Homeless Clients Research Articles

Homeless Clients' Circulation in Emergency Care: Rethinking Poverty Governance as Urban Impasse

AbstractStudies concerned with how local states govern the urban poor have long focused on the state's attempts to control, criminalise and exclude individuals from public spaces. Researchers recently shifted this focus; they increasingly engage with organisations and front‐line practices relating to care. Underlying these analyses is the question of how urban governance rubs off on front‐line work and conditions for the urban poor. In their research, scholars rarely study through which organisational mechanisms front‐line workers and clients encounter each other. This article addresses 112 calls issued for unhoused individuals by third parties in Urgencity, a city in Germany. It sheds light on institutional and everyday logics that regularly bring third parties, emergency care front‐line workers and marginalised clients into contact. These calls often blur boundaries of illness and poverty and care and control and result in clients' circulation in emergency care: an urban impasse for front‐line workers.

Impact of Medicaid expansion on inclusion of medications for opioid use disorder in homeless adults' treatment plans

IntroductionPeople experiencing homelessness (PEH) bear disproportionate opioid mortality. This article aims to determine how state Medicaid expansion under the Affordable Care Act impacted the inclusion of medications for opioid use disorder (MOUD) in treatment plans for housed versus homeless individuals. MethodsThe Treatment Episodes Data Set (TEDS) provided data on 6,878,044 U.S. treatment admissions between 2006 and 2019. Difference-in-differences analysis compared MOUD treatment plans and Medicaid enrollment for housed versus homeless clients in states that did and did not expand Medicaid. ResultsMedicaid expansion was associated with a 35.2 (95 % CI, 11.9 to 58.4) percentage point increase in Medicaid enrollment and an 8.51 (95 % CI, 1.13 to 15.9) percentage point increase in MOUD-inclusive treatment plans for housed and homeless clients alike. Yet the pre-existing MOUD disparity persisted, with PEH being 11.8 (95 % CI, −18.6 to −5.07) percentage points less likely to have MOUD-inclusive treatment plans. ConclusionsMedicaid expansion may be an effective tool for increasing MOUD treatment plans for PEH in the 11 states that have not yet implemented the policy, but additional efforts to increase MOUD initiation for PEH will be necessary for closing their treatment gap.

'Trials and Tribulations': The Ambivalent Influence of Temporary Accommodation on Mental Health Recovery in Chronically Homeless Adults.

Relatively few studies have explicitly examined whether and how shelter-type, temporary or emergency accommodation shapes homeless clients' personal (mental health) recovery. A transatlantic phenomenological qualitative study was conducted to examine the influence of those services on personal recovery. Eighteen chronically homeless adults with a history of serious mental illness were recruited from several temporary accommodation services in New York City (NYC), U.S., and Glasgow, Scotland. Participants completed repeat in-depth interviews and a novel one-week multimedia mobile phone diary. The interpretative phenomenological analysis (IPA) produced three overarching group experiential themes: 'everything was just starting to fall into place'; 'caught in a trap'; and 'trials and tribulations'. Collectively, the findings underscore the duality of influence of temporary accommodation on recovery. Those ambiguous spaces confronted participants with existential uncertainty, volatility and chronic boredom, but also proffered opportunities for envisioning and enacting recovery. Embarking on recovery while residing in temporary accommodation is possible, even for those enduring chronic life adversity. However, it is contingent upon enabling socio-material, affective and relational resources. Implications are discussed for theorising recovery as a contextually embedded, relational phenomenon, and for providing recovery-oriented support across the housing continuum.

What Makes Intentional Unidirectional Peer Support for Homeless People Work? An Exploratory Analysis Based on Clients' and Peer Workers' Perceptions.

Homeless people are increasingly supported by peer workers in one-on-one mentorship relations called intentional unidirectional peer support (IUPS). Insight is therefore needed into the application and outcome of IUPS for this vulnerable population. This study examined the outcomes, critical elements, and working mechanisms of IUPS within homeless services from the perspective of both clients receiving IUPS and peer workers providing IUPS. Semi-structured face-to-face interviews were held with ten homeless clients and ten peer workers. According to participants, IUPS enhances clients’ self-image, advances their personal growth, and results in better engagement with needed services. Rapport and empathy, a trustworthy and empowering relationship, as well as support, guidance, and mediation are what makes IUPS work according to the participants. The inclusion of both perspectives has led to a deeper understanding of what makes IUPS work for homeless people. Implications for practice are discussed.

Homeless Opioid Treatment Clients Transitioning to Dependent and Independent Housing: Differential Outcomes by Race/Ethnicity

Purpose: Homeless opioid treatment clients who transition into housing generally demonstrate better outcomes, but housing environments vary widely and may not benefit racial/ethnic minority populations equally. We sought to identify how race/ethnicity moderates the association between positive opioid treatment response and moving into dependent or independent living environments. Methods: We used the Treatment Episode Dataset-Discharges (2018–2019) to identify outpatient treatment clients who were homeless at admission and indicated heroin or other opioids as their primary drug of choice (n = 20,021). We defined positive treatment response as a reduction in opioid use between admission and discharge. We used multivariable logistic regression to model treatment response. We included an interaction between housing at discharge (remained homeless [reference], dependent living, or independent living) and race/ethnicity, and adjusted for relevant confounders. Results: Transitioning from homeless to dependent living was positively associated with treatment response among White (aOR = 3.57, 95% CI = 3.15-4.06), Hispanic (aOR = 2.11, 95% CI = 1.55-2.86), and Black clients (aOR = 1.79, 95% CI = 1.41-2.27), but no association was observed for homeless American Indian/Alaska Native clients. Transitioning from homeless to independent living was strongly associated with treatment response among all groups with the strongest association observed among White clients (aOR = 4.70, 95% CI = 4.26-5.19). Conclusions: Interventions aimed at improving OUD treatment outcomes among homeless clients should identify individual and structural factors that support moving into fully housed and independent living environments. Dependent living offers needed support during crises, but should be temporary and priority should be placed on independent, permanent, and autonomous living environments.

Predictive risk modeling to identify homeless clients at risk for prioritizing services using routinely collected data

For most homelessness service providers, the number of clients who are eligible for long-term housing outstrips the availability. This study uses a cohort of housing assessments taken from a mid-size county in the US and machine learning methods to train a Predictive Risk Model (PRM) that identifies clients who would experience multiple adversities in the future. The PRM outperforms the Vulnerability Index-Service Prioritization Decision Assistance Tool (VI-SPDAT) in flagging clients at the greatest risk of adversities. The proposed method can be readily used by any Continuum of Care (CoC) that holds electronic housing assessments and service records.

The educational needs of Canadian homeless shelter workers related to traumatic brain injury.

Traumatic brain injury (TBI) has a higher prevalence in the homeless population. Caregivers to individuals who have TBIs may require better education surrounding screening, diagnosis and management of this disease to tailor interventions to their clients' needs. To assess the insight and educational needs of homeless care providers in recognizing and dealing with clients who had experienced a TBI. A survey assessing the point of views of homeless care providers across Canada regarding their level of confidence in identifying and managing symptoms of TBI. Eight-eight completed surveys were included. Overall, frontline workers expressed a moderate level of confidence in identifying and managing TBI, stating that educational initiatives in this context would be of high value to themselves and their clients. Frontline workers to homeless clients rate their educational needs on the identification and management of TBI to be high such that educational initiatives for shelter workers across Canada may be beneficial to increase their knowledge in identifying and managing the TBI-related symptoms. Improved education would not only benefit frontline workers but may also have a positive effect on health outcomes for their clients.

“I Have Failed Them and Failed My Duties”: Experiences of Hospital Social Workers Discharging Patients into Homelessness

Homelessness is a long-standing issue at the forefront of healthcare globally, and discharge of homeless patients from hospital settings can exacerbate gaps and burdens in healthcare systems. In hospitals, social workers often take on the majority of responsibility for facilitating patient discharge transitions out of hospital care. Research in this area to date has explored experiences and outcomes of homeless clients, and the experiences of social workers in these roles are not well known. The current study's objective was to elucidate observations and experiences of hospital social workers who discharge patients into homelessness. A total of 112 social workers responded to an online questionnaire, and responses to open-ended questions were analyzed for thematic content. Four overarching themes emerged: (1) complexity of clients, (2) systemic barriers, (3) resource gaps, and (4) negative impact on social workers. It is clear that significant change is required to address the multitude of challenges that intersect to reinforce health inequities. Results can be used by social workers, health authorities, community providers, researchers, and policymakers in discussions about best practices for homeless clients.

Quality of Life of the Homeless and Restored Women with Psychosis

The present study endeavoured to evaluate the quality of life of the homeless and restored women with psychosis. The influence of their living conditions in three different psycho-social milieus and the disability levels on their Quality of Life was also examined. This study was carried out on women clients with sychosis who received medical and psycho-social care under three different programs of Iswar Sankalpa (a Kolkata - based NGO), India. Methods : A matched group design using mixed method technique was adopted for the study. The sample of 50 clients with psychosis was comprised of 16 homeless clients under the Out-reach program, 18 homeless clients under the Shelter home program and 16 previously homeless clients under the Restoration program. The sample was evaluated using the IDEAS and WHOQOL-BREF. After collection of data, statistical analysis was done using the SPSS- version 22. Results : The results mirrored that a statistically significant negative correlation exists between the clients’ disability and two domains of QOL, these are- social relationships and environment. Regarding the psychological health and environment domains of QOL, the Shelter home and the Restoration groups significantly differed from the Outreach group. The mildly disabled clients differed significantly from the severely disabled clients in respect to the social relationships domain of the QOL. Conclusion : The knowledge of specific areas of dissatisfaction in QOL of the women with psychosis may have implications for the service providers and service planners for more improved medico and psychosocial intervention.Key Words : QOL- Quality of Life, SZ- Schizophrenia.

Transforming Worker–Client Identities: From Shelters to Housing First

The Housing First (HF) approach to counteracting homelessness, stemming from the USA, is advocated as a blueprint for homelessness policy change in Europe, including the Nordic countries. In contrast to traditional homelessness policies based on shelters as the first step towards ending homelessness, the HF policy discourse regards access to one’s own housing as a basic human right that should not be conditional upon good or acceptable behaviour. Building on ethnographic research in a Swedish HF unit striving to implement the HF approach ‘by the book,’ which includes both focus group interviews with workers and observations of worker–client interactions during home visits, we show how the new HF policy challenges both workers and clients, who used to encounter each other in shelters but now meet in clients’ own homes, transforming their identities. We demonstrate how workers account for transformations in worker–client identities by referring to how they and their clients used to think, talk and act, thus contrasting their new identities with their former selves. Moreover, in their efforts to accomplish their actual work tasks within the framework of the new HF policy discourse in the homes of formerly homeless clients, we show how workers struggle with their identities when they encounter clients in practice. In their accounts of policy change, the workers embraced their new identities with pleasure, but in practice, they were hesitant when dealing with issues of concern, such as their clients’ use of tobacco, alcohol and drugs. In sum, it becomes complicated in practice.

“You Start with the Youth”: Narratives of Deservingness and Dissent at a Homeless Service Organization

As they provide social services to people experiencing poverty and homelessness, many nonprofit organizations perpetuate ideologies that obscure the political and economic causes of poverty and blame poor people for their plight. But the ideologies and practices of service provision are more diverse than many scholars of the nonprofit industry have assumed. What are the processes by which professionalized service organizations not tied to broader social movements might nonetheless facilitate rather than hinder structural explanations of inequality among their clients? Using ethnographic observation, in-depth interviews, and analysis of art and writing by young adults experiencing homelessness, I investigate the prevalence of structural explanations of poverty among clients at a large homeless youth service organization. I find that the organization’s liberal assimilationist narratives about “youth” facilitate more critical analyses of poverty and inequality among homeless participants. As the organization’s public-facing communications emphasize the positive meanings of youth to assert clients’ deservingness, homeless clients leverage the organization’s assimilationist discourse to advance more radical critiques of the systems that oppress them. Building on scholarship about the medicalization of homelessness and the nonprofit industrial complex, this case study demonstrates how multiple ideologies and practices spanning the continuum from repressive to mobilizing can take hold within a single organization, and by extension, the nonprofit service industry.

Evaluation of Hepatitis C Test and Treat Interventions Targeted at Homeless Populations (Outside London) in England During the COVID-19 Pandemic.

Evaluation of Hepatitis C Test and Treat Interventions Targeted at Homeless Populations (Outside London) in England During the COVID-19 Pandemic.

An Experimental Approach to Assessing the Attitudes of Social Service and Healthcare Employees toward the Homeless

The current study examined attitudes about the homeless among a range of social service and healthcare employees using both self-report and an experimental approach. Ninety-six respondents were recruited from drop-in shelters, medical facilities and social service agencies. After completing an initial measure of homelessness stigmatization, participants were randomly assigned into one of two experimental conditions in which they were given a description of a fictional 20-year-old client described as either homeless or domiciled. It was hypothesized that prior to the manipulation there will be no differences between the two groups and that the manipulation would induce those who read about the homeless client to subsequently endorse more stereotyped beliefs than those who read about a domiciled counterpart. The results revealed no pre-manipulation differences between the groups, while the manipulation invoked beliefs that the homeless client was dangerous, needed help with reading and financial literacy, and needed advice on personal hygiene, compared to the control group. These results highlight the work that still needs to be done in training service providers in terms of providing a bias-free environment for potential clients. Future studies should investigate whether proper training and education reduce preexisting assumptions about homeless clients.

The Role of Transportation in Sustaining and Reintegrating Formerly Homeless Clients

ABSTRACT This study analyzes spontaneous qualitative interviews with formerly homeless individuals living alone, on the importance of transportation in meeting everyday needs. Some participants identified that transportation subsidies were often haphazard, sometimes requiring tremendous effort to obtain, and discouraging use. Those who had access to transportation note the importance of access to healthcare, personal fitness needs, reduced food insecurity, increased access to health-care needs, and increased quality of life. This paper argues that piecemeal approaches to transportation denies the inherent needs of people living in extreme poverty, thereby increasing the chances of reentry into homelessness using principles of social exclusion.

Nobodies and somebodies

This article draws on ethnographic research to examine the bureaucratic matrix of temporal, material, and legal scales that come together to constitute the rehousing process for a group of rough sleepers seeking passage out of homelessness in contemporary London. Further, it explores the ways in which different bureaucratic technologies mediate the relations between the rehousing hub’s staff, its homeless clients, and local housing authorities, paying particular attention to the way these economies solidify the already asymmetrical power relations that existed between the homeless and those employed to manage them. For the homeless, this process is constituted by a spatiotemporality of confinement and seemingly endless waiting that shunts them into the margins of citizenship, caught between being a nobody and a somebody. Thinking through contemporary debates in political theory, this article approaches the rehousing process (or failure thereof) not as a linear pathway but as a constellation of disciplinary and bureaucratic procedures within which exceptional structures of sovereignty and neoliberal governmentality intersect. Applying these ideas anthropologically, I demonstrate how this intersectionality works to continually shape and reshape the existential realities, possibilities, and aspirations of the hub’s homeless clients.

Adapting a peer recovery coach-delivered behavioral activation intervention for problematic substance use in a medically underserved community in Baltimore City.

Low-income, racial/ethnic minority groups have disproportionately high rates of problematic substance use yet face barriers in accessing evidence-based interventions (EBIs). Peer recovery coaches (PRCs), individuals with lived experience with problematic substance use, may provide an effective approach to reaching these individuals. Traditionally PRCs have focused on bridging to other types of care rather than delivering EBIs themselves. The aim of this study was to assess perceptions of the appropriateness of a PRC-delivered adapted behavioral activation (BA) intervention to reduce problematic substance use for individuals not engaged in care. This study was conducted at a community resource center in Baltimore, Maryland serving low-income and homeless clients who have high rates of problematic substance use yet also face barriers to accessing care. Guided by the ADAPT-ITT framework, we conducted semi-structured key informant interviews with clients (n = 30) with past or present problematic substance use, and a focus group with community providers, including staff at the community resource center (n = 5) and PRCs (n = 6) from the community. Thirty percent (n = 9) of clients interviewed reported past problematic substance use and 70% (n = 21) met criteria for current use, most commonly cocaine and opioids. Clients, center staff, and PRCs shared that PRC-delivered BA could be acceptable and appropriate with suggested adaptations, including adding peer-delivered case-management and linkage to care alongside BA, and tailoring BA to include activities that are accessible and feasible in the community. These findings will inform the adaptation of PRC-delivered BA to address problematic substance use in this setting.

How to Enhance Social Participation and Well-Being in (Formerly) Homeless Clients: A Structural Equation Modelling Approach

In the present study we examined care-related and demographic predictors of well-being among 225 (formerly) homeless clients of a Dutch organisation providing shelter services and ambulatory care (shelter facility). The role of social participation as a mediator was considered. Social participation is important for homeless people, as they are often socially isolated. Moreover, social participation enhances well-being and induces happiness. In this study we used the following care-related predictors: (1) participation in various group activities in the shelter facility, and (2) client’s experiences with care, such as their satisfaction with the social worker and the shelter facility. Additionally, age and education level were included as demographic predictors. Results from Structural Equation Modelling show that the client’s experiences with care and education level are predictors of well-being with a mediating role for social participation, and that participation in activities at the shelter facility is a direct predictor of well-being. However, age is not significantly related to social participation or well-being. We suggest that interventions for the homeless should be based on a combination of individual and group approaches. Special attention should be given to the client–worker relationship. We also recommend that vulnerable children are provided with solid education, and we call for research into the cost-effectiveness of group-based interventions.

Growth Through Participation: A Longitudinal Study of a Participation-Based Intervention for (Formerly) Homeless People

The current longitudinal study examined a participation-based intervention for homeless and formerly homeless clients, growth through participation (GTP), developed by a Dutch organization providing shelter services and ambulatory care. GTP is based on a combination of group and individual approaches, whereby clients are enabled to learn to identify their strengths and talents, to develop social skills through interaction with each other, and to learn to once more lead a structured life. The study was conducted among 172 (formerly) homeless clients and comprised three measurement time points. It examined whether (1) quality of life increased during the GTP intervention; (2) social participation (e.g., labor/recreation), self-esteem, clients’ experiences with care (i.e., satisfaction with the services received and with the client–worker relationship), and psychological distress improved during GTP; (3) clients exhibiting psychological distress benefit more from GTP than others. Results from latent growth modeling showed that quality of life and the amount of time clients spent on labor activities increased significantly, but the amount of time clients spent on recreational activities decreased over time. Clients with psychological distress experienced increased quality of life and self-esteem, and reduced psychological distress. Other variables did not significantly change during GTP. Although not all hypotheses were (fully) confirmed, it can be concluded that GTP seems to be a potentially promising intervention. It is recommendable to conduct a multisite RCT to determine the efficacy of GTP.

‘Take whatever you can get’: practicing Housing First in Alberta

Housing First (HF) is an increasingly widespread and influential response to chronic homelessness. Programs using an HF approach typically rely on market apartments to house homeless clients as rapidly as possible. This reliance means HF programs are dependent on the availability and affordability of market housing. Little attention has been given to how shortages of affordable rental housing influence the practice of HF. To address this gap, we undertook qualitative research in Alberta, Canada. Interviews with service providers revealed that high rents and low vacancy rates had profound impacts on program operations, and complicated efforts to follow HF principles. Clients often experienced delays in being housed and felt pressure to accept the first apartment they were offered. In response, HF programs devoted resources to improve relationships with landlords. Ultimately, however, reliance on market housing undermined programs’ ability to fulfil the potential of HF in the Alberta context.

Assessing levels of student nurse learning in community based health placement with vulnerable families: Knowledge development for future clinical practice.

Community services work with vulnerable families to assist them to link with health, education and welfare services. Community placements provide nursing students with understandings of the health impacts of social circumstances on broad population's. Nurses provide health care for vulnerable populations so it is important for students to gain experience in dealing with various population groups in a variety of settings. Community placements can increase student confidence to provide care for all people in the acute care setting. The research project explored the use of a community placement to assist nursing students in applying psychosocial theories to practice; determining the affect of nursing students to the community service; and if the learning achieved in the placement was applicable to their future nursing practice were also objectives of the research. The mixed methods design used placement suitability focused questionnaires, and student, staff and clinical supervisor one-to-one interviews. In 2015 a community based homelessness service which provides a home visiting service approached the School of Nursing and Midwifery to provide a community placement for nursing students. The urban homelessness service caters for 350 homeless clients per month. Eight second year nursing students and six fulltime homelessness staff, mainly social workers, participated in the surveys and interviews. Nursing students were 'buddied' with a social worker and visited individuals and families recently placed in emergency housing. The student nurses (8) and homelessness staff (6) were surveyed and interviewed about their knowledge, skills and perceptions about the value of community based placements. Findings indicate student's recognition of the skills to be learned in a non-acute setting are applicable to all clinical settings and enhance student knowledge and potential future care. The staff in the homelessness service espouse the enhancement provided by the expertise of the nursing students working with vulnerable populations. This paper highlights the benefits as perceived by students on often undervalued community based placements. It is essential that universities collaborate with industry and consumers to ensure that the undergraduate programs offer a high standard of care and address current trends in the health care industry. There is a growing need for workforce development in primary healthcare and an increased understanding about how adversity can lead to ill health.