Homeless Services Research Articles

Assessing Racial Heterogeneity in “Housing First” Supports’ Effectiveness among Older Adults Experiencing Homelessness: Evidence from Los Angeles County

Abstract Background and Objectives Just as the U.S. population is aging and racially diversifying, housing prices are spiking. These conditions could spur a homelessness crisis among older adults of color. Although researchers have examined racial stratification and age-based differences in homelessness risk, separately, few studies probe whether age and race interact to render older adults of color more vulnerable to repeated episodes of homelessness than younger adults and older White adults. Fewer still have considered whether and why “Housing First” interventions (e.g., rapid rehousing/RRH, permanent supportive housing/PSH) are disproportionately effective— or ineffective— in reducing this risk for older adults of color. Research Design and Methods Using individual-level data from Los Angeles County’s Homelessness Management Information System, tracking Continuum of Care (CoC) services received between 2013 and 2019, we show how race and age jointly shape the risk of receiving additional CoC homelessness services after an initial CoC service. Linear probability models reveal whether PSH and RRH disproportionately reduce this risk for Black versus White older adults. Results Our analyses indicate an age-race interaction, whereby Black adults aged 55-64 exhibit the highest risk of receiving additional CoC homelessness services after an initial service. PSH disproportionately reduces this risk for Black older adults. Discussion and Implications We conclude that “Housing First” interventions may hold particular promise for older adults of color, perhaps because these groups sort into more effective programs, on average. Future research on aging and housing should highlight heterogeneity and consider program sorting processes as a potential explanation for it.

Staff Safety and Experiences with Electronic Safety Devices among a Sample of Veterans Affairs Homeless Service Providers.

The current survey examined Veterans Affairs (VA) homeless service providers' experiences with electronic personal protective safety devices (EPPSDs). The survey was completed by 153 homeless service providers based at VA medical centers in New York, New Jersey, and Florida. The survey asked about feelings of safety while performing work duties, safety incidents, use of EPPSDs, and experiences with EPPSDs. Forty-three percent of respondents reported using an EPPSD at work. Respondents who used an EPPSD described using the technology primarily to check in while working in the community. Overall, feelings of safety and confidence in the ability to call for help while at work did not differ between providers who used an EPPSD and those who did not. These findings need replication in a larger sample. EPPSDs may not increase feelings of safety among homeless service providers. VA homeless service providers generally reported feeling safe at work. Feelings of safety were not significantly associated with using an electronic safety device.

Understanding What Makes Them Stay: Retention in the Frontline Workforce for Those Unhoused

Soaring rates of physical and mental health among the homeless population demand a workforce with increasingly sophisticated treatment knowledge and skills to address their complex experiences and socio-behavioral needs. However, the retention of frontline workers in this industry is a rising concern. More information is needed to understand how frontline workers within homeless services experience their daily work and their motivations for continuing in this field. The current study reports findings from 11 frontline worker interviews on what facilitates workforce retention in two homeless service agencies in Florida, where homelessness has increased in recent years. The themes identified in this study (a culture of caring for workers, empathetic attunement, and a commitment to agency mission) highlight the importance of organizational culture for continuing in these agencies despite low wages and insufficient intervention options for this population. Recommendations include increasing efforts to prepare frontline workers during onboarding trainings for this work and supporting supervisors to respond to the diverse client experiences frontline workers face. Future research should explore if job embeddedness factors, differences in supervisory support, and resources available in different locations to assist those unhoused impact retention of frontline workers.

‘You Can Really See the Pain in Their Eyes’: Stressors and Supports Affecting the Well-being of Homelessness Services Staff in Ireland During COVID-19

Despite their crucial roles, the well-being narratives of those working in homelessness services have frequently been overlooked in research and policy. This paper addresses that gap, presenting qualitative evidence from interviews with homelessness service workers in Cork, Ireland, during 2021 and 2022. We explore the multidimensional, layered character of service staff members’ well-being narratives, showing they are intimately connected to relationships with their own families, commitment to service users, fears about COVID-19, and their motivation to the social mission of their work: to support vulnerable people with multiple, interlinking needs. Our data reveals that stressors encountered in pre-COVID times, relating to burnout, emotional labour, inter-agency working, and career progression, were exacerbated due to government restrictions and new challenges encountered by service users. We focus on the period covering pandemic-related lockdowns in 2020 and 2021, and the immediate aftermath, to consider how those delivering crucial services coped, the informal and formal support they accessed, and the value of this support in their lives. Significantly, our analysis reflects upon the longer-term implications of these findings, contextualised against the backdrop of the housing crisis in Ireland, changing demographics of persons accessing homelessness services, and increased systemic and social pressures.

New York City’s Public Health Program to Provide Immunizations and Primary Care to Immigrant Children and Families

Since April 2022, more than 220,000 immigrants seeking asylum or other legal status have arrived in New York City from southern U.S. border states. The New York City Department of Homeless Services quickly established a network of sanctuary shelters to respond to the unprecedented volume of newly arrived immigrants. Approximately 37% of recent arrivals have been children, many with unknown or incomplete immunization status jeopardizing their compliance with city vaccine requirements for school and day care attendance. The number of children facing school exclusion, and varicella outbreaks in the shelter system, emerged as a top priority for public health response. The New York City Department of Health and Mental Hygiene collaborated with partner agencies and community health care providers to connect children and their parents to school-required immunizations and primary care. From September 2022 to November 2023, 10,122 doses of school-required vaccines, Covid-19 vaccines, and influenza vaccines were administered to 3,279 children in 51 city-run shelters, and 1,295 appointments were made for vaccinations and primary care. This article describes the challenges and lessons learned in conducting a major public health campaign amid a rapid influx of immigrants, including coordination across all relevant government agencies and community partners. Having an established public health infrastructure in place is key.

Applying Normalisation Process Theory to a peer-delivered complex health intervention for people experiencing homelessness and problem substance use

BackgroundThe Supporting Harm Reduction through Peer Support (SHARPS) study involved designing and implementing a peer-delivered, harm reduction intervention for people experiencing homelessness and problem substance use. Normalisation Process Theory (NPT) provided a framework for the study.MethodsFour Peer Navigators (individuals with personal experience of problem substance use and/or homelessness) were recruited and hosted in six third sector (not-for-profit) homelessness services in Scotland and England (United Kingdom). Each worked with participants to provide practical and emotional support, with the aim of reducing harms, and improving well-being, social functioning and quality of life. NPT guided the development of the intervention and, the process evaluation, which assessed the acceptability and feasibility of the intervention for this cohort who experience distinct, and often unmet, health challenges. While mixed-methods data collection was undertaken, this paper draws only on the qualitative data.ResultsThe study found that, overall, the intervention is feasible, and acceptable to, the intervention participants, the Peer Navigators and staff in host settings. Some challenges were encountered but these were outweighed by benefits. NPT is particularly useful in encouraging our team to focus on the relationship between different aspects of the intervention and context(s) and identify ways of maximising ‘fit’.ConclusionsTo our knowledge, this is the first application of NPT to this cohort, and specifically by non-clinicians (peers) in non-healthcare settings (homelessness services). Our application of NPT helped us to identify ways in which the intervention could be enhanced, with the key aim of improving the health/well-being of this underserved group.

Promoting performance in multilevel governance and delivery of homelessness services

Promoting performance in multilevel governance and delivery of homelessness services

Liberty or life: the Aotearoa New Zealand perspective.

A description is provided of the current situation in Aotearoa New Zealand with regard to compulsory treatment of people with schizophrenia. This is placed within the context of homelessness in New Zealand and the provision of services to the incarcerated mentally ill. There are high rates of homelessness and incarceration and services are struggling to meet their needs. This is particularly a problem for the indigenous population. The current Mental Health Act allows for compulsory treatment of people who as a result of schizophrenia are seriously impaired in their capacity to care for themselves, and this will include people where there is a nexus between homelessness and their illness. The Mental Health Act is being reformed, with a new act likely to emphasize autonomy and capacity to a greater degree. Finally, the author considers the learnings from 5years working within the Fixated Threat Assessment Centre, which provides a unique perspective on these issues.

THE TECHNOPOLITICS OF WAITING: CASE STUDIES OF AI TRAINING IN CHINA AND HOMELESS SERVICES SYSTEMS IN THE U.S.

Many theorists of the information economy have argued that digitization has resulted in a “speeding up” of our experience of time (i.e. Gleick, 1999). This work contends that for many, especially those with less power, the techno-utopian vision characterized by datafication and Artificial Intelligence (AI) instead produces a state of prolonged waiting. Drawing from two long-term ethnographic studies examining the production and implementation phases of data-driven technologies in China and U.S., we demonstrate how the “long-standing but mistaken belief, hegemonic in Silicon Valley, that automation will deliver us more time” (Wajcman, 2019) belies the highly stratified temporal impacts of automation, datafication, and AI. Specifically, this work uses AI training and the homeless services system as case studies to reveal the politics of waiting; despite the promise of data-driven technologies, pervasive waiting serves as evidence of an enduring residue—an unequal power structure. Our findings also suggest that the technologies which mediated the experience of waiting in the first, more immediate sense, also impacted how people conceptualize the future.

Understanding uptake of the COVID-19 vaccination among the homeless: A mixed methods evaluation.

Ensuring effective access to vaccinations for people experiencing homelessness is crucial to protecting the health of a vulnerable, yet often overlooked population. Reaching this goal takes more than a one size fits all approach. This study evaluates how a dedicated health team collaborated with multiple agencies to register and deliver the COVID-19 vaccine to people experiencing homelessness. This is a mixed methods study co-designed with the Adult Homeless Integrated Team, a multi-disciplinary team who work with local agencies to provide care to people experiencing homelessness in Cork, Ireland's second largest city. Quantitative data collected at the point of vaccine registration described socio-demographics of the population. To explain the quantitative findings, eleven agencies involved in provision of homeless services were invited to participate in interviews. A manager in each of the agencies acted as a gatekeeper to clients. Interviews explored experiences with the pandemic and the delivery (staff) or receipt (clients) of the COVID-19 vaccine. Interviews were recorded and transcribed, transcriptions were thematically analysed. There were 728 vaccine doses administered to people experiencing homelessness during the first roll-out of vaccines; 401 first doses and 325 second doses. Of those who received a vaccine, the majority were male (76%), and more than half were Irish (55%). Ten semi-structured interviews, seven staff members and three clients, were conducted. There were three themes that provided further insights into the quantitative findings: Adapting to unprecedented times, Misinformation causing vaccine hesitancy and The importance of building relationships. This study provides valuable insights into how a multidisciplinary approach resulted in a successful well received vaccination programme among a traditionally hard to reach group.

The Rhode Island transitions clinic: connections to social and healthcare services after release from incarceration

BackgroundAfter release from incarceration, individuals are rarely connected to primary care or to social services despite bearing a disproportionate burden of poor health (e.g., chronic illness) and structural determinants of health (e.g., housing instability). The Rhode Island Transitions Clinic (RITC) works to fill this gap, particularly for patients with complex needs, by linking individuals to primary care and social services. However, prior work has not formally assessed how successful the TCN is at connecting patients to social services. Our objective was to assess the relationship between RITC and connections to healthcare use and services addressing structural determinants of health.MethodsThis retrospective cohort study utilizes data among those released from the Rhode Island Department of Corrections (RIDOC) from 2018–2020. These data were linked with state agency data (e.g., unemployment, Medicaid medical claims, housing and homelessness services). We estimated 6-month risk differences (RDs) of each outcome, using stabilized inverse probability weights to account for censoring and confounding.ResultsOf 8,694 individuals, the 68 enrolled in RITC are, on average, older, more likely to be Black, and have had more incarcerations. The RITC was associated with higher likelihood of connection to housing and homelessness services (RD: 0.29; 95% CI: 0.17, 0.41), (re)instatement of Supplemental Security Income (RD: 0.17, 95% CI: 0.06, 0.28), Emergency Department (RD: 0.29; 95% CI: 0.17, 0.41), and primary care visits (RD: 0.32; 95% CI: 0.21, 0.43), and lower likelihood of receiving taxable wages (RD: -0.05; 95% CI: -0.14, 0.05) compared to not being in RITC within six-months of release.ConclusionsRITC patients have complex healthcare and social service needs. The RITC is an innovative approach that is successful at connecting its patients to primary care and social services.

Behavioral Medicine Can Help Reduce Premature Mortality among People who Experience Homelessness

Unprecedented numbers of Americans experienced homelessness in 2023. Homelessness causes premature mortality from several preventable causes. Historically, research in homelessness has been driven by psychiatric and social science fields and has focused on neither health behavior nor valid measurement of health outcomes. Only in HIV/AIDS populations is there specific evidence linking housing with improved health outcomes. A partnership between behavioral medicine researchers and housing and homeless service providers could address health behaviors linked to premature mortality. This requires improving measurement of homeless mortality and validating health and wellness measures for people experiencing homelessness. We outline implications for policy to pair support for health behavior change in the context of homelessness with various housing support programs. When done with attention to multi-level health drivers and inclusion of people with lived experience, this partnership could improve health outcomes and reduce premature mortality for people without housing.

Managing Health Without Stable Housing: Dimensions of Treatment Burden and Patient Capacity for People With Chronic Health Conditions Experiencing Homelessness.

Although chronic health conditions and homelessness are prevalent problems in the United States and globally, little research has used the lens of burden of treatment theory to examine the experiences of people facing these challenges simultaneously. This study aimed to illuminate dimensions of treatment burden, which refers to the work of being a patient with chronic conditions, and patient capacity to manage this burden in a sample of people experiencing homelessness and chronic health problems in Buffalo, New York, United States. We completed in-depth interviews with men and women recruited from a homelessness services organization (N = 27) and applied core concepts from burden of treatment theory to our analysis to probe how participants navigated tasks related to treatment and self-care. Using codebook thematic analysis involving three coders, results revealed four interconnected themes of complex coordination, self-monitoring, obtaining and using prescriptions and medical supplies, and communication and explaining health issues, which were confirmed through member checking (N = 6). These dimensions of treatment burden were dynamically impacted by patient capacity factors-which included trauma, medical mistrust, health literacy, and social support-as well as by social determinants of health such as housing and income. Findings support the need for more formal collaboration mechanisms between healthcare providers and social service agencies, active involvement of patients in their health plans, and policies such as Housing First to improve access to stable and affordable housing and social services for people with complex health issues.

Findings from a Project Which Established Hepatitis C Point-of-Care Testing and Linkage to Care at a Homelessness Service in Adelaide, Australia, 2021-2022.

Point-of-care hepatitis C virus (HCV) testing streamlines testing and treatment pathways. In this study, we established an HCV model of care in a homelessness service by offering antibody and RNA point-of-care testing. A nurse and peer-led HCV model of care with peer support were implemented between November 2021 and April 2022 at a homelessness service in Adelaide, Australia. All clients of the service were eligible to participate. Clients were offered an initial antibody point-of-care test, and antibody positive clients were immediately offered RNA point-of-care testing. Clients who tested RNA positive were linked to a viral hepatitis nurse for treatment. A total of 230 clients received an HCV antibody point-of-care test, of which 68 (30%) were antibody positive and 11 (5%) were RNA positive. Of these, seven (64%) clients successfully completed treatment and five (45%) received a sustained virological response (SVR) test to confirm cure. We successfully established HCV testing and a treatment pathway at a homelessness service using HCV antibody and RNA point-of-care testing. The high testing uptake underscores the utility of HCV point-of-care testing when establishing HCV testing and treatment pathways. The low RNA positivity suggests that an initial HCV antibody test was cost-effective, and the four clients diagnosed with chronic HCV who were lost to follow-up indicate a need for enhanced treatment support.

BORN INTO HOMELESSNESS: A RETROSPECTIVE OBSERVATIONAL STUDY

ObjectiveTo evaluate the differences in the antenatal and neonatal courses of maternal-infant dyads within a homeless population as compared to the general hospital population. DesignThis was a retrospective observational study. SettingA large single tertiary maternity hospital (8,500 deliveries/year) in Ireland. PatientsWe retrospectively reviewed perinatal outcomes for homeless women who delivered liveborn infants at a tertiary maternity hospital, during the calendar year 2020. Homelessness was defined as either A) A designated homeless accommodation service listed as the home address; or B) Self-identified as homeless with an address other than homeless accommodation. We then compared the study cohort with the general hospital population who delivered liveborn infants in the year 2020. Outcome MeasureA set of key clinical variables (maternal, antenatal, birth and postnatal outcomes) were obtained and descriptive statistics were performed and compared to available hospital wide data. ResultsA total population of 145 infants born to 143 homeless mothers were included. Compared with the general hospital population, infants born into homelessness were more likely to be born preterm (15% vs 7%), with lower median birth weight (3.1 kg vs 3.4 kg) and higher rates of admission to the neonatal unit (35% vs 14%). Following discharge, there was a greater incidence of missed appointments to the neonatal clinic (29% vs 8%), and lower rates of exclusive breastfeeding (16% vs 45%). ConclusionsAddressing societal inequalities starts before birth. Infants born into homelessness are particularly vulnerable to perinatal factors associated with negative long-term outcomes when compared with the general population.

Association between receipt of a continuum of supportive housing services and mortality among Veterans with experience of housing instability

Veterans face elevated risk of suicide and homelessness, with housing instability being a significant, independent risk factor among this population. Addressing housing instability through primary, secondary, and tertiary prevention services is crucial for improving health and mortality outcomes, though research remains limited. The objective of this study is to assess the association between receipt of primary, secondary, and tertiary homelessness prevention services and risk of suicide and all-cause mortality among Veterans within 24 months of experiencing housing instability. Data were extracted from national U.S. Department of Veterans Affairs (VA) electronic health records (EHR), 2014-2019, and mortality data from National Death Index. Logistic regressions conducted in 2024 modeled suicide and all-cause mortality using a time-discreet survival framework with person-month as the unit of analysis. Cohort included 662,682 Veterans with indicators of housing instability in EHR. Veterans who received homeless services across the three levels of public health prevention had reduced odds of suicide compared to non-participants while Veterans exiting these programs had higher odds of suicide (p-value ranges <.001 - 0.05). Consistent results were found for all-cause mortality. Continued receipt of services to address housing instability is associated with reduced mortality risk. Exiting programs to address housing instability may be a vulnerable period for Veterans, and investment in homelessness prevention is crucial to reduce mortality and improve outcomes among Veterans. Ongoing support is essential to mitigate risks associated with program exit.

Optimising the Nursing Scope of Practice in a Homeless Health Service: A Qualitative Descriptive Study.

To explore specialist homeless health professionals' perceptions of gaps in homeless health care and understand whether these might be addressed through existing nursing scopes of practice. Qualitative descriptive study. Semi-structured interviews and focus groups with a purposive sample of 22 staff in nursing (11) and non-nursing (11) roles, engaged with a Homeless Health Service. Data were collected via videoconferencing and recordings transcribed verbatim. An exploratory framework guided deductive and inductive thematic analysis. Service gap themes included the need for integration with mainstream health services, more specialised health professionals, and adaptations to the existing models of care. Addressing these gaps involved enhancements to the broad scope of nursing practice, workforce development by establishing homeless health as a nursing specialty and optimising organisational governance to minimise risk. The most pressing homeless health service delivery gap was lack of health service integration, and it was unclear how this could be resolved through nursing scopes of practice. Other service gaps could be addressed through skilling nurses to practice preventative health care, as well as crisis management. Enhancing nurses' capability in physical and mental health assessment skills including alcohol and other drugs and procedural skills would support wraparound care for people experiencing homelessness. We conclude that a homeless health nursing specialty could be established that formalises the scope of practice of nurses in this field to ensure future post-graduate training aligns with service gaps. This study identifies opportunities to optimise nursing scopes of practice to address Homeless Health Service gaps through reviewing models of care and nursing practice. For example, enhancing nurses' capability to provide preventative and wraparound care. This research may inform a development pathway to enhance education and training for nurses working with vulnerable populations. COREQ 32-item checklist. No patient or public contribution.

Veterinary care and flea preventatives are limited in homeless shelters and outreach organizations serving people experiencing homelessness.

Pet ownership among people experiencing homelessness (PEH) is common, but access to shelter, veterinary care, and flea-preventative products for PEH who own pets in the US is not well described. We sought to evaluate current knowledge of fleas and flea-borne diseases and characterize practices around pets and service animals among staff at homeless shelters and outreach organizations. In-person surveys were administered to staff at homeless shelters and on outreach teams in 7 states from August 2022 to April 2023 to evaluate knowledge, attitudes, and practices and to assess homeless shelter/organizational characteristics. Surveys were administered to 333 staff members at 60 homeless shelters and among 29 outreach teams. Seventy-eight percent of homeless shelters allowed pets or service animals. Only 2% of homeless shelters and 7% of outreach teams provided veterinary care; 15% of homeless shelters and 7% of outreach teams provided flea preventatives. Nearly three-quarters of surveyed homeless shelter staff responded that no steps were taken to treat fleas at their shelters. Veterinary care and availability of flea-preventative products are limited in homeless shelter and outreach organizations serving people experiencing homelessness. Pets of PEH might be at an increased risk of flea infestation and flea-borne diseases because of limited access to veterinary care and preventatives. Improving knowledge and access to flea prevention, screening, and treatment are critical to ensure PEH and their pets can consistently access homeless shelters or outreach services, and to prevent flea-borne disease transmission.

Displacement Into New York City’s Shelter System: Exploring the Roles of Neighborhood-Level Housing Dynamics

This study examines the associations between neighborhood-level housing dynamics and displacement rates into the homeless shelter system in New York City (NYC). We analyze a novel dataset obtained from NYC’s Department of Homeless Services that tracks the neighborhood of origin for shelter entrants. Using descriptive methods, mapping, and ordinary least squares (OLS) regression, we examine the relationships between community characteristics and rates of shelter entry, shedding light on an under-studied level of analysis in homelessness research—neighborhoods. This article proposes two potential mechanisms that could contribute to shelter entry at the neighborhood level beyond the aggregation of individual risk: an increased risk of displacement and limited housing choices for displaced households. We find that neighborhood-level eviction rates, poverty rates, and proportions of African American/Black residents are positively associated with rates of displacement into the shelter system, with evictions being the strongest predictor of shelter entry. The study provides the first comprehensive examination of neighborhood-level correlates of shelter entry in NYC in nearly 30 years and fills a gap in the very small empirical literature examining the relationship between housing insecurity indicators and homelessness at the neighborhood level. Findings support policy recommendations that address homelessness at the neighborhood level and curb eviction and displacement to reduce instances of shelter entry.

Intermediation: Algorithmic Prioritization in Practice in Homeless Services

Homelessness is a significant and growing crisis in the United States. In an effort to more efficiently and fairly distribute limited housing resources, jurisdictions across the US have adopted algorithmic prioritization systems to help select which unhoused people should receive resources. Given the impact of algorithmic prioritization on the lives of unhoused people, there is a need to more fully examine how these systems are implemented in practice by frontline workers such as social service workers. In this paper, we present a qualitative study that draws on interviews and artifact walkthroughs with fifteen social service workers to examine how they interacted with algorithmic prioritization systems as part of their job duties. We found that social service workers employed discretionary work practices to mediate between the rigid formats of algorithmic prioritization systems and the messy, situated realities of homelessness. We term these discretionary work practices 'intermediation' and provide four examples that illustrate how our interlocutors were able to maintain their commitment to advocacy and to express their expertise despite the automation of major aspects of their professional decision-making. These work practices, which we argue were motivated by care for clients, as well as a desire to preserve professional autonomy, lead us to conclude that discretion cannot easily be removed from bureaucratic systems and that removing discretion is not necessarily a desirable outcome.