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Homelessness

Individuals experiencing homelessness undergo limited opportunity for meaningful occupational engagement, from ability to safely engage in activities of daily living (ADLs) to leisure and work. The ability to participate in desired occupations is restricted by many external factors, including local and national policy, shelter and health systems, and available community resources. Individuals experiencing homelessness also manage significant personal factors, such as chronic health conditions, histories of trauma, and limited economic and social supports, that influence their ability to navigate and respond to existing systems. Individuals who are homeless may also have long and familial histories of living in poverty and housing instability. Homelessness takes many forms, as those who are homeless may be living in shelters or on the streets, lack stable housing or “doubling up” with others, or experiencing displacement from their homes, such as refugees or survivors of natural disasters. Interventions to prevent homelessness and transition individuals into communities of their choice are critical. The goal of this special issue of WORK is intended to highlight the specific needs of homeless and refugee populations, and emerging programs developed to address these needs.

Recently in the United States (US), there has been an attempt to re-initiate work requirements for individuals to access public support programs, such as Medicaid or supplemental food benefits (SNAP). However, there is limited evidence on the effectiveness of these programs in transitioning individuals out of poverty, and also indicates this is not effective for those with disabilities [3]. Although “work” is traditionally identified as paid employment, for those experiencing homelessness, “work” is day-to-day survival. Those who lack stable housing must focus much of their time on maintaining safety and addressing basic needs, such as eating, ADL, and managing personal belongings. Acquiring these resources while homeless can take much of a person’s day, while navigating the time structure of various agencies. “Work” therefore becomes acquisition and engagement in basic needs.

Models of care for this population, such as Housing First/Permanent Supportive Housing and Federally Qualified Health Centers, have identified the importance of meeting basic needs for safety and housing first, to allow for individuals to better manage their health and then integrate into the community as desired [1, 2]. Programs developed to address the needs of individuals experiencing homelessness often seek to provide opportunity to meet basic needs, as well as additional complex social and health needs. Existing literature supports agencies and programs that have flexible service delivery and minimize barriers to access [4]. Although evidence and research is important to guide and inform best practices, literature regarding health services for individuals experiencing homelessness is not robust. Many agencies providing services do not have the bandwidth to both provide services and conduct research on the efficacy of services. National research priorities and funding do not often focus on more marginalized populations and can be influenced by current policy. Rigorous research may not be accessible, as control groups may limit those who need services from accessing them. Although many effective programs and interventions for those experiencing homelessness exist, it can be difficult to capture.

There are two important goals of this issue. First, it is to provide a greater understanding for all practitioners on the barriers faced by those in poverty and experiencing homelessness. Second, to provide a framework for continued development of programs and interventions that address the needs of this population, based on existing programs and research. This issue includes several types of articles, including: program descriptions with initial outcomes, identifying occupational and programmatic needs of adults experiencing homelessness, and exploration of factors that can influence health and housing status.

Evidence in many of these articles are reflected through case studies. It is critical to include the first-hand experience of those experiencing homelessness. Although considered less rigorous, qualitative research, case studies, and reflections of consumer experience provides valuable insight. This is especially important for vulnerable and marginalized populations who are often not given voice or agency. Although less rigorous by research standards, the articles included in this issue provide clinical implications and models for other programs to develop and adopt, to continue to improve outcomes for those they serve.

In the publication of this issue, it is my hope that programs and services in all settings implement services focused on the empowerment of individuals, and the transition from survival to engagement.

Finally, a special thank you to our guest reviewers, Dr. Beth Merryman, Dr. Kate Egleseder, Dr. Maren Voss, and Dr. Darlene Jenkins for your thoroughness and diligence throughout the publication process.

References

[1] 

Aubry T , Tsemberis S , Adair CE , Veldhuizen S , Streiner D , Laitmer E , et al. One-year outcomes of a randomized controlled trial of Housing First with ACT in five Canadian cities. Psychiatric Services. 2015;66:463–9.

[2] 

Tsemberis S , Asmussen S . From streets to homes. Alcoholism Treatment Quarterly. 1999;17:113–31.

[3] 

Hahn H , Pratt E , Allen E , Kenney G , Levy D , Waxman E . Work requirements in social safety net programs. Washington, DC: Urban Institute; 2017. pp. 50.

[4] 

Bonin E , Brehove T , Carlson C , Downing M , Hoeft J , Kalinowski A , et al. Adapting your practice: General recommendations for the care of homeless patients. Nashville, TN: National Health Care for the Homeless Council; 2010. Available from: http://www.nhchc.org/wp-content/uploads/2011/09/GenRecsHomeless2010.pdf