Outreach to People Who Are Homeless in Streets and Shelters
Outreach was one of the earliest strategies targeted at people residing in street locations, public parks, transportation depots, and other settings not meant for human habitation (Cohen, 1990). Street outreach teams employ an array of approaches to engage people who are mentally ill in a dialogue on eventual involvement in services (Tsemberis & Elfenbein, 1999). Despite anecdotal evidence of the value of street outreach in engaging people in needed treatment and support services and the widespread dissemination of street outreach services, there is as yet no specific strategy of engagement per se that can be considered evidence based. In many cases, repeated brief contacts to establish a relationship often precede an agreement to accept services. Strategies of initial engagement include the offering of food and other concrete services, medical care, and housing. Increasingly, outreach alone is viewed as having limited success potential unless it is combined with housing placement (Burt et al., 2004).
Lam and Rosenheck (1999) have reported that clients enrolled in the Access to Community Care and Effective Services (ACCESS) program (a multisite effort that evaluated the integration of service systems and its impact on outcomes for over 7,000 participants) initially engaged through street outreach, tended to be men with a psychotic disorder who were older and had longer durations of homelessness (living on the streets or in emergency shelter). Shern et al. (2000) conducted a randomized controlled trial to test a psychiatric rehabilitation program for street-dwelling homeless people that consisted of outreach and engagement; an invitation to join the Choices Center, a low-demand day setting offering food, showers, socialization, and assistance combined with health, mental health, and other services if desired; respite housing in an informal church-based shelter or a staff-supervised YMCA room; and rehabilitation services both on site and in the community to assist individuals in finding and maintaining housing in the community. The control group had standard treatment that consisted of a range of programs including outreach, case management, drop-in centers, health and mental health services, and private and municipal shelters for homeless adults. Compared to the standard treatment group, those in the Choices Center program were more likely to attend a day program, spent less time in the streets and more time in community housing, had less difficulty meeting their basic needs, showed greater improvement in life satisfaction, and experienced a greater reduction in psychiatric symptoms. The research team found that housing was difficult to procure, forcing the Choices program ultimately to develop a supported apartment program. A significant contribution of the Choices project was that it demonstrated a comprehensive approach to homeless people that began with the process of street outreach and was carried through until the person was successfully housed and off the streets.
Similarly, the provision of mental health and substance abuse treatment services on site in shelter settings as a means of engaging people in services has also gained wide currency. A recent study conducted by Bradford et al. (2005) focused on a shelter-based intervention targeted at homeless individuals with psychiatric and/or substance abuse problems. The program consisted of outreach by a psychiatric social worker and weekly visits by a psychiatrist. Findings revealed that individuals receiving the intervention were more likely to participate in substance abuse treatment services than subjects in the control group. Studies of outreach to homeless people living on the street and in shelters remain an important area for further research.
Services to Facilitate the Transition from Shelter to Housing
An innovative program for people who are homeless developed over the past decade, Critical Time Intervention (CTI), has focused on discharge planning for the shelter-based homeless population as a springboard for developing a more comprehensive package of services that includes housing placement and treatment support and post-release follow-up to assist program participants in working through issues in the transition from the shelter to a stable residence in the community. Susser et al. (1997) conducted a randomized controlled trial in which a 9-month time-limited case-management CTI intervention targeted at homeless men with severe mental illness was compared to usual care. Over the 18-month follow-up period, subjects in the CTI group had an average of 30 nights homeless, compared to 91 in the usual services group. The intervention was also found to be cost-effective, yielding a significantly greater net housing stability benefit compared to the control group (Jones et al., 2003). The success of CTI has led to its adaptation for other high-risk groups at critical junctures in their lives, such as discharge from mental institutions, jails, and prisons (Herman et al., in press). Controlled trials of adaptations of CTI are in progress.
Case Management and Assertive Community Treatment for Homeless People with Mental Illness
Various forms of case management and assertive community treatment have gained wide currency in the last quarter century (Morse, 1999). A common denominator of interventions classified as case management or assertive community treatment is that they all provide individualized treatment planning and long-term follow-up to clients with severe mental illness. However, there are important differences in how these programs are defined as well as the results they achieve. Traditional case managers are typically people with a bachelors or masters degree in social work who provide limited direct care, brokering needed services on behalf of the individual from other providers in the community. In contrast, as originally developed by Stein and Test (see Morse, 1999), assertive community treatment (ACT) is characterized by comprehensive community-based treatment delivered in situ by a multidisciplinary team. The team is directed by a psychiatrist but other mental health care professionals provide vital elements of treatment and support. ACT teams have shared caseloads with a limited number of clients, and treatment is provided on a 24-hour open-ended basis, assisting the individual with symptom management, issues in the living environment, relationships with family and friends, and locating and maintaining stable employment.
Models similar to ACT, such as the Continuous Treatment Team (CTT) (see Johnsen et al., 1999), appear to share many elements in common. A study of the fidelity of four case management models to ACT principles in the ACCESS study found that the four treatment variations were more alike than different (Johnsen et al., 1999). ACT has been studied experimentally and evidence has accumulated concerning its effectiveness in reducing hospitalization (Morse, 1999).
ACT has been applied to the management of people who are homeless and severely mentally ill. Morse et al. (1997) conducted a random assignment study focused on homeless mentally ill persons in which three types of case management were tried: broker case management in which the persons assessed needs were purchased from multiple providers, ACT alone in which services were provided by a treatment team for an unlimited period, and ACT with community workers who assisted with activities of daily living and were available for leisure activities. Findings revealed that both ACT interventions were superior to broker case management on a number of outcomes, including resource utilization, symptomatology, and client satisfaction. ACT alone was associated with longer time in stable housing. Further evidence for the usefulness of ACT for homeless mentally ill adults has been provided by Dixon et al. (1997), whose study demonstrated that this approach improved treatment compliance. In addition, Wolff et al. (1997), in a cost analysis of broker case management versus ACT, found that ACT has superior client outcomes at no greater cost than broker case management, and is therefore the more cost-effective of the two interventions. A meta-analysis of studies of assertive community treatment for homeless people with severe mental illness underscores its superiority over standard case management models in reducing homelessness and improving symptom outcomes (Coldwell & Bender, 2007).
Recent studies suggest that duration and intensity of services can be tailored to the clinical needs of the client. ACT is typically provided to all clients for an unlimited period of time. Rosenheck and Dennis (2001) conducted an analysis of the outcome of homeless patients with severe mental illness in the ACCESS study with varying durations of participation in ACT. Study findings suggested that clients could be discharged from the program to less intensive case management without losing gains in mental health status, control of substance use, housing stability, or employment. Min, Wong, and Rothbard (2004) found that use of vocational and rehabilitative services delivered through case management was associated with a lower probability of shelter reentry after termination in the ACCESS project, suggesting the need to emphasize rehabilitation in the prevention of recurrent homelessness. A study by Clark and Rich (2003) lends support to the notion that service intensity can be calibrated to the clinical needs of the individual without a negative result. This team studied a comprehensive housing program for people who were homeless and severely mentally ill, in which access to housing was guaranteed along with housing support services and case management. The comprehensive housing program was compared to case management only. This quasi-experimental investigation made use of propensity scoring to enable an analysis of how people with different levels of symptom severity fared in each type of program. Findings revealed that persons with high psychiatric severity and high substance use disorder achieved better outcomes with the comprehensive housing program. Persons with low to medium symptom severity and minimal alcohol or drug use did just as well with case management alone.
Adaptations of Assertive Community Treatment for People with Co-Occurring Mental Illness and Substance Use Disorders
Over time the ACT model has been adapted to better meet the needs of homeless people who have co-occurring mental illness and substance use disorders. The efficacy of integrated mental health and substance abuse treatment programs in the management of patients with co-occurring disorders is rapidly becoming established (Drake et al., 2004). Integrated treatment is characterized by treatment of the mental illness and the problem with substance abuse by the same clinician or clinical treatment team. This approach eliminates the need for the client to seek treatment for each disorder from different clinicians in separate systems of care. Integrated dual diagnosis treatment would seem to be appropriate for people who are difficult to engage in services or who may have problems accessing services located in different sites. Morse et al. (2006) compared costs and outcomes of two types of assertive community treatment for homeless patients with dual disorders. In this investigation, ACT alone was compared to integrated ACT, a program in which treatment for severe mental illness and substance use disorders was provided by the same treatment team. Both treatments were compared to standard care. Patients in both types of ACT programs were more satisfied with their treatment and had more days in stable housing compared to controls. There were, however, no differences in psychiatric symptoms or patterns of substance use. The integrated ACT program had lower total costs than the ACT program alone, suggesting that the enriched ACT team approach is more cost-effective in treating homeless patients with dual disorders. In an another analysis from the same study, Calsyn et al. (2005) found that the treatment approaches had limited impact on criminal justice outcomes, suggesting the need for new, more specialized interventions to reduce criminal behavior among people with dual disorders.
Essock et al. (2006) conducted a random assignment study of two methods of community case management, ACT and standard case management, for delivering integrated mental health and substance abuse treatment services for consumers with dual disorders who were homeless or unstably housed. Clients receiving integrated dual diagnosis treatment in both the ACT and standard clinical case management venues showed steady reductions in substance use and improved in many areas over the course of the study, suggesting that integrated dual diagnosis treatment can be successfully delivered with either community case management approach.
Promising New Approaches to Managing Homeless People with Dual Disorders
In recent years new interventions for homeless people with co-occurring severe mental illness and substance use disorders have been developed. The very fact of their existence attests to the pressing need for approaches that can successfully engage clients in ongoing treatment of this devastating combination of afflictions. Three such innovative approaches, described below, are presented as promising new approaches despite the fact that they are not yet evidence-based.
Dyadic case management. Kirby et al. (1999) used a pair of case managers to address the service needs of homeless men and women with mental illness who were chronically debilitated due to alcohol and drug dependence. The dyadic case management model, developed by Denvers Arapahoe House, is geared to individual need and is characterized by techniques of recruitment and engagement, relationship and skills building, housing stabilization, and advocacy. It is contended that having two case managers builds on the professional strengths of two people rather than one, and that a duo of case managers can more readily ensure continuity of services and provide greater staff safety when carrying out street outreach. Although an evaluation of this intervention is planned, there is as yet no report of the programs efficacy in the scientific literature.
Modified therapeutic community. Therapeutic community models have achieved widespread utility in the treatment of people with serious problems with alcohol and drug abuse. Typically, therapeutic communities are residential settings in which a comprehensive array of services, including psychological, educational, medical, legal, and advocacy, are offered to facilitate a significant change in the lifestyle of the person afflicted with substance abuse and a concomitant reduction in substance use and criminality (De Leon, 2000). Skinner (2005) conducted a quasi-experimental study of a modified therapeutic community located in a homeless shelter serving men with mental illness and substance use disorders, comparing it with a general shelter program serving male veterans with the same co-occurring conditions. Study data consisted of a retrospective review of closed case records for 70 subjects in each type of shelter. Although the modified therapeutic community showed no clear benefit in this analysis, the established success of this approach in other settings suggests that it may be promising and should be studied further.
Treatment as an alternative to incarceration. Collaborations involving mental health service providers, homeless services providers, and the criminal justice system are growing increasingly more common as it has become clear that these systems of care share a common caseload of clients who cycle among mental hospitals, emergency rooms, detox facilities, homeless shelters, and jails and prisons. San Diegos Serial Inebriate Program (SIP) targets individuals who are chronically homeless and intoxicated in public, often traveling a circuit from jails to emergency departments to a downtown sobering center. Service utilization costs for this population are extremely high. When police encounter intoxicated individuals who have had at least five transports to the local inebriate reception center within the past 30 days, they transport them to jail where, for each conviction after the first, they are given progressively longer sentences of time in jail (30 to 180 days). The SIP program offers an alternative to this experience. In lieu of custody, the client can participate in a six-month intensive outpatient clinical intervention program. While successful completion of the program satisfies the conditions of probation, clients who resume drinking or fail to complete treatment face a return to jail where they must complete their sentence. Dunford et al. (2006) conducted a retrospective review of health care utilization records of clients who did and did not participate in the SIP program. At the time of enrollment, the average participant had been homeless for more than 15 years. Treatment was offered to 268 individuals, but only 58 percent accepted. Clients typically accepted treatment only after repeated convictions with longer sentences. Participation in the SIP program was associated with a decline of more than 50 percent in utilization of ambulance, emergency room, and inpatient hospital care. Among those who rejected treatment, there was little change in patterns of health care utilization.