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PubMed2006

An examination of fulfilled housing preferences and quality of life among homeless persons with mental illness and/or substance use disorders.

This study examined the types of housing features considered important to a sample of homeless persons diagnosed with a mental illness and/or substance use disorder and the relationship between the degree to which important features were obtained in subsequent housing and subjective quality of life, clinical and housing outcomes at 3-month and 1-year follow-up periods. After controlling for significant clinical and sociodemographic covariates, results from regression analyses indicate that the degree to which a client's individual housing preferences were realized in dwellings is significantly associated with greater quality of life in the future, but not clinical outcomes or housing tenure.

Adult↗
PubMed1994

Alcohol and drug abuse treatment of homeless persons: results from the NIAAA Community Demonstration Program.

In a national evaluation, we assessed the implementation and outcomes of a multisite demonstration program for homeless persons with alcohol and other drug problems. We developed comprehensive case studies from data on client characteristics, utilization of services, implementation of interventions, and community systems of care at nine project sites. Client-level outcome data were analyzed to estimate the effectiveness of the interventions in a subset of projects with experimental or quasi-experimental evaluation designs. After controlling for baseline predictors, treatment clients in the majority of sites were significantly more likely than comparison clients to report improvement on one or more outcome dimensions. On alcohol use, for example, under conservative assumptions the average treatment client was drinking less at follow-up than were 57 percent of comparison clients. Analyses of predictor-by-treatment interactions suggested that clients with fewer problems benefited most from the interventions. The implementation analysis yielded a number of lessons for policymakers and program planners.

Adult↗
PubMed2004

Old and sleeping rough: elderly homeless persons on the streets of Boston.

Older individuals living on the streets of our urban cities are a unique sub-group of the homeless population. No studies have been published about these elderly "rough sleepers" who face daunting obstacles to health care while facing a litany of health risks on the streets that are magnified by the physical and mental limitations of advancing years. To improve our understanding of this itinerant group, the Street Team of the Boston Health Care for the Homeless Program prospectively followed 30 individuals aged 60 or older living on Boston's streets for the four-year period from 2000 through 2003. This cohort included 8 (27%) women and 22 (73%) men ranging in age from 60 to 82 years. The average age was 67 years old At the end of the four year study period, 9 (30%) had died and 6 (20%) were in nursing homes. Despite intense efforts, only 5 (17%) found housing. Seven (23%) were still on Boston's streets after four years, and one was lost to follow-up. We conclude that elderly rough sleepers have high morbidity and mortality and pose significant challenges to programs seeking to provide housing and supportive health care services for this vulnerable sub-group of elderly homeless persons. New and creative housing options are needed, and the delicate issues of competency and guardianship must be addressed.

Age Factors↗
PubMed1997

Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders.

This study evaluated the impact of an integrated (mental health/substance abuse) assertive community treatment program on homeless persons with serious mental and substance use disorders. High rates of retention in treatment, housing stability, and community tenure were attained, and all but the most severe substance users appeared to gain these benefits. While the intervention appears to be an effective means of retaining in services and monitoring such difficult-to-treat and costly populations, it did not yield high rates of abstinence and social benefits in severe users.

Adult↗
PubMed2006

Assertive outreach: an effective strategy for engaging homeless persons with substance use disorders into treatment.

The purpose of this study was to examine substance abuse treatment referrals that were made by outreach workers in a homeless outreach project. Ten outreach workers completed questionnaires on each of their clients who they had referred to a substance abuse treatment program over the previous year. Additional data was collected on the client's motivation level at the point the referral was made, which agencies the client was referred to, and if the client was rejected from any of the treatment programs. Bivariate correlation analyses were used to examine relationships between the variables. Of 73 project clients who were referred to substance abuse treatment in a one-year period of time, 41% successfully entered treatment. As might be expected, there was a statistically significant relationship between clients' motivation level and completed referral, and between referrals made and program acceptance. This study provides evidence that assertive outreach is effective in engaging and linking homeless persons with substance use disorders to substance abuse treatment services.

Adolescent↗
PubMed2003

Diagnostic compared with abstinence outcomes of day treatment and contingency management among cocaine-dependent homeless persons.

Substance use disorder diagnoses were used as a treatment outcome measure in a randomized comparison of day treatment (DT) and day treatment plus contingency management (DT+) among homeless persons with primarily crack/cocaine disorders. Participants (N = 127, DT+ = 69, DT = 58, 73.2% male, 82.7% African American) were assessed at baseline and 6-month treatment completion. Binary positive and negative diagnostic outcomes for cocaine, marijuana, and alcohol were compared by treatment group. DT+ was 2.1 times more likely to have a positive treatment outcome than DT. Concordance between diagnostic change and point and continuous abstinence outcomes were found. The use of diagnostic change can be a practical addition to drug toxicology and self-report treatment outcome measures for research and practice.

Adult↗
PubMed1998

The participation of families of homeless persons with severe mental illness in an outreach intervention.

OBJECTIVES: This study describes how an Assertive Community Treatment (ACT) team which employs a family outreach worker (FOW) interacts with homeless persons with severe mental illness and their families. METHODS: The team's ratings of the frequency and importance of clients' and treatment team's family contact are summarized and compared with independent research reports on patients' satisfaction with family relations, housing and hospitalization outcomes. RESULTS: 73% of clients had contact with their families. ACT worked with families of 61% of clients. ACT had less contact with the families of men (p < .01) and substance abusers (p < .01). Client days in stable housing were associated with increased ACT family contact (p < .05). CONCLUSIONS: Most ACT clients had significant family contact. ACT established contact with most families, and the work with families appeared to be associated with higher levels of satisfaction with family relations and housing. The role of the FOW should be explored further.

Adult↗
PubMed1998

Services for mentally ill homeless persons: street-level integration.

The key elements of a systems integration approach to delivery of human services are reviewed in terms of their application to services for mentally ill homeless persons. The example of a mental health outreach project illustrates the service- and systems-integrating influences of clinical case management with this population, and the ability of a "bottom-up" street-level approach to improve coordination and service accessibility for clients in general is discussed.

Community Health Workers↗
PubMed1996

Impact of a psychiatric outreach service for homeless persons with schizophrenia.

Since 1988 a 24-hour psychiatric out reach service has been in operation in the inner city of Sydney to provide services to residents of refuges for the homeless. A total of 506 homeless persons with schizophrenia were referred to the outreach service between April 1988 and mid-1992, of whom 91 failed to attend. Hospitalization data were collected for the four years before and the four years after each individual's referral to the service. After the introduction of the service, the rate and duration of psychiatric hospital admissions for residents with schizophrenia who were treated by the outreach service decreased significantly, whereas those who failed to attend showed no such decrease.

Adult↗
PubMed2003

Outcomes of contact investigation among homeless persons with infectious tuberculosis.

SETTING: Homelessness is an important risk factor for tuberculosis (TB). Health departments often fail to identify contacts for homeless TB cases, but little else is known about the outcome of contact investigations for these cases. OBJECTIVE: To describe the outcomes of identification, tuberculin skin testing (TST), clinical evaluation and treatment for contacts of infectious homeless TB cases. DESIGN: Retrospective multicenter review of data of contact investigations conducted in 1996 by five health departments in the United States. RESULTS: Twenty-seven (8%) of 349 TB cases were homeless. Failure to identify contacts occurred in six (50%) of 12 cases residing in shelters vs. one (7%) of 15 non-shelter cases. Of 479 contacts identified, 297 (62%) were fully evaluated, 97 (20%) had only initial testing, and 85 (18%) were not evaluated. Of the 394 evaluated contacts, 13 (3%) had a prior positive TST. Of the remaining 381 contacts, six (1.6%) had active TB and 67 (17.6%) were TST-positive. Only 27 (44%) of 61 contacts completed treatment for latent TB infection. CONCLUSION: Despite the failure to identify contacts for some cases, contact investigations for homeless TB cases identified large numbers of contacts for whom evaluation and treatment were often not completed. Prospective studies with more complete documentation are needed to improve contact investigations for homeless TB cases.

Contact Tracing↗
PubMed1999

Improving access to disability benefits among homeless persons with mental illness: an agency-specific approach to services integration.

OBJECTIVES: This study evaluated a joint initiative of the Social Security Administration (SSA) and the Department of Veterans Affairs (VA) to improve access to Social Security disability benefits among homeless veterans with mental illness. METHODS: Social Security personnel were colocated with VA clinical staff at 4 of the VA's Health Care for Homeless Veterans (HCHV) programs. Intake assessment data were merged with SSA administrative data to determine the proportion of veterans who filed applications and who received disability awards at the 4 SSA-VA Joint Outreach Initiative sites (n = 6709) and at 34 comparison HCHV sites (n = 27 722) during the 2 years before and after implementation of the program. RESULTS: During the 2 years after the initiative began, higher proportions of veterans applied for disability (18.9% vs 11.1%; P < .001) and were awarded benefits (11.4% vs 7.2%, P < .001) at SSA-VA Joint Initiative sites. CONCLUSION: A colocation approach to service system integration can improve access to disability entitlements among homeless persons with mental illness. Almost twice as many veterans were eligible for this entitlement as received it through a standard outreach program.

Adult↗
PubMed2003

Public health dispatch: tuberculosis outbreak among homeless persons--King County, Washington, 2002-2003.

The Public Health-Seattle and King County (PH-SKC) Tuberculosis Control Program, with assistance from the Washington State Department of Health and CDC, is continuing to investigate an ongoing outbreak of tuberculosis (TB) disease among homeless persons in Seattle. This report describes patient characteristics, methods used to identify active TB cases and contacts at highest risk for exposure, and control measures under way to prevent further transmission of this outbreak strain of Mycobacterium tuberculosis.

Contact Tracing↗
PubMed1998

Gender differences in homeless persons with schizophrenia and substance abuse.

The purpose of this study was to test the generalizability of previous research on gender differences between men and women with co-occurring schizophrenia and substance abuse. One hundred eight patients with schizophrenia or schizo-affective disorder involved in a study of treatment for homeless persons were interviewed for information regarding substance use, social functioning and support, comorbid disorders, victimization, medical illness, and legal troubles. We found that women had more children and were more socially connected than men. Women also had higher rates of sexual and physical victimization, comorbid anxiety and depression, and medical illness than men. We conclude that homeless women with dual disorders, like women with substance use disorders in the general population, have distinct characteristics, vulnerabilities, and treatment needs compared with men. In addition to comprehensive treatment of psychiatric and substance use disorders, gender-specific services should be developed, including prevention and treatment of victimization and related problems as well as help with accessing medical services.

Adolescent↗
PubMed1997

Impact of representative payees on substance use by homeless persons with serious mental illness.

OBJECTIVE: Assignment of representative payees, third parties responsible for managing clients' funds, has been proposed to counter potential use of public support payments for abused substances by people with severe mental illness and substance use disorders. This study examines substance use outcomes in a sample of homeless persons with serious mental illness and substance use disorders, some of whom were assigned representative payees. METHODS: The subjects were participating in the Access to Community Care and Effective Services and Supports (ACCESS) program, a federally funded demonstration program on integrating service systems. Clients were assessed at baseline and three months after case management services were initiated. Factorial repeated-measures analysis of covariance was used to examine substance use among four client subgroups, two of which had payees and two of which did not. RESULTS: Clients in this sample (N = 1,348) showed significant improvement on all measures of substance use over the first three months in the program. Those with payees showed no greater improvement in substance abuse than those without payees, although they did have fewer days of homelessness. CONCLUSIONS: This study failed to find evidence that merely adding external money management services to existing services improves substance abuse outcomes among clients who had dual diagnoses and were homeless. Besides assigning a payee, structured behavioral interventions may be needed to produce additional clinical benefits.

Adult↗
PubMed1995

Modifying the PACT model to serve homeless persons with severe mental illness.

The success of the Program for Assertive Community Treatment (PACT) has led to its replication with different client populations, especially those who are underserved by the traditional treatment system. This paper describes a program in Baltimore that has adapted the PACT model to serve homeless persons with severe mental illness. Although the essential ingredients and philosophy of the original model were maintained, the original team approach has been modified by the use of "miniteams." All staff share knowledge of all program clients through formal mechanisms such as daily meetings; however, each client is assigned to a miniteam composed of a clinical case manager, a psychiatrist, and a consumer advocate. Another deviation from the PACT model is that services can be time limited. The authors describe four phases of treatment and problems, including interventions characteristic of each phase.

Adult↗
PubMed2000

Initiating abstinence in cocaine abusing dually diagnosed homeless persons.

This study measured effectiveness of behavioral day treatment plus abstinence contingent housing and work therapy (DT+) versus behavioral day treatment alone (DT). A randomized controlled trial assessed participants at baseline, 2 and 6 months. Participants (N=110) met criteria for cocaine abuse or dependence, non-psychotic mental disorders, and homelessness. DT+ achieved greater abstinence at 2 and 6 months and more days housed at 6 months than DT. Effectiveness of DT+ was demonstrated, with greatest impacts on abstinence outcomes. Results replicated earlier work demonstrating effectiveness of behavioral day treatment and contingency management as an effective combination for cocaine abusing homeless persons.

Adult↗
PubMedDate not supplied

Interviewer effects on self-reported substance use among homeless persons.

This study examines respondent editing of survey responses to questions regarding substance use. Previous research has identified several types of interviewer effects that may be associated with respondent editing, including direct and social distance effects. Little is known, however, regarding how these potential effects may influence self-reported substance use behavior. Data analyzed for this study were collected as part of a survey of substance use among homeless persons conducted in Cook County, Illinois. A total of 481 respondents were sampled at random in emergency and transitional shelters, soup kitchens, drop-in centers, and single room occupancy (SRO) hotels. Overall, a direct, gender-based effect was observed, with homeless respondents of both genders more willing to reveal substance use behaviors to male interviewers. Some race- and age-related direct effects were also identified, with White and older interviewers obtaining more reports of substance use. These findings yield important evidence regarding respondent editing of self-reported substance use and have implications for the common practice of demographically matching interviewers and respondents.

Adolescent↗
PubMed2002

Service systems integration and outcomes for mentally ill homeless persons in the ACCESS program. Access to Community Care and Effective Services and Supports.

OBJECTIVE: The authors evaluated the second of the two core questions around which the ACCESS (Access to Community Care and Effective Services and Supports) evaluation was designed: Does better integration of service systems improve the treatment outcomes of homeless persons with severe mental illness? METHODS: The ACCESS program provided technical support and about $250,000 a year for four years to nine sites to implement strategies to promote systems integration. These sites, along with nine comparison sites, also received funds to support outreach and assertive community treatment programs to assist 100 clients a year at each site. Outcome data were obtained at baseline and three and 12 months later from 7,055 clients across four annual cohorts at all sites. RESULTS: Clients at all sites demonstrated improvement in outcome measures. However, the clients at the experimental sites showed no greater improvement on measures of mental health or housing outcomes across the four cohorts than those at the comparison sites. More extensive implementation of systems integration strategies was unrelated to these outcomes. However, clients of sites that became more integrated, regardless of the degree of implementation or whether the sites were experimental sites or comparison sites, had progressively better housing outcomes. CONCLUSIONS: Interventions designed to increase the level of systems integration in the ACCESS demonstration did not result in better client outcomes.

Community Mental Health Services↗