Slide 1:

Addressing Chronic Homelessness
What Works: Evidence-Based Practices & Best Practice Models

Fred C. Osher, M.D.

Slide 2:

Case Example: Kevin

• 33 y.o. AA male
• Homeless
• Schizophrenia
• Alcohol Dependence

Slide 3:

“From time to time, we all run into people like Kevin Evans: poor, black, homeless, probably unkempt, talking to themselves or to imaginary persons, perhaps on drugs, or drunk, or simply acting odd. Shop owners do not want them around their stores because they might pilfer or simply intimidate customers. They become too much for even the well-intentioned relatives or friends to handle. They carry their few possessions in shopping carts and roam the streets. They go through the revolving doors of jails, in and out, in and out, time and again. The unluckiest of these people may, like Kevin Evans, be asphyxiated as he is being placed in restraints.”

Slide 4:

A snapshot of homelessness...

• 2-3 million people 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

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Is all homelessness the same?

• 80% of the estimated 2-3 million people who experience homelessness each year exit within 3-4 weeks
• 10% are homeless more episodically
• 10% experience chronic homelessness

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Why address chronic homelessness?

• They have greater difficulty exiting homelessness on their own. Why?
  • Extreme poverty and lack of affordable housing
  • Service system barriers to accessing and receiving needed supports
  • Disabling health and behavioral health conditions
• Although small in numbers, they use half of all emergency assistance for people who are homeless

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What have we learned?

• People who experience chronic homelessness and have serious mental health and substance use disorders…
  • are a subgroup not served well by traditional programs, yet with modifications they:
    • can be engaged
    • will use accessible, relevant community services
    • want permanent, affordable housing

Slide 8:

Best Practices/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 -- “ping-pong” treatment
  • parallel treatment -- burden of integration on individual
• Integrated treatment associated with better outcomes
• Supported by integrated systems of care

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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

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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)

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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

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5. Longitudinal perspective

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

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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

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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

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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, tolerance, and tailored supports required to efficiently/effectively retain people in housing

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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

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10. Optimism

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

Slide 19:

Hopeful Directions

Service Components of Promising Practices

• Outreach and engagement
• Comprehensive discharge planning from shelters, hospitals, and jails
• A range of housing options with flexible support services
• Clinical case management
• Integrated health and behavioral health care
  • Substance abuse treatment
  • Primary health care
  • Mental health treatment
• Income support and entitlement assistance
• Rehabilitation, training and employment services
• Life skills training
• Legal assistance
• Transportation

Slide 20:

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

-Hubert Humphrey

Slide 21:

A picture of the case study, Kevin, on the street.