services and linkages to meet these needs (Morse, 1987). The assessment process is informal and usually takes place over time. Outreach workers, rather than asking direct questions, may make inferences (Cohen and Marcos, 1992) about an individuals' mental and physical state. As the relationship builds, workers may be able to ask more direct questions as they try to get more history.
The crises faced by many homeless persons are usually related to basic survival, such as lack of food and water, lack of clothing, exposure, poor health, and deteriorated mental status. Outreach workers must initially provide basic triage assessment to help identify and respond to potential life-threatening problems.
When clients are experiencing potentially life-threatening problems such as dangerousness to self or others, serious medical problems, or exposure to extreme cold or heat, outreach workers must be prepared to intervene. Whenever possible, workers should encourage clients to voluntarily accept treatment, and present this treatment within the context of the client's perceived needs. When the situation is life-threatening, workers should be prepared to initiate involuntary treatment or interventions that will reduce harm. Clinical supervision in this situation is highly recommended so as to not infringe upon clients' rights and self-determination.
In response to a lack of homeless persons being able to get their basic needs met, workers help them to access food, clothing, shelter (Axelroad, 1987), showers, laundry, and basic medical care. In some cases, homeless persons may not perceive these as basic needs, particularly in the case of those with severe mental illness who have decompensated and/or those with chronic substance use problems. They may perceive other needs as more important. In these cases, workers can educate people about the resources available when they’re ready for them, encourage them to use them when needed, accompany them to the service sites, and suggest what may be a marriage of the worker’s perception of what the homeless person may need, and what the person him/herself feels they need.
Outreach programs should attempt to engage individuals who are unserved or underserved by existing agencies, and link them to resources. Many persons who are homeless are unaware of what is available (McMurray-Avila, 1997). Effective workers learn about available resources and establish working relationships with the people who provide these resources. Workers also tap into the knowledge of other homeless persons, who are often more aware of details and subtleties of changing resources. Effective workers are able to make durable linkages across systems: homeless/non-homeless systems, youth to adult systems, and across private and public systems. When these systems aren’t user friendly to homeless persons, workers advocate for change.
Clients who are disenfranchised and discriminated against, often need outreach workers to assume an advocacy role on their behalf. This occurs on many levels such as when helping clients access benefits and services to which they are entitled, within the outreach worker's own agency, and within the criminal justice system. Indeed, in many communities, political views about homelessness are resulting in what may be perceived as meaner streets where persons are criminalized because of their homelessness. This can be seen in arrests for trespassing, criminal littering, and loitering. Legislation is increasingly pursued as a vehicle to continue criminalization of homeless persons, the effects of which are devestating to the homeless person and counterproductive to the outreach process.
Effective workers provide short-term follow up with respect to immediate tasks at hand and long-term follow-up with clients to ensure that they remain in a stable situation.
Primary health, mental health, and substance abuse treatment approaches similarities in outreach approaches are found in different treatment areas and client populations including families, veterans, mentally ill and transgendered persons, sex industry workers, substance users, HIV+ persons, and youth.
A significant characteristic of homeless persons is poor health. A one-year study of 300 mentally ill homeless persons in New York City, revealed that 73 percent suffered from at least one medical condition in addition to a psychiatric diagnosis. The most common medical conditions were peripheral vascular diseases, anemia, infestations, and respiratory diseases, particularly tuberculosis. 35 percent had a secondary diagnosis of substance abuse (Marcos, 1988).
A two-year study of 1,751 homeless clients in Honolulu showed exceptionally high rates of mortality, with an average life expectancy of 48 years. Death rates have long been used as a measure of deprivation and as a guideline for public health resource allocation. With that in mind, homeless populations are in urgent need of increased attention and health care spending (Martell, 1992). A Philadelphia study of mortality rates for homeless people was 3.5 times that of the general population (Hibbs, 1994). Another study showed that causes of death varied by age group: (1) homicide: men ages 18-24; (2) HIV/AIDS: persons 25-44; and (3) heart disease and cancer: persons 45-64 (Hwang, 1997). In a study of hospitalizations of homeless persons, admissions to acute care hospitals were five times greater than the general population. They were admitted nearly one hundred times more often to the state psychiatric hospital (Martell, 1992).
Health care delivery to homeless persons can be challenging due to: lack of insurance, distrust of service-providers, bad experiences with health care in the past, difficulty making and keeping appointments, difficulty with complex medical and follow up care routines, and lack of understanding or interest in health problems in relation to seemingly more important issues at hand.
As with mental health and substance abuse, health care approaches for homeless persons are based on a process of engagement, assessment, planning, advocacy, education/motivation, and follow up. There are different models of health care approaches to serving persons who are homeless. Health care services may be provided at either permanent or mobile clinics and at rotating sites, some of which may be near homeless shelters. Health care providers may include salaried or voluntary physicians, physician assistants, nurses, and/or nurse practitioners who comprise a medical team. They reach out to homeless persons at sites where they have agreements with the host agencies. The goal is to provide care and help clients access a more mainstream medical system that will continue to be available to them. Staff make referrals and arrange transportation and an escort if needed (Plescia, et al 1997).
Escorting clients to appointments can be critical if a person is unable to go on his/her own. Staff can help clients by making medical appointments, preparing them for the appointment (getting insurance card/paperwork in order, educating them about what might be expected), advocating for them if needed, translating medical jargon, and helping them follow through with aftercare instructions and appointments. Further, outreach workers can be the "eyes" and "ears" on the streets for health care providers who are monitoring clients from afar. When clients reach a dangerous state of health, outreach workers can elicit assistance from mobile medical outreach staff, or stationary medical staff who are willing to leave a clinic and provide in-vivo services.
Often, homeless persons are more willing to address health problems because of decreased stigma, compared to willingness to address mental health or substance abuse issues. As outreach workers continue to engage clients during the health care process, they can begin to slowly and gently address other issues. For example, they may work toward obtaining clinical history and the client's thoughts and perspectives regarding their experiences with mental illness, substance abuse, and other areas.
Outreach workers play a key role in illness prevention, from providing blankets and socks, helping clients access insurance and free medication/medical care, and educating them about topics like safe sex, hepatitis, TB, harm reduction, and nutrition. They can help clients get food and vitamins, and help them obtain past medical records and reconnect with previous service providers who may be familiar with their medical case(s). Outreach workers can also help by being aware of other organizations' involvement in medical care so that there can be nd ears" for psychiatrists and clinicians making decisions about the direction of mental health care.
Effective outreach workers are able to demonstrate flexibility in their treatment responses. For example, with some clients, the connection can be so tenuous that the engagement phase can take months or even years of gentle, slow, and careful interactions. Other clients' mental status may indicate the need to set limits. For clients who lack insight into their mental illness, workers take an education and normalizing approach, emphasizing the stressful nature of homelessness (Morse, 1991). Workers can help clients make connections between homelessness and their perception of the bad things that happen to them, hoping to spark some motivation to consider housing and other related social services. Workers can also help clients make connections between negative symptoms and the potential relief that medications or other interventions might offer. However, discussion about medication can only occur after sufficient trust has been established. For many people, the only mental health involvement they recall has been involuntary and coercive, usually resulting in unwanted medication and treatment.
Some clients may persist in denying the existence of a mental illness, but become successful in housing (Barrow, 1991). Workers can help clients translate street skills into independent living skills while treatment and referrals progress. Engagement strategies can help with linkage to services. For example, one client on the streets liked jewelry, and a lot of it. The outreach worker invited her to the clinic where health and mental health services are provided, stating that they had "a lot of jewelry there." The outreach worker alerted staff, who the next day brought in jewelry from home and from thrift stores. The client enjoyed picking out one piece of jewelry every time she came to the clinic. This allowed linkage to services in a clinic where she learned to trust service-providers. Similar creative linkages are required to ensure success.
Outreach workers can help prepare clients as they begin to access services, at the same time informing staff at those agencies about the client's unique needs, strengths, and interests to help ensure successful transition.
Outreach to substance users crosses many sub-groups, such as those with dual diagnoses, sex industry workers, and persons with HIV/AIDS. One major gap in services to persons with substance abuse problems is the lack of an entry point into services for those who don't want formal treatment (Bonham, et al., 1990). A sub-group of this population are the "public inebriates" (Willenberg, et al., 1990). Three errors in treatment modalities have contributed to failures with this population. One is that the population is severely and chronically disabled. Second, programs often have unrealistic and high goals. Third, treatment models used are those that are more successful with middle-class, non-alienated alcoholics (Willenberg, et al., 1990). Moreover, treatment programs often fail to take into consideration cultural factors and fail to address the serious marginalization of disenfranchised groups. Engagement strategies are much the same as with health or mental health outreach—a non-judgmental stance, listening, educating, and linking. Project Connect's service model is based on principles that services fit client needs, focus on their strength rather than weaknesses, and that the worker/client relationship is primary and essential (Bonham, et al., 1990). Worker activities can include education about safe sex and safer drug use and newsletters, and connecting clients to support groups and sobering up stations (Bonham, et al. 1990). Incentive items may include vitamins, condoms, bleach kits, and clean needles. Alcoholics and drug users who are homeless frequently lack the motivation or skill to seek out currently available services. They often distrust service-providers because of real or imagined poor treatment in the past, or difficulty negotiating the system (McCarty, et al., 1990).
Since many street users do not have insight into the harmfulness of their drug use, outreach workers may implement the use of a "Motivational Interviewing" (Miller and Rollnick, 1991) or "Stages of Change" (Prochaska, et al., 1994) approach. Programs may want to consider training in these models for all staff, rather than having one designated substance abuse counselor. Homeless persons with co-occurring substance abuse issues will be better served by outreach workers with a working familiarity with these models. Workers are familiar with and provide linkage to community resources or support groups, when the person begins to express interest. A Harm Reduction approach is generally the best engagement strategy.
The main tenets of Harm Reduction are:
Common strategies successfully used to help addicted homeless persons include:
Successful Outreach and Engagement Strategies
Studies have shown that outreach and engagement strategies, while initially time-consuming and slow-moving, are successful because they reach more severely impaired persons who are less motivated to seek out services (Lam and Rosenheck, 1998). Three month outcome data compiled via the ACCESS study (Lam and Rosenheck, 1998), showed that clients reached in outreach on the streets experienced improvement on nearly all outcome measures equivalent to clients who were contacted in other services agencies and shelters. Outreach clients did equally well in areas of housing outcomes, quality of housing, improved mental health and decrease of psychiatric admissions, substance abuse, employment, social support, reduced victimization, and quality of life. This suggests that this hard-to-reach population has the same capacity for improvement as groups more connected to services and who may be more high-functioning.
The ACCESS program has demonstrated that people will use services if they are accessible and relevent and that effective outreach will lead to an increase in access to other services. Although helping homeless persons access mainstream services is difficult nationwide, ACCESS has shown that programs with sufficient resources can help people to be successfully treated in a community setting and that the bridge from homeless services to mainstream services is possible.
Positive housing outcomes, a major focus of homeless services, was also found by Bybee, et al., to be linked to outreach services (1994 and 1995). The likelihood of success in independent living was impacted by the amount of services, and a wide range of interventions and the intensity of those interventions and services. Recruitment sources also impacted housing success, in that those recruited from inpatient psychiatric settings were more likely to experience housing success than long-term Community Mental Health clients, suggesting that greater stabilization possibilities follow acute psychiatric episodes across populations. Anyone may have the opportunity for successful housing placement following a crisis. Those recruited from shelters also had greater likelihood of successful independent living, but also may continue to live in temporary settings, suggesting the variance of the degree to which persons from shelters can be easily housed. There was a smaller, yet significant predictability between housing status and client functioning, symptomatology, and substance abuse problems.
Improvement is often so subtle that it doesn't register on typical functional improvement scales. One program measures number of days per month spent in housing, number of times victimized, level of hygiene, number of contacts with other service providers, and so on (Axelroad, 1987).
In some cases, quantitative measures can be deceptive, as evidenced in Barrow's 1988 survey. After a six month survey of completed referrals, only a small minority were successful, such as only 24 percent of entitlement referrals, 42 percent of housing referrals, and 13 percent of psychiatric referrals. While this appeared to be a reflection of ineffective services, it also reflected a short study period, discrepancies between client and program perceived needs, and lack of resources.
One outreach program measures success by four criteria: present living arrangement, receipt of financial aid or other income, enrollment in a program for the treatment of alcohol abuse of mental illness when appropriate, and receipt of treatment for other medical conditions. The first year's data suggest that about four out of five persons have made at least one significant change (Rosnow, 1988).
Project Connect uses quantitative methods including face to face pre- and post-interview data with clients, monthly program data on clients, self-administered pre- and post-questionnaire data for community agency staff, and selected administrative record data from Project Connect agencies (Bonham, et al., 1990).
As part of the continuum of care delivery, workers can implement successful strategies described in Critical Time Intervention (CTI) to prevent recurrent homelessness and promote successful transitions to housing. One component of CTI is to strengthen the relationship between the individual and family, friends, and services, and secondly to provide emotional and practical support during the critical time after discharge from a shelter. Outcomes of CTI included significant reduction in homelessness and a preliminary indication that CTI is cost-effective (Jones et al., 1994, Susser, et al., 1997). Interventions are short in duration, simple, can be implemented by nonprofessional staff, and can be implemented in marginal settings (Susser et al., 1997).
A series of studies of homeless veterans by Rosenheck et al. (1989, 1993, 1995) evaluated the impact of outreach programs for homeless veterans with mental illness and found that outreach services are successful. The 1993 study found that outreach services increased access to outpatient and domiciliary services and reduced inpatient services. The 1989 study found outreach to be successful in that a significant number of homeless vets eventually wanted services and that outreach and advocacy efforts enhanced access to health care services. Outreach services have been found to be costly although there was a slight reduction in inpatient costs. Rosenheck, et al. (1995) caution that one cannot conclude, on the basis of cost alone, that less expensive treatments should replace more expensive ones. Many outreach programs have found that the initial cost of outreach and engagement pays off in the end.
Studies evaluating substance abuse programs found that offering an array of stabilization services along with case management services, contributed to recovery and utilization of services (McCarty, et al., 1990, Willenberg, et al., 1990, and Ridlen, et al., 1990).
Qualitative measures are useful for service providers in evaluating program functioning (Axelroad, 1987). One helpful technique is questioning formerly homeless individuals who have been outreach clients to find out which elements in the outreach team's approach were appealing or useful and which were perceived as negative. Project Connect uses ethnographic observations, interviews, and journals maintained by immediate program personnel (Bonham, et al., 1990). Qualitative evaluations can also be helpful in demonstrating to potential funders the complex nature of clients, outreach efforts, linkages, and length of engagement periods (Axelroad, 1987).
The very factors which contribute to a successful outreach effort—flexibility, ability to alter service systems—may impede evaluations which strive to concretely measure their effectiveness (Axelroad, 1987). There is a lack of controlled studies that demonstrate effectiveness and a lack of longitudinal studies. These are critical evaluation designs, yet are often difficult to implement with outreach clients who may be difficult to track.
Evaluations aimed at measuring the overall effectiveness of an outreach program must focus on the extent to which services and resources are available to outreach clients. In addition to evaluating effectiveness of services provided by the program, programs must also determine who is not being served by the program (Axelroad, 1987), why they are not being served, and how they might be served in the future.
Successful outcomes are not necessarily related to program services and should be considered in evaluating those programs. In one study, for example, success in obtaining housing and remaining housed were found to be related to socioeconomic background, defined by education and past employment, and level of functioning. Program services that were related to positive housing outcomes included an early focus on entitlements and housing-related services and participation on the part of the homeless person in defining housing goals were critical to their long-term success (Barrow, 1991).
While it is difficult to generalize outcome parameters across populations, regions, culture, and other factors across the country, a standard set of street outreach outcome measures is desirable at the national level. These standard outcomes should be different from standard outcomes used for other homeless populations which may be unrealistic for outreach populations. Outcome standards should also be set by individual programs. HUD requires Supportive Housing applicants to provide goals and objectives and later the extent to which goals were attained.
Future research and programmatic goals might include: identifying what national homeless outreach measureable outcomes might be; identifying specific factors that allow for successful transition from homeless to mainstream systems for the general outreach homeless population and for specific populations; the extent to which outreach teams are successfully used; the extent to which peer based outreach models and consumer involvement in program planning, implementation, and evaluation are successful; the development of more controlled and longitudinal studies; how the use of data-tracking within information systems might be implemented ethically and effectively; incorporating outreach outcomes within the managed care system; and the cost-effectiveness of providing outreach services and answering whether or not exemplary practices should be equated with effectiveness.
There are effective strategies for influencing the adoption of exemplary practices and policies on each major administrative level—agency, local community, state and federal. There are also many questions still open for discussion. Outreach workers rarely can be successful unless exemplary practices exist at other levels.
Agency
Effective administrators or program directors must educate the agency board about outreach activities and philosophy and advocate on behalf of outreach staff at the board level. Directors must also support the outreach team and advocate for their efforts with other service providers in the community; (Axelroad, 1987; Wobido, 1990).
Outreach staff must be given flexibility in work schedules so they can seek out and find persons in the evening and on weekends. Funds must be available for incentive and basic need items, as well as equipment. Providing outreach workers with on-call medical and psychiatric consultants is critical as is promoting a sense of teamwork—preferably a multi-disciplinary one. This helps workers feel supported and provides them with tools with which they can provide better services. Exemplary agencies, with outreach as a component, make provisions in service delivery for outreach clients, like allowing clients to receive medical/ psychiatric/substance abuse services when needed rather than by appointment. They allow bypassing of unnecessary forms and paperwork, and adopt the engagement stance.
Orientation and training of new outreach staff is critical particularly in the area of street safety. Training should include: street safety, characteristics of the target population, substance abuse/dual diagnosis, the criminal justice system, benefits and entitlements, community resources, involuntary hospitalization, client rights, harm reduction, confidentiality, de-escalation, boundaries, CPR, basic first aid, regional laws regarding child and elder abuse, engagement strategies, cultural competency, and infection control. Safety training should require that new staff sign a document indicating that they understand safety guidelines. This makes worker risks clear prior to hiring, while protecting the worker from injury and the agency from future liability.
Outreach workers often feel a sense of isolation in the field, from other homeless and non-homeless service providers and are likely to be viewed as marginalized themselves. As a result, agencies need to ensure a system of support, advocacy, and inclusion for their outreach staff.
Exemplary agencies provide opportunity for ongoing discussion around ethical issues. Clinical supervision and/or peer supervision is recommended for outreach staff who need to get second opinions on implementation of their ideas to creatively engage persons. The question must always be asked, to what extent are the engagement strategies used by workers non-coercive and non-deceptive (Lopez, 1996)? Supervision can also address issues like engagement versus enabling, boundaries, legal issues, and service-provision.
Outreach workers sometimes get harassed and are discriminated against along with their clients. If outreach workers function as service and/or rights advocates, their agency needs to determine which parameters of advocacy efforts are allowed and encouraged. They should also develop positive relationships with police and security personnel. Finally, outreach workers should attempt to develop positive relationships with intake workers and staff at other agencies where they might refer clients.
Community
In addition to direct services, outreach workers and administrators can enhance the knowledge base of effective outreach practices on a community-wide level, by providing consultation, education, training and referrals (Morse, 1991; Slagg, et al., 1994). Outreach workers can start an "outreach coalition," sharing resources, ideas, information, client tracking efforts, and mutual support. This process is essential in providing linkages to resources. In many communities, there are a dearth of resources, and outreach workers end up providing intensive case management, in a continuous relationship model.
Outreach workers can share success stories—they encourage other workers, combat the community's "compassion fatigue," and give hope to those clients still in crisis. Success stories are an essential part of informing funders, politicians, and policy-makers that services work.
Outreach programs cannot be designed in isolation from other service programs (Axelroad, 1987; Morse, 1987; Barrow, 1988). Survival depends upon community networking: providing referrals, sharing resources, pooling knowledge, and participating in community-wide groups (Nasper, 1992). In discussing outreach, it is essential to discuss the gaps and barriers in these systems (Axelroad, 1987). The most flexible, well-staffed and funded outreach program will have little impact if the mental health, health, housing and social service systems in a community are not capable of serving people linked through outreach efforts.
One urban outreach program made efforts to minimize coordination problems by expanding the makeup of a coalition with representatives of human service organizations in both the public and private sector; getting active participation with various planning and coordination bodies concerned with homelessness; and structuring the outreach program so that the workers could become familiar enough with their counterparts in other service-provider agencies (Rosnow, 1988).
Public-private partnerships can lead to effective service-provision. One example is the Times Square Consortium (TSC). This is a partnering of the Times Square Business Improvement District and social service agencies to provide outreach and a drop-in center for homeless persons in the Times Square area. Rather than a business-community attempting to simply arrest and move along persons who are homeless, they provided the impetus for social services. Together the TSC has applied for and received funds from state and HUD (Porter, 1997).
Project Respond in Portland, Oregon, won the 1997 Gold Achievement Award by the American Psychiatric Association for its exemplary outreach program. Exemplary community practices cited include successful and collaborative relationships with "community partners" like police, housing managers, service-providers, and businesses. Also cited was the reduction of stigma, seeking of missing persons, consultation, community education, including police education, and diversion (Talbot, 1997).
These approaches are heartening in an apparent climate toward the criminalization of homeless people. There has been an increase in anti-vagrancy laws which prohibit sitting, panhandling, or being in an airport during certain hours. Outreach is one of the few formal contacts where service professionals connect with homeless people who may be breaking laws. Outreach workers and their agencies could be held legally accountable because of their association with these homeless persons.
State/Federal
One outstanding issues that still needs to be addressed at the state/federal level is funding. Who should pay for outreach? Through the Continuum of Care process, communities are encouraged to include outreach as part of the continuum. On a national level, service-providers must advocate that managed care plans make point-of-access exceptions for homeless persons, and the homeless Medicaid population must be carved out of Medicaid managed care and financed separately (Plescia, 1997).
The cost-effectiveness of outreach programs often comes into question. One reason is related to the comparison of numbers of people served on outreach versus the number of people served in homeless shelters. If funders think of effectiveness in terms of the numbers of people served, then homeless shelters will be viewed as more effective. The people outreach programs tries to serve are those who don’t readily come to and accept services and who need a period, sometimes a lengthy one, of engagement. The positive outcomes of outreach services may not be readily seen. Yet, the cost of providing outreach services may divert costs from other systems such as emergency rooms, hospitals, psychiatric units, jails, and other crisis systems of care. This issue also reflects a structural obstacle to demonstrating cost savings between systems. For example, at the federal level, HUD funds many outreach programs, but the cost savings are realized in other systems such as Medicaid, the mental health system and substance abuse system. The same obstacles to demonstrating cost savings exists at state and community levels as well.
Agencies and communities need to ask what more could be done on a federal level to support outreach programs. One possibility could be a requirement of outreach services in states' Medicaid plans. HUD does not fund emergency services or prevention of homelessness, and perhaps they should. Another possibility, could be a mandate that all Continuum of Care proposals include a strong outreach component, with penalties if outreach is not included.
More publications and guidelines for outreach are needed. Federal departments charged with addressing homelessness could provide "how to" information for service providers, and present options for service delivery based on research findings. Exploration of the range of services could be done nationally to determine specific trends related to successful outreach. Inquiry into what is optimal and what should be expected of outreach programs can take place federally. For example, the authors are familiar with outreach programs with a range of hours—from weekdays only to 7 days/week 16 hours/day. What have we learned about optimal services delivery? Several cities combine outreach with police escorts. Does this implied concern for worker safety in fact drive away potential clients and eliminate a Harm Reduction approach? Expertise is needed in this area if outreach programs decide to try and build collaborative relationships with police and security.
Homelessness among severely mentally ill persons, and chronic substance abusers represents a failure of state and federal policy to adequately address or sustain long-term community support systems. Rather than stimulating new funding mechanisms and service delivery systems, they should be preventing homelessness by bolstering basic community resources for the long-term care of disabled persons (Rosnow, 1988). In the long run, prevention efforts should be incorporated in structural measures to prevent homelessness and provide appropriate services to those with chronic disabilities.
Most of the following references are found in the National Resource Center on Homelessness and Mental Illness’ Annotated Bibliography: Outreach Services to Homeless People with Serious Mental Illnesses.
Axelroad, S. E. & Toff, G. E. (1987). Outreach Services for Homeless Mentally Ill People. Washington, DC: George Washington University.
Barrow, S. M. (1988). Delivery of Services to Homeless Mentally Ill Clients: Engagement, Direct Service and Intensive Case Management at Five CSS Programs. New York, NY: New York State Psychiatric Institute.
Barrow, S. M., Hellman, F., Lovell, A. M., Plapinger, J. D. & Stuening, E. L. (1991). Evaluating Outreach Services: Lessons from a Study of Five Programs. In N. Cohen (Ed.), Psychiatric Outreach to the Mentally Ill (New Directions for Mental Health Services), 52: 29-45.
Bennett, R. W., Weiss, H. L., & West, B. R. (1990). Alameda County Department of Alcohol and Drug Programs Comprehensive Homeless Alcohol Recovery Services (CHARS). Alcohol Treatment Quarterly, 7(1): 111-128.
Berman, S., Barilich, J. E., Rosenheck, R. & Koerber, G. (1993). The VA’s First Comprehensive Homeless Center: A Catalyst for Public and Private Partnerships. Hospital and Community Psychiatry, 44(12): 1183-1184.
Bonham, G. S., Hague, D. E., Abel, M. H., Cummings, P. & Deutsch, R. S. (1990). Louisville’s Project Connect for the Homeless Alcohol and Drug Abuser. Alcoholism Treatment Quarterly 7(1): 57-78.
Bronstein, L. R. (1996). Intervening with Homeless Youths: Direct Practice without Blaming the Victim. Child and Adolescent Social Work Journal 13(2): 127-138.
Bybee, D., Mowbray, C. T., & Cohen, E. (1994). Short Versus Longer Term Effectiveness of An Outreach Program for the Homeless Mentally Ill. American Journal of Community Psychology 22(2): 181-209.
Bybee, D., Mowbray, C. T., & Cohen, E. H. (1995). Evaluation of a Homeless Mentally Ill Outreach Program: Differential Short-Term Effects. Evaluation and Program Planning 18(1): 13-24.
Cohen, M. B. (1989). Social Work Practice with Homeless Mentally Ill People: Engaging the Client. Social Work 34(6): 505-509.
Hibbs, J. R., Benner, L., Klugman, L., Spencer, R., Macchia, I., Mellinger, A. K. & Fife, D. (1994). Mortality in a Cohort of Homeless Adults in Philadelphia. New England Journal of Medicine 331(5): 304-309.
Hopper, K., Mauch, D. & Morse, G. (1989). The 1986-1987 NIMH-Funded CSP Demonstration Projects to Serve Homeless Mentally Ill Persons: A Preliminary Assessment. Rockville, MD: National Institute of Mental Health.
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Jones, K., Colson, P., Valencia, J. D., & Susser, E. (1994). A Preliminary Cost Effectiveness Analysis of an Intervention to Reduce Homelessness Among the Mentally Ill. Psychiatric Quarterly 65(4): 243-256.
Lam, J., & Rosenheck, R. (1998). Street Outreach for Homeless Persons With Serious Mental Illness: Is It Effective? Draft Report. Rockville, MD: Federal Center for Mental Health Services.
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Lopez, M. (1996). The Perils of Outreach Work: Overreaching the Limits of Persuasive Tactics. In Dennis, D. & Monahan, J. (eds.) Coercion and Aggressive Community Treatment: A New Frontier in Mental Health Law. Plenum Publishing Corporations, 85-92.
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Martell, J. V., Kobayashi, J., Seitz, R., Harada, J. (1992). The Honolulu Urban Homeless Project: Mortality in an Urban Homeless Population. Honolulu: University of Hawaii, John A. Burns School of Medicine. Unpublished. 1992.
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McCarty, D., Argeriou, M., Krakow, M., & Mulvey, K. (1990). Stabilization Services for Homeless Alcoholics and Drug Addicts. Alcoholism Treatment Quarterly 7(1): 31-45.
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McQuistion, H. L., D’Ercole, A., & Kopelson, E. (1996). Urban Street Outreach: Using Clinical Principles to Steer the System. New Directions for Mental Health Services, 52 (Winter): 17-27.
Mindell, A. (1988). City Shadows: Psychological Interventions in Psychiatry. London: Arkana.
Morse, G. (1987). Conceptual Overview of Mobile Outreach for Persons Who are Homeless and Mentally Ill. St. Louis, MO: Malcolm Bliss Mental Health Center.
Morse, G. (1997). Reaching Out to Homeless People Under Managed Care: Outreach and Engagement to People With Serious Mental Illness Within the Changing Marketplace. Paper prepared for the National Resource Center on Homelessness and Mental Illness, April.
Morse, G. A., Calsyn, R. J., Miller, J., Rosenberg, P., West, L., & Gilliland, J. (1996). Outreach to Homeless Mentally Ill People: Conceptual and Clinical Considerations. Community Mental Health Journal, 32(3): 261-274.
Morse, G., Calsyn, R. J., West, L., Rosenberg, P., & Miller, J. (1991). Mental Health Outreach to the Homeless: Conceptual and Clinical Considerations. St. Louis, MO: State of Missouri Department of Mental Health (In Press).
Mullins, S. D. (undated). Steps Out: A Peer-Integrated Outreach and Treatment Model for Homeless Persons with Co-Occurring Disorders. Rockville, MD: Substance Abuse and Mental Health Services Administration.
Nasper, E., Curry, M., & Omara-Otunnu, E. (1991). Aggressive Outreach to Homeless Mentally Ill People. New England Journal of Public Policy 8(1): 715-727.
Plescia, M. Watts, R., Neibacher, S., & Strelnick, H. (1997). A Multidisciplinary Health Care Outreach Team to the Homeless: The 10-Year Experience of the Montefiore Care for the Homeless Team. Family and Community Health, 20(2): 58-69.
Porter, B. (1997). To Reach the Homeless. New York, NY: Times Square Business Improvement District.
Ridlen, S., Asamoah, Y., Edwards, H. G., & Zimmer, R. (1990). Outreach and Engagement for Homeless Women At Risk of Alcoholism. Alcoholism Treatment Quarterly 7(1): 99-109.
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Rosenheck, R., Frisman, L., & Gallup, P. (1995). Effectiveness and Cost of Specific Treatment Elements in a Program for Homeless Mentally Ill Veterans. Psychiatric Services 46: 1131-1139.
Rosenheck, R., Gallup, P., & Frisman, L. K. (1993). Health Care Utilization and Costs After Entry Into an Outreach Program for Homeless Mentally Ill Veterans. Hospital and Community Psychiatry 44(12): 1166-1171.
Rosenheck, R., Leda, C., Gallup, P., et al. (1989). Initial Assessment Data From A 43-Site Program for Homeless Chronic Mentally Ill Veterans. Hospital and Community Psychiatry 40(9): 937-942.
Rosnow, M. (1988). Milwaukee’s Outreach to the Homeless Mentally Ill. In Assisting the Homeless: State and Local Responses in an Era of Limited Resources. Washington, DC: Advisory Commission on Intergovernmental Relations.
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Talbot, J. A. (Ed). (1997). Gold Award: Linking Mentally Ill Persons with Services Through Crisis Intervention, Mobile Outreach, and Community Education. Psychiatric Services 48(11): 1450-1453.
Task Force on Homelessness & Severe Mental Illness. (1992). Outcasts on Main Street. Washington, DC: Interagency Council on Homeless.
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Wasmer, D. (1998). Engagement of Persons Who Are Homeless and Have a Serious Mental Illness: An Overview of the Literature and Review of Practices By Eight Successful Programs. De Paul University, Master’s Thesis.
Weinreb, L., Browne, A.., & Berson, J. D. (1995). Services for Homeless Pregnant Women: Lessons From the Field. American Journal of Orthopsychiatry 65(1): 491-501.
Willenbring, M. L., Whelan, J. A., Dahlquist, J. S., & O’Neal, M. E. (1990). Community Treatment of the Chronic Public Inebriate I: Implementation. Alcoholism Treatment Quarterly 7(1): 79-97.
Winarski, J. (1998). Outreach Services. Presentation on Implementing Interventions for Homeless Individuals with Co-Occurring Disorders. April 23.
Winarski, J. T. (1994). Providing Outreach Outside the Shelter. In Bassuk, E., Birk, A., & Liftik, J. (eds.), Community Care for Homeless Clients with Mental Illness, Substance Abuse, and Dual Diagnosis. Newton, MA: The Better Homes Fund.
Wobido, S. L., Frank, T., Merritt, B., Orlin, S., Prisco, L., Rosnow, M., & Sonde, D. (1990). Outreach. In Bricknew, P. W., Scharer, L. K., Conanan, B. A., Savarese, M., & Scanlan, B. C. (eds.), Under the Safety Net: The Health and Social Welfare of the Homeless in the United States. New York: NY: W.W. Norton & Company.
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