# Presentation: 202489

## An Overview of Homelessness and Best Practices

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

## 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

## 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

## 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

## 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

## 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

## 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

## 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

## 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 individual
- Fragmentation
- Integrated treatment associated with better outcomes

## 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

## 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)

## 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

## 5.	Longitudinal perspective

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

## 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

## 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

## 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

## 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

## 10.	Optimism

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

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