STREET OUTREACH DANCING WITH GRACE PART 2

Linkage
Outreach programs should attempt to engage individuals who are unserved or underserved by existing agencies, and link them to resources. Many persons who are homeless are unaware of what is available (McMurray-Avila, 1997). Effective workers learn about available resources and establish working relationships with the people who provide these resources. Workers also tap into the knowledge of other homeless persons, who are often more aware of details and subtleties of changing resources. Effective workers are able to make durable linkages across systems: homeless/non-homeless systems, youth to adult systems, and across private and public systems. When these systems aren’t user friendly to homeless persons, workers advocate for change.

Advocacy
Clients who are disenfranchised and discriminated against, often need outreach workers to assume an advocacy role on their behalf. This occurs on many levels such as when helping clients access benefits and services to which they are entitled, within the outreach worker’s own agency, and within the criminal justice system. Indeed, in many communities, political views about homelessness are resulting in what may be perceived as meaner streets where persons are criminalized because of their homelessness. This can be seen in arrests for trespassing, criminal littering, and loitering. Legislation is increasingly pursued as a vehicle to continue criminalization of homeless persons, the effects of which are devestating to the homeless person and counterproductive to the outreach process.

Follow-up
Effective workers provide short-term follow up with respect to immediate tasks at hand and long-term follow-up with clients to ensure that they remain in a stable situation.

Outreach Across Populations
Primary health, mental health, and substance abuse treatment approaches similarities in outreach approaches are found in different treatment areas and client populations including families, veterans, mentally ill and transgendered persons, sex industry workers, substance users, HIV+ persons, and youth.

Health
A significant characteristic of homeless persons is poor health. A one-year study of 300 mentally ill homeless persons in New York City, revealed that 73 percent suffered from at least one medical condition in addition to a psychiatric diagnosis. The most common medical conditions were peripheral vascular diseases, anemia, infestations, and respiratory diseases, particularly tuberculosis. 35 percent had a secondary diagnosis of substance abuse (Marcos, 1988).

A two-year study of 1,751 homeless clients in Honolulu showed exceptionally high rates of mortality, with an average life expectancy of 48 years. Death rates have long been used as a measure of deprivation and as a guideline for public health resource allocation. With that in mind, homeless populations are in urgent need of increased attention and health care spending (Martell, 1992). A Philadelphia study of mortality rates for homeless people was 3.5 times that of the general population (Hibbs, 1994). Another study showed that causes of death varied by age group: (1) homicide: men ages 18-24; (2) HIV/AIDS: persons 25-44; and (3) heart disease and cancer: persons 45-64 (Hwang, 1997). In a study of hospitalizations of homeless persons, admissions to acute care hospitals were five times greater than the general population. They were admitted nearly one hundred times more often to the state psychiatric hospital (Martell, 1992).

Health care delivery to homeless persons can be challenging due to: lack of insurance, distrust of service-providers, bad experiences with health care in the past, difficulty making and keeping appointments, difficulty with complex medical and follow up care routines, and lack of understanding or interest in health problems in relation to seemingly more important issues at hand.

As with mental health and substance abuse, health care approaches for homeless persons are based on a process of engagement, assessment, planning, advocacy, education/motivation, and follow up. There are different models of health care approaches to serving persons who are homeless. Health care services may be provided at either permanent or mobile clinics and at rotating sites, some of which may be near homeless shelters. Health care providers may include salaried or voluntary physicians, physician assistants, nurses, and/or nurse practitioners who comprise a medical team. They reach out to homeless persons at sites where they have agreements with the host agencies. The goal is to provide care and help clients access a more mainstream medical system that will continue to be available to them. Staff make referrals and arrange transportation and an escort if needed (Plescia, et al 1997).

Escorting clients to appointments can be critical if a person is unable to go on his/her own. Staff can help clients by making medical appointments, preparing them for the appointment (getting insurance card/paperwork in order, educating them about what might be expected), advocating for them if needed, translating medical jargon, and helping them follow through with aftercare instructions and appointments. Further, outreach workers can be the “eyes” and “ears” on the streets for health care providers who are monitoring clients from afar. When clients reach a dangerous state of health, outreach workers can elicit assistance from mobile medical outreach staff, or stationary medical staff who are willing to leave a clinic and provide in-vivo services.

Often, homeless persons are more willing to address health problems because of decreased stigma, compared to willingness to address mental health or substance abuse issues. As outreach workers continue to engage clients during the health care process, they can begin to slowly and gently address other issues. For example, they may work toward obtaining clinical history and the client’s thoughts and perspectives regarding their experiences with mental illness, substance abuse, and other areas.

Outreach workers play a key role in illness prevention, from providing blankets and socks, helping clients access insurance and free medication/medical care, and educating them about topics like safe sex, hepatitis, TB, harm reduction, and nutrition. They can help clients get food and vitamins, and help them obtain past medical records and reconnect with previous service providers who may be familiar with their medical case(s). Outreach workers can also help by being aware of other organizations’ involvement in medical care so that there can be nd ears” for psychiatrists and clinicians making decisions about the direction of mental health care.

Effective outreach workers are able to demonstrate flexibility in their treatment responses. For example, with some clients, the connection can be so tenuous that the engagement phase can take months or even years of gentle, slow, and careful interactions. Other clients’ mental status may indicate the need to set limits. For clients who lack insight into their mental illness, workers take an education and normalizing approach, emphasizing the stressful nature of homelessness (Morse, 1991). Workers can help clients make connections between homelessness and their perception of the bad things that happen to them, hoping to spark some motivation to consider housing and other related social services. Workers can also help clients make connections between negative symptoms and the potential relief that medications or other interventions might offer. However, discussion about medication can only occur after sufficient trust has been established. For many people, the only mental health involvement they recall has been involuntary and coercive, usually resulting in unwanted medication and treatment.

Some clients may persist in denying the existence of a mental illness, but become successful in housing (Barrow, 1991). Workers can help clients translate street skills into independent living skills while treatment and referrals progress. Engagement strategies can help with linkage to services. For example, one client on the streets liked jewelry, and a lot of it. The outreach worker invited her to the clinic where health and mental health services are provided, stating that they had “a lot of jewelry there.” The outreach worker alerted staff, who the next day brought in jewelry from home and from thrift stores. The client enjoyed picking out one piece of jewelry every time she came to the clinic. This allowed linkage to services in a clinic where she learned to trust service-providers. Similar creative linkages are required to ensure success.

Outreach workers can help prepare clients as they begin to access services, at the same time informing staff at those agencies about the client’s unique needs, strengths, and interests to help ensure successful transition.

Substance Abuse
Outreach to substance users crosses many sub-groups, such as those with dual diagnoses, sex industry workers, and persons with HIV/AIDS. One major gap in services to persons with substance abuse problems is the lack of an entry point into services for those who don’t want formal treatment (Bonham, et al., 1990). A sub-group of this population are the “public inebriates” (Willenberg, et al., 1990). Three errors in treatment modalities have contributed to failures with this population. One is that the population is severely and chronically disabled. Second, programs often have unrealistic and high goals. Third, treatment models used are those that are more successful with middle-class, non-alienated alcoholics (Willenberg, et al., 1990). Moreover, treatment programs often fail to take into consideration cultural factors and fail to address the serious marginalization of disenfranchised groups. Engagement strategies are much the same as with health or mental health outreach—a non-judgmental stance, listening, educating, and linking. Project Connect’s service model is based on principles that services fit client needs, focus on their strength rather than weaknesses, and that the worker/client relationship is primary and essential (Bonham, et al., 1990). Worker activities can include education about safe sex and safer drug use and newsletters, and connecting clients to support groups and sobering up stations (Bonham, et al. 1990). Incentive items may include vitamins, condoms, bleach kits, and clean needles. Alcoholics and drug users who are homeless frequently lack the motivation or skill to seek out currently available services. They often distrust service-providers because of real or imagined poor treatment in the past, or difficulty negotiating the system (McCarty, et al., 1990).

Since many street users do not have insight into the harmfulness of their drug use, outreach workers may implement the use of a “Motivational Interviewing” (Miller and Rollnick, 1991) or “Stages of Change” (Prochaska, et al., 1994) approach. Programs may want to consider training in these models for all staff, rather than having one designated substance abuse counselor. Homeless persons with co-occurring substance abuse issues will be better served by outreach workers with a working familiarity with these models. Workers are familiar with and provide linkage to community resources or support groups, when the person begins to express interest. A Harm Reduction approach is generally the best engagement strategy.

The main tenets of Harm Reduction are:

a non-judgmental and respectful approach
helping residents to identify harmful effects of drug and alcohol use and the benefits of decreasing and/or ceasing use
exploring alternate, safer routes and patterns of use
praising small successes
developing flexible plans that address substance abuse issues.
Common strategies successfully used to help addicted homeless persons include:

Stabilization services like detox centers (McCarty, et al., 1990), inebriate reception centers (Bennett, 1990), and sobering-up stations (Bonham, et al., 1990) help to address immediate needs, provide respite, and an entry to substance abuse services.
Case management services (McCarty, et al., 1990, Bonham, et al., 1990, and Willenberg, et al., 1990) help link persons to services, provide support, and help clients reach decisions regarding their own recovery. Persons can move back and forth between basic and intensive case management based on their needs (Bonham, et al., 1990).
Jail liaisons (Bonham, et al., 1990) help explain services and link clients to them, identify those in need of case management, track clients, and advocate for mandated treatment rather than incarceration for revolving “public inebriates.”
Vocational training (Bonham, et al., 1990 and Ridlen, et al., 1990) in a variety of areas is offered to homeless men and women who are ready for such services.
Housing in conjunction with supportive services (Willenberg, et al., 1990 and Ridlen, et al., 1990) are offered along with education in areas of housing management like tenant rights, budgeting, and problem-solving. Families are further assisted in areas of childcare and linkage to schools (Ridlen, et al., 1990).
Drop-in centers (Bennett, et al., 1990) which offer showers, meals, information and referral services, on-site substance abuse services, benefits counseling, telephone, transportation, a warm, homelike environment, and friendly faces.
Access to treatment (Bennett, et al., 1990). Successful programs reduce barriers for homeless persons needing substance abuse treatment. This may include reserving a percentage of beds for homeless persons, reducing waitlists, and improving inter-agency relationships.
Measurable Outcomes
Successful Outreach and Engagement Strategies

Studies have shown that outreach and engagement strategies, while initially time-consuming and slow-moving, are successful because they reach more severely impaired persons who are less motivated to seek out services (Lam and Rosenheck, 1998). Three month outcome data compiled via the ACCESS study (Lam and Rosenheck, 1998), showed that clients reached in outreach on the streets experienced improvement on nearly all outcome measures equivalent to clients who were contacted in other services agencies and shelters. Outreach clients did equally well in areas of housing outcomes, quality of housing, improved mental health and decrease of psychiatric admissions, substance abuse, employment, social support, reduced victimization, and quality of life. This suggests that this hard-to-reach population has the same capacity for improvement as groups more connected to services and who may be more high-functioning.

The ACCESS program has demonstrated that people will use services if they are accessible and relevent and that effective outreach will lead to an increase in access to other services. Although helping homeless persons access mainstream services is difficult nationwide, ACCESS has shown that programs with sufficient resources can help people to be successfully treated in a community setting and that the bridge from homeless services to mainstream services is possible.

Positive housing outcomes, a major focus of homeless services, was also found by Bybee, et al., to be linked to outreach services (1994 and 1995). The likelihood of success in independent living was impacted by the amount of services, and a wide range of interventions and the intensity of those interventions and services. Recruitment sources also impacted housing success, in that those recruited from inpatient psychiatric settings were more likely to experience housing success than long-term Community Mental Health clients, suggesting that greater stabilization possibilities follow acute psychiatric episodes across populations. Anyone may have the opportunity for successful housing placement following a crisis. Those recruited from shelters also had greater likelihood of successful independent living, but also may continue to live in temporary settings, suggesting the variance of the degree to which persons from shelters can be easily housed. There was a smaller, yet significant predictability between housing status and client functioning, symptomatology, and substance abuse problems.

Quantitative Measures
Improvement is often so subtle that it doesn’t register on typical functional improvement scales. One program measures number of days per month spent in housing, number of times victimized, level of hygiene, number of contacts with other service providers, and so on (Axelroad, 1987).

In some cases, quantitative measures can be deceptive, as evidenced in Barrow’s 1988 survey. After a six month survey of completed referrals, only a small minority were successful, such as only 24 percent of entitlement referrals, 42 percent of housing referrals, and 13 percent of psychiatric referrals. While this appeared to be a reflection of ineffective services, it also reflected a short study period, discrepancies between client and program perceived needs, and lack of resources.

One outreach program measures success by four criteria: present living arrangement, receipt of financial aid or other income, enrollment in a program for the treatment of alcohol abuse of mental illness when appropriate, and receipt of treatment for other medical conditions. The first year’s data suggest that about four out of five persons have made at least one significant change (Rosnow, 1988).

Project Connect uses quantitative methods including face to face pre- and post-interview data with clients, monthly program data on clients, self-administered pre- and post-questionnaire data for community agency staff, and selected administrative record data from Project Connect agencies (Bonham, et al., 1990).

As part of the continuum of care delivery, workers can implement successful strategies described in Critical Time Intervention (CTI) to prevent recurrent homelessness and promote successful transitions to housing. One component of CTI is to strengthen the relationship between the individual and family, friends, and services, and secondly to provide emotional and practical support during the critical time after discharge from a shelter. Outcomes of CTI included significant reduction in homelessness and a preliminary indication that CTI is cost-effective (Jones et al., 1994, Susser, et al., 1997). Interventions are short in duration, simple, can be implemented by nonprofessional staff, and can be implemented in marginal settings (Susser et al., 1997).

A series of studies of homeless veterans by Rosenheck et al. (1989, 1993, 1995) evaluated the impact of outreach programs for homeless veterans with mental illness and found that outreach services are successful. The 1993 study found that outreach services increased access to outpatient and domiciliary services and reduced inpatient services. The 1989 study found outreach to be successful in that a significant number of homeless vets eventually wanted services and that outreach and advocacy efforts enhanced access to health care services. Outreach services have been found to be costly although there was a slight reduction in inpatient costs. Rosenheck, et al. (1995) caution that one cannot conclude, on the basis of cost alone, that less expensive treatments should replace more expensive ones. Many outreach programs have found that the initial cost of outreach and engagement pays off in the end.

Studies evaluating substance abuse programs found that offering an array of stabilization services along with case management services, contributed to recovery and utilization of services (McCarty, et al., 1990, Willenberg, et al., 1990, and Ridlen, et al., 1990).

Qualitative Measures
Qualitative measures are useful for service providers in evaluating program functioning (Axelroad, 1987). One helpful technique is questioning formerly homeless individuals who have been outreach clients to find out which elements in the outreach team’s approach were appealing or useful and which were perceived as negative. Project Connect uses ethnographic observations, interviews, and journals maintained by immediate program personnel (Bonham, et al., 1990). Qualitative evaluations can also be helpful in demonstrating to potential funders the complex nature of clients, outreach efforts, linkages, and length of engagement periods (Axelroad, 1987).

Challenges and Limitations In Determining Effectiveness
The very factors which contribute to a successful outreach effort—flexibility, ability to alter service systems—may impede evaluations which strive to concretely measure their effectiveness (Axelroad, 1987). There is a lack of controlled studies that demonstrate effectiveness and a lack of longitudinal studies. These are critical evaluation designs, yet are often difficult to implement with outreach clients who may be difficult to track.

Evaluations aimed at measuring the overall effectiveness of an outreach program must focus on the extent to which services and resources are available to outreach clients. In addition to evaluating effectiveness of services provided by the program, programs must also determine who is not being served by the program (Axelroad, 1987), why they are not being served, and how they might be served in the future.

Successful outcomes are not necessarily related to program services and should be considered in evaluating those programs. In one study, for example, success in obtaining housing and remaining housed were found to be related to socioeconomic background, defined by education and past employment, and level of functioning. Program services that were related to positive housing outcomes included an early focus on entitlements and housing-related services and participation on the part of the homeless person in defining housing goals were critical to their long-term success (Barrow, 1991).

While it is difficult to generalize outcome parameters across populations, regions, culture, and other factors across the country, a standard set of street outreach outcome measures is desirable at the national level. These standard outcomes should be different from standard outcomes used for other homeless populations which may be unrealistic for outreach populations. Outcome standards should also be set by individual programs. HUD requires Supportive Housing applicants to provide goals and objectives and later the extent to which goals were attained.

Future research and programmatic goals might include: identifying what national homeless outreach measureable outcomes might be; identifying specific factors that allow for successful transition from homeless to mainstream systems for the general outreach homeless population and for specific populations; the extent to which outreach teams are successfully used; the extent to which peer based outreach models and consumer involvement in program planning, implementation, and evaluation are successful; the development of more controlled and longitudinal studies; how the use of data-tracking within information systems might be implemented ethically and effectively; incorporating outreach outcomes within the managed care system; and the cost-effectiveness of providing outreach services and answering whether or not exemplary practices should be equated with effectiveness.

To Dance In A Bigger Ballroom—Toward Exemplary Practice At All Levels
There are effective strategies for influencing the adoption of exemplary practices and policies on each major administrative level—agency, local community, state and federal. There are also many questions still open for discussion. Outreach workers rarely can be successful unless exemplary practices exist at other levels.

Agency

Effective administrators or program directors must educate the agency board about outreach activities and philosophy and advocate on behalf of outreach staff at the board level. Directors must also support the outreach team and advocate for their efforts with other service providers in the community; (Axelroad, 1987; Wobido, 1990).

Outreach staff must be given flexibility in work schedules so they can seek out and find persons in the evening and on weekends. Funds must be available for incentive and basic need items, as well as equipment. Providing outreach workers with on-call medical and psychiatric consultants is critical as is promoting a sense of teamwork—preferably a multi-disciplinary one. This helps workers feel supported and provides them with tools with which they can provide better services. Exemplary agencies, with outreach as a component, make provisions in service delivery for outreach clients, like allowing clients to receive medical/ psychiatric/substance abuse services when needed rather than by appointment. They allow bypassing of unnecessary forms and paperwork, and adopt the engagement stance.

Orientation and training of new outreach staff is critical particularly in the area of street safety. Training should include: street safety, characteristics of the target population, substance abuse/dual diagnosis, the criminal justice system, benefits and entitlements, community resources, involuntary hospitalization, client rights, harm reduction, confidentiality, de-escalation, boundaries, CPR, basic first aid, regional laws regarding child and elder abuse, engagement strategies, cultural competency, and infection control. Safety training should require that new staff sign a document indicating that they understand safety guidelines. This makes worker risks clear prior to hiring, while protecting the worker from injury and the agency from future liability.

Outreach workers often feel a sense of isolation in the field, from other homeless and non-homeless service providers and are likely to be viewed as marginalized themselves. As a result, agencies need to ensure a system of support, advocacy, and inclusion for their outreach staff.

Exemplary agencies provide opportunity for ongoing discussion around ethical issues. Clinical supervision and/or peer supervision is recommended for outreach staff who need to get second opinions on implementation of their ideas to creatively engage persons. The question must always be asked, to what extent are the engagement strategies used by workers non-coercive and non-deceptive (Lopez, 1996)? Supervision can also address issues like engagement versus enabling, boundaries, legal issues, and service-provision.

Outreach workers sometimes get harassed and are discriminated against along with their clients. If outreach workers function as service and/or rights advocates, their agency needs to determine which parameters of advocacy efforts are allowed and encouraged. They should also develop positive relationships with police and security personnel. Finally, outreach workers should attempt to develop positive relationships with intake workers and staff at other agencies where they might refer clients.

Community

In addition to direct services, outreach workers and administrators can enhance the knowledge base of effective outreach practices on a community-wide level, by providing consultation, education, training and referrals (Morse, 1991; Slagg, et al., 1994). Outreach workers can start an “outreach coalition,” sharing resources, ideas, information, client tracking efforts, and mutual support. This process is essential in providing linkages to resources. In many communities, there are a dearth of resources, and outreach workers end up providing intensive case management, in a continuous relationship model.

Outreach workers can share success stories—they encourage other workers, combat the community’s “compassion fatigue,” and give hope to those clients still in crisis. Success stories are an essential part of informing funders, politicians, and policy-makers that services work.

Outreach programs cannot be designed in isolation from other service programs (Axelroad, 1987; Morse, 1987; Barrow, 1988). Survival depends upon community networking: providing referrals, sharing resources, pooling knowledge, and participating in community-wide groups (Nasper, 1992). In discussing outreach, it is essential to discuss the gaps and barriers in these systems (Axelroad, 1987). The most flexible, well-staffed and funded outreach program will have little impact if the mental health, health, housing and social service systems in a community are not capable of serving people linked through outreach efforts.

One urban outreach program made efforts to minimize coordination problems by expanding the makeup of a coalition with representatives of human service organizations in both the public and private sector; getting active participation with various planning and coordination bodies concerned with homelessness; and structuring the outreach program so that the workers could become familiar enough with their counterparts in other service-provider agencies (Rosnow, 1988).

Public-private partnerships can lead to effective service-provision. One example is the Times Square Consortium (TSC). This is a partnering of the Times Square Business Improvement District and social service agencies to provide outreach and a drop-in center for homeless persons in the Times Square area. Rather than a business-community attempting to simply arrest and move along persons who are homeless, they provided the impetus for social services. Together the TSC has applied for and received funds from state and HUD (Porter, 1997).

Project Respond in Portland, Oregon, won the 1997 Gold Achievement Award by the American Psychiatric Association for its exemplary outreach program. Exemplary community practices cited include successful and collaborative relationships with “community partners” like police, housing managers, service-providers, and businesses. Also cited was the reduction of stigma, seeking of missing persons, consultation, community education, including police education, and diversion (Talbot, 1997).

These approaches are heartening in an apparent climate toward the criminalization of homeless people. There has been an increase in anti-vagrancy laws which prohibit sitting, panhandling, or being in an airport during certain hours. Outreach is one of the few formal contacts where service professionals connect with homeless people who may be breaking laws. Outreach workers and their agencies could be held legally accountable because of their association with these homeless persons.

State/Federal

One outstanding issues that still needs to be addressed at the state/federal level is funding. Who should pay for outreach? Through the Continuum of Care process, communities are encouraged to include outreach as part of the continuum. On a national level, service-providers must advocate that managed care plans make point-of-access exceptions for homeless persons, and the homeless Medicaid population must be carved out of Medicaid managed care and financed separately (Plescia, 1997).

The cost-effectiveness of outreach programs often comes into question. One reason is related to the comparison of numbers of people served on outreach versus the number of people served in homeless shelters. If funders think of effectiveness in terms of the numbers of people served, then homeless shelters will be viewed as more effective. The people outreach programs tries to serve are those who don’t readily come to and accept services and who need a period, sometimes a lengthy one, of engagement. The positive outcomes of outreach services may not be readily seen. Yet, the cost of providing outreach services may divert costs from other systems such as emergency rooms, hospitals, psychiatric units, jails, and other crisis systems of care. This issue also reflects a structural obstacle to demonstrating cost savings between systems. For example, at the federal level, HUD funds many outreach programs, but the cost savings are realized in other systems such as Medicaid, the mental health system and substance abuse system. The same obstacles to demonstrating cost savings exists at state and community levels as well.

Agencies and communities need to ask what more could be done on a federal level to support outreach programs. One possibility could be a requirement of outreach services in states’ Medicaid plans. HUD does not fund emergency services or prevention of homelessness, and perhaps they should. Another possibility, could be a mandate that all Continuum of Care proposals include a strong outreach component, with penalties if outreach is not included.

More publications and guidelines for outreach are needed. Federal departments charged with addressing homelessness could provide “how to” information for service providers, and present options for service delivery based on research findings. Exploration of the range of services could be done nationally to determine specific trends related to successful outreach. Inquiry into what is optimal and what should be expected of outreach programs can take place federally. For example, the authors are familiar with outreach programs with a range of hours—from weekdays only to 7 days/week 16 hours/day. What have we learned about optimal services delivery? Several cities combine outreach with police escorts. Does this implied concern for worker safety in fact drive away potential clients and eliminate a Harm Reduction approach? Expertise is needed in this area if outreach programs decide to try and build collaborative relationships with police and security.

Homelessness among severely mentally ill persons, and chronic substance abusers represents a failure of state and federal policy to adequately address or sustain long-term community support systems. Rather than stimulating new funding mechanisms and service delivery systems, they should be preventing homelessness by bolstering basic community resources for the long-term care of disabled persons (Rosnow, 1988). In the long run, prevention efforts should be incorporated in structural measures to prevent homelessness and provide appropriate services to those with chronic disabilities.