Slide 1:

An Overview of Homelessness and Best Practices

Fred C. Osher, M.D.
April 10, 2002

Slide 2:

A snapshot of homelessness...

• 2-3 million persons over the course of a year
• two-thirds single adults, three-quarters men
• African Americans vastly over-represented
• Of homeless single adults:
  • 45-55% substance use disorders
  • 20-25% serious mental illnesses
  • 10-20% co-occurring disorders
• High risk of serious physical health problems such as diabetes, asthma, tuberculosis and HIV/AIDS

Slide 3:

Is all homelessness the same?

• Most exit relatively quickly
• About 10% have greater difficulty exiting. Why?
  • Extreme poverty and lack of affordable housing
  • Service system barriers to accessing and receiving needed supports
  • Disabling health conditions

Slide 4:

Comparison of homeless persons with and without mental illness

• Homeless individuals with mental illness
  • are more likely to have been homeless longer
  • have fewer family and social supports
  • have poorer physical health (HIV,HCV)
  • have more frequent contact with the legal system
    

Slide 5:

Where does our knowledge come from?

1987-1990	Service Demonstrations
1990-1993	Research Demonstrations
1993-1998	ACCESS Demonstration
1995-present	CMHS/CSAT Demonstration Programs - Co-occurring Disorders - Prevention of Homelessness - Housing Initiative - Homeless Families Initiative

Slide 6:

What have we learned?

• People who are homeless and have serious mental health and substance use disorders…
  • can be engaged
  • will use accessible, relevant community services
  • want permanent, affordable housing

Slide 7:

What have we learned? (cont.)

• Integrated systems of care have a positive impact on:
  • access to housing
  • access to income supports and entitlements
  • overall quality of life

Slide 8:

Principles of care

1. Integrated treatment
2. Individualized treatment planning
3. Assertiveness
4. Close monitoring
5. Longitudinal perspective
6. Harm reduction
7. Stages of change
8. Stable living situation
9. Cultural competency and consumer centeredness
10. Optimism

Slide 9:

1. Integrated treatment

• Traditional models of treatment for dual disorders results in poor outcomes
  • no treatment -- high utilization of E.R., jails, hospitals
  • sequential treatment
  • parallel treatment -- burden of integration on individua
  • Fragmentation
• Integrated treatment associated with better outcomes
  

Slide 10:

2. Individualized treatment planning

• Treatment planning is derived from a comprehensive assessment
• Accurate assessment is difficult to do:
  • poor clinician assessment skills
  • lack of standardized instruments
  • inaccuracy of self-report
• Use of several approaches concurrently
• Longitudinal nature of assessments

Slide 11:

3. Assertiveness

• Responsibility of systems to support outreach and engagement services
• Successful interventions:
  • “go wherever the client is”
  • work with family, landlords and employers
• Assertive Community Treatment (ACT)

Slide 12:

4. Close monitoring

• Intensive supervision needed until stable
• Sometimes coercive, always persuasive
  • representative payeeship
  • mandatory substance abuse treatment
  • urine testing
• Often used as an extension of court sanctions

Slide 13:

5. Longitudinal perspective

• Mental health, substance use disorders, and disease are chronic, relapsing conditions
• Treatment occurs continuously over years
• Progress measured over time

Slide 14:

6. Harm reduction strategies

• Assume:
  • continuum from abstinence — problematic use — abuse/dependence
  • reducing quantity/frequency of use decreases likelihood of negative consequences
• Provide alternatives to traditional abstinence only philosophies
• More likely to engage those who don’t yet have abstinence as a goal

Slide 15:

7. Stages of change

• Engagement - connecting people to treatment
• Persuasion - convincing engaged clients to accept treatment
• Active treatment - range of behavioral, psychoeducational and medical interventions
• Relapse prevention - prevention and management of relapses

Slide 16:

8. Stable living situation

• Not having a home makes assessment difficult and protracted
• Range of safe, affordable housing options are necessary
  • safe havens or low demand residences for engagement and persuasion
  • alcohol and drug free housing during active treatment and relapse prevention
• Separate assessment and treatment from housing
• Flexibility and tolerance required to retain people in housing

Slide 17:

9. Cultural competency and consumer centeredness

• Seek to understand - don’t assume a shared set of values or impose one’s own
• Respect cultural differences
• Value the consumer’s point of view

Slide 18:

10. Optimism

• Critical ingredient for recovery
• Hope as an antidote to despair
• Peer supervision and training to bolster staff optimism

Slide 19:

“The mark of a great society is the extent to which it serves the most disabled”

-Hubert Humphrey