Program for the Mentally Ill Homeless Population

¶ … Program for the Mentally Ill Homeless Population

This research project is an attempt to determine if a community-based program serving the mentally ill homeless population has met its goal of reducing hospitalizations for acute psychiatric episodes. An attempt to identify the elements that define the difference in this program will be identified and evaluated. The literature shows that treating the mentally ill homeless population is especially difficult in terms of building lasting relationships based on trust. The population tends to move from one area to another within the city and become elusive when they are looked for. This program will be evaluated for its effectiveness in preventing hospitalizations for acute psychiatric episodes, the usefulness of case managing, including ensuring clients have and are taking their medications and whether this program has been more successful than traditional programs in finding permanent housing for it's clients.

Problem and Purpose

Homelessness is on the rise. There is no way to accurately count the number of homeless. This is because the homeless are alternately in shelters, on the street, hospitalized or doubled up with family for short periods of time. The Urban Institute approximated that in 2000, there were about 3.5 million people who were homeless and of that, 1.35 million were children (The Urban Institute, 2000).

A significant number of homeless are also mentally ill. The problems with the homeless accessing mental health care makes the possibility of easier access very sought-after. An innovative program designed to reduce acute psychiatric hospitalizations has been running for one year and, as a consultant, I have been asked to evaluate the effectiveness of this program. Specifically, I will be looking for data that will show if the clients have been admitted to any hospital or clinic expressly for psychiatric care (as opposed to for social or legal reasons). The assumption of this is that the reduction of acute psychiatric hospitalizations means "better" mental health.

A plan to review the records of the community-based program and eliminate any clients who have problems other than just homelessness and mental illness. The clients who have diagnoses such as alcohol or drug abuse alone or together with a mental illness will not be considered in the study.

A plan to determine the rate of hospitalization of these clients as opposed to clients in a similar situation, which is homeless and mentally ill. I will also determine the rate of hospitalization from the year before the community-based program was in operation and the past year since it has opened.

Literature Review

The problem of homelessness is not going to go away unless we help. There are several programs set up for the mentally ill homeless. The task force responsible for addressing actions on homelessness among the severely mentally ill, according to Leshner (1992), has developed four main objectives. The first is to make it easier for the mentally ill homeless person to access all of the services they need, such as food, shelter and treatment. The second objective is to find substitute housing choices for the homeless. The third is to develop better outreach efforts and the fourth is to get the information out there to the clients and other agencies involved with the mentally ill homeless.

The literature by Aday shows that there are significant obstacles to providing the services the mentally ill homeless client needs (Aday, 1993). Some of the obstacles are funding, inability to coordinate services and the lack of a delivery system that can handle all or at least most of the needs. Most agencies have tried to integrate their services and provide the service they can and refer the client to another agency for service (Alter, 1993). This can lead to agencies depending on one another for services for their client. They can ask for services for their client, but in the process they lose their independence. The problem with this scenario is that the agency can no longer function primarily how they think is best for their client. They now have to consider what another agency, or other agencies want from and for their clients. This can lead to reduced services for the clients (Weick, 1976). Interestingly, this actually can lead to the opposite of what the agency was originated for. For example, a community-based agency may enjoy the fact that they are small and can provide what they consider is best for their clients, but when they enter into a "relationship" with other service agencies and begin their linking, they lose the focus on service and start focusing on the administrative function of the agency (Bolland & Wilson, 1994).

In accordance with the above information, it only seems reasonable that one agency or provider should be involved with managing the coordination of services (Outcasts on Main Street, 1994). Furthermore, most mentally ill homeless people are not able to maneuver through the maze of appointments and different agencies they need to seek help from. A homeless person should first have their immediate needs taken care of. They need a place to stay and food to eat. Intervention with the homeless mentally ill person should be accomplished in the streets and in the shelters. They often live in dangerous situations and crisis teams should evaluate their circumstances and provide services accordingly (Outcasts on Main Street, 1994). This same article also recommends the use of small drop-in programs and case management.

Much of the literature relates homelessness and mental illness to substance abuse. The presence of substance abuse increases the risks of homelessness and leads to increased re-hospitalization for mental illness (Treatment of homeless men, 1994). Additionally, the mentally ill homeless person is more at risk for being alienated from their family than is the homeless person who has no mental illness (DeMino, 2000). This family connection can often help alleviate the homeless person's feelings of alienation and being an outcast in society.

Research Problem

An innovative community-based program for the mentally ill homeless population has been in operation for one year. Treating this population has been difficult in terms of keeping them out of the hospital for acute psychiatric treatment due to a variety of reasons. The mentally ill homeless population has a difficult time maneuvering through the maze of agencies that are set up to help them. They have little resources in terms of people to help them, such as family members or friends. Shelters are often temporary solutions and the times when the homeless are not in shelters, they are generally in unsafe conditions. The homeless feel less need to take their medications and seek psychiatric treatment than the general population. In fact, most are only treated when they reach a crisis situation and they are court ordered for treatment, jailed or persuaded to enter the hospital. This community-based program has been initiated as a different type of program; one that will attempt to meet many of the needs of the mentally ill homeless population and case manage this vulnerable population so that their needs are met through some resource of the program's direction.

One question that will be asked in this evaluative stage will be "has the incidence of psychiatric hospitalizations been reduced from the year prior to the program opening to this past year for the population treated at the program"? The second question will address the use of case management for the coordination of services for the clients, including their use of psychiatric medications. The third question will be to determine if this program was able to find more permanent housing for their clients.

The question of "has the incidence of psychiatric hospitalizations been reduced from the year prior to the program opening this past year to the program opening to this past year for the population treated at the program?" will be measured quantitatively. The clients have either been hospitalized less or they haven't. The fact that this area has only two hospitals that provide psychiatric care and only one of those has a 72 holding unit for court ordered admissions, will assist in developing of this information. There is no room for qualitative data in this question.

The second question relates to the program's use of case managers to help the clients find the services they need. This includes whether the clients have continued to receive and use their psychiatric medications. This is an integral part of the successful treatment of the mentally ill homeless client, as the continuation of medication helps alleviate readmission for psychiatric treatment. The data for this question is both quantitative and qualitative. The ability of the client to maneuver through the system of agencies can be identified by how many agencies they have been in contact with and also can be determined on the referral process to the other services. Included in this question is whether case management was able to effect a difference in making sure clients took their psychiatric medications and kept the appointments related to this. The qualitative measuring of this will be how the relationship has developed between the client and the case managers and the other program staff. Interviews with the clients who are willing to discuss this will be conducted as well as reviewing the records for referrals and services.

The third question to be reviewed will be whether this program has been able to find more permanent housing for their clients than formerly was available. This will be evaluated quantitatively. Most clients who are homeless move between shelters and have little money to live in an apartment. This particular program has access to grant money to provide more permanent housing and has a vocational specialist and benefits specialist to work with the clients to effect more stability in income, employment and housing. Records for all of these benefits and referrals will be reviewed and housing referrals and numbers of clients able to move into other housing will be quantitatively reviewed.

Research Design

The first consideration to be reviewed is the hospitalizations for acute psychiatric episodes of the mentally ill homeless clientele. The program manager has had every client sign a release of information for services, referrals and for evaluative purposes. They are told at the inception of services that there will be an evaluative process after one year and that their records will be reviewed, including hospitalizations. Only the clients who are willing to sign this will be reviewed. The program manager will have the list of all of the clients who have been served in the last year who have signed this release. Some information can be gathered from the list, as a prerequisite for operation of the program was to keep track of hospitalizations. Additionally, the two local hospitals have been contacted and they have been provided with the list of the names of the clients served by this program (again, only those who have signed a release). The names are matched in the computer programs of the hospitals for the year prior to the inception of the program and also the past year of operation. The two figures are matched, both individually and as an entire list to see how many hospitalizations for acute psychiatric episodes have occurred. A 20% reduction in hospitalizations is considered a successful reduction in hospitalizations. The hospitals have also developed a list of how many homeless persons were admitted in their hospital for the last two years. By reducing that amount by the numbers we have of homeless people admitted for psychiatric episodes who are clients of this program, we have a general idea of many people are admitted annually for psychiatric hospitalizations. The homeless people who are not involved with this program are not identified by name. Ethically and legally, the hospital is not able to release any information on patients who have not signed a release and this information is numbers only. The hospital has high-risk admission forms for their psychiatric admissions, which identify the homeless person, among other identifying information, including age and specific diagnoses. The information is entered into the computer for every admission and correlated from those records is a list of each of those issues. For example, all of the persons admitted to that unit who are also diabetics are on one list as are all of the people who are homeless extrapolated from the information and are on one list. This makes it easier to see how many admissions have been made to the psychiatric facilities and how any of these patients were identified as homeless. Homeless identification is not required in this study, as the program and hospital have identified homeless as pertains to their programs. The information collected will not be 100% correct, because of other variables, such as admissions of transients and multiple admissions for clients. However, a trend can be discerned.

The second question that will be addressed is whether the case managers have been able to make referral for services an easier thing for the clients to accomplish. Reviewing each client's record and counting the referrals that have been made will accomplish part of this task. Each case manger is required to make a copy of a letter referral or to make a note in the client's record each time a referral is made on the client's behalf. The vocational rehabilitation specialist and the benefits advisor also make notes in the chart. Every time the client is in the program center, it is marked on a calendar in front of the record. The clients are asked about the use of their medication and whether they need refills. Each case manager also documents calls to the pharmacy and the psychiatrist. The clients who are willing to be interviewed by evaluator will be asked about their experience with the program and how they view the ease of accessing services in the community in the last year, as opposed to the year before. The information that is collected by using both of these methods will be developed into trends and data to be used in evaluation.