“Why don’t homeless people work at low-wage, entry-level jobs, which should help them get over their homelessness?” – anonymous Quora.com user

Introduction

In the United States, homeless persons use the emergency room more than housed persons.¹  These individuals may come to the ER sick due to their living conditions and unstable environment and lack of shelter which may expose them to disease and crime. Risky behaviors include substance abuse and sex work.²  These group of individuals often present with complex issues such as mental health disorders in addition to physical conditions. Case management and discharge planning may also be more complex due to a lack of support, finances, a stable environment, and a history of trauma. This article will focus on the discharge planning of the homeless and indigent for occupational therapy practitioners.

Stigma

Occupational therapists working with this population should be aware of the stigma and their own judgment toward the homeless client. This puts up a barrier to therapeutic treatment that is holistic and client-centered.

Examples:

• The homeless person who is unkempt.
• The homeless person who has not showered.
• The homeless person without clothes to wear.
• The homeless person with unmanaged diabetes.

I like the quote that I found from one homeless organization: A hand-up, not a hand-out. As a practitioner, you should question your own beliefs, stereotypes, and stigma for this population. Don’t assume all homeless clients are looking for a hand-out, or that they are lazy, etc.

Hospital as a Safe Place

Those who are homeless access the hospital at a much higher rate than those who are housed – likely because its used a safe place. A study of nurses who work with this population revealed that the hospital is likely a safe place for homeless people to go when they have reached a crisis point.¹ 

Likewise, trauma-informed care (TIC) suggests that those who are homeless may have had a negative experience with the hospital system and may become distrustful of it. This is likely due to being let down or not feeling like they were listened to in their past hospital stays.

Discharge Planning

Overall, nurses report a lack of suitable discharge options from the hospital into society.¹  Other challenges include lack of effective communication and unsustainable accommodation options. While it is not solely up to the OT to coordinate the discharge plan, collaboration with the team of doctors, case managers, nurses, and others on-board help to ensure the safety of the homeless person who is discharging as well as to maximize their occupational participation.

The ideal goal is to break the cycle of homelessness for the individual.

Shelters

Depending on the location where a homeless individual comes through the hospital system, there may be shelters available for safety and to obtain basic needs – or not.

Barriers to this resource include the lack of shelters (such as in rural areas), overcrowding, and the lack fo special care services to meet the individual’s needs. Shelters often require these individuals to be fairly independent with their own health management.¹ 

Interventions

Approaches

Before we get into the OT interventions, how do we go about ‘breaking the cycle’? What I would use is goal-setting and motivational interviewing. The research, however is mixed.

“This study suggests that a single, brief session of MI can be a very useful intervention for severely distressed, homeless, substance dependent veterans, and that it may prove useful with other severely distressed populations as well. Furthermore, a protocol that does not require conducting a formal assessment and providing feedback would be much simpler to apply in a clinical setting than more complex interventions.”³  This study is promising because of its 1 session delivery intervention which is more realistic for this population. Longer-term sessions have also shown promising results for substance use and risky sexual behavior in young adults.⁴ 

Being aware of my confirmation bias for using MI with this population, I found the opposite evidence. Another review of the literature actually discouraged the use of MI as a stand-alone intervention for. substance use in homeless populations.⁵ 

Unfortunately, I don’t have the answer at the moment – as homelessness is a complex multifaceted issue. Like many things in life, it may be better to use a combined approach. Perhaps also implementing occupationally based goals. Or perhaps, as used in Acceptance and Commitment Therapy (ACT), value-based goals would be more effective. In my opinion, addressing substance abuse should be quite high on the list. What likely will make clients who are homeless more successful is finding social support and programs.

To Standardize or Not?

You likely learned that standardized is better, and I often agree. One AOTA article I read suggests the ACL or the MoCA or the MMSE.⁶  While I understand the intention and the research reasons, I don’t necessarily think that this will help you get the client’s buy-in. I don’t think it promotes the therapeutic use of self, at least initially, thinking about TIC. Time is valuable and these clients often leave AMA. To the client, they may think testing, testing, testing – instead of directly getting help. Just my 2 cents. I think it may be better to get to the core underlying issues at hand using a narrative approach.

Occupations

With regards to occupations, a review of studies identified common interventions of OT needs for the homeless population. These include:⁷ 

• Money management
• Banking skills
• Budgeting
• Employment opportunities
• Education opportunities
• Leisure activities instead of substance abuse and unsafe sexual activity
• Coping skills for mental illness, stress, anger management, and assertiveness

Ongoing Research

In the meantime, I’ll be conducting more ongoing research on this topic. Feel free to contact me if you have any experience or insights for me to include in this post.

Sources

1. Canham, S. L., Davidson, S., Custodio, K., Mauboules, C., Good, C., Wister, A. V., & Bosma, H. (2018). Health supports needed for homeless persons transitioning from hospitals. Health & Social Care in the Community, 27, 531–545. https://doi.org/10.1111/hsc.12599↑↑↑↑
2. Hammig, B., Jozkowski, K., & Jones, C. (2014). Injury-related visits and comorbid conditions among homeless persons presenting to emergency departments. Academic Emergency Medicine, 21, 449–455. https://doi.org/10.1111/acem.12343↑
3. Wain, R. M., Wilbourne, P. L., Harris, K. W., Pierson, H., Teleki, J., Burling, T. A., & Lovett, S. (2011). Motivational interview improves treatment entry in homeless veterans. Drug and Alcohol Dependence, 115(1-2), 113-119.↑
4. Tucker, J. S., D’Amico, E. J., Ewing, B. A., Miles, J. N., & Pedersen, E. R. (2017). A group-based motivational interviewing brief intervention to reduce substance use and sexual risk behavior among homeless young adults. Journal of substance abuse treatment, 76, 20-27.↑
5. Orciari, E. A., Perman-Howe, P. R., & Foxcroft, D. R. (2022). Motivational Interviewing-based interventions for reducing substance misuse and increasing treatment engagement, retention, and completion in the homeless populations of high-income countries: An equity-focused systematic review and narrative synthesis. International Journal of Drug Policy, 100, 103524.↑
6. Forkin, J & Veltre, T. (2022). OT considerations in the acute care setting. AOTA.↑
7. Thomas, Y., Gray, M., & McGinty, S. (2011). A systematic review of occupational therapy interventions with homeless people. Occupational therapy in health care, 25(1), 38-53.↑